Internal Septations Research Articles

Abstract P414: Systems Genetics Analysis Reveals Significant Eqtls Associated With Echocardiography Parameters In Genetic Reference Population Of Bxd Strains.

Background: Causal and modifier genes, genetic background and environment underlie clinical heterogeneity in cardiomyopathy (CM). The BXD recombinant inbred (RI) family represents a murine genetic reference population (GRP) that are descendants from crosses between C57BL/6J (B6) and DBA/2J (D2) mice. The parental D2 mouse is a natural model of hypertrophic CM (HCM). The study aimed to dissect genetic architecture of cardiac traits in BXD GRP using systems genetics analysis. Methods: Echocardiography was performed in 88 strains of male (M) and female (F) BXDs (N>5/sex) at 4-5 months of age. Cardiac traits were then associated with heart transcriptome, and expression quantitative trait loci ( eQTL) mapping was performed. Results: More than 2-fold variance in ejection fraction (EF%), fractional shortening (FS%), left ventricular (LV) volumes at end-systole and end-diastole (Vol;s and Vol;d), internal dimensions (ID;s and ID;d), posterior wall (PW), and interventricular septum (IVS) thickness was found among BXDs. Traits seen in dilated CM (DCM) patients such as reduced EF%, FS%, and LVPW and increased Vol;s and ID;s are found in BXD78 (M, F), BXD32, 111, and 68 (F) strains. Strains D2, BXD90 and 155 (M, F), BXD44 and 65 (M), and BXD113, 16, 77 (F) had significantly greater LV mass, LVPW and IVS thickness compared to sex-matched controls, suggestive for traits seen in HCM patients. A 6.4 Mb QTL (peak LRS=18.50) was identified on chromosome (Chr) 8 to be significantly associated with ID;s, ID;d, Vol;s and Vol;d among male BXDs. eQTL mapping for each of 131 genes on Chr8 QTL identified 6 genes ( Coq9 , Ndrg4 , Crnde, Irx3, Rpgrip1l, and Rbl2 ) being cis -regulated and Ndrg, Slc6a2 and Ces1d being significantly (p < 0.05) correlated with LV volumes. In female BXDs, a significant QTL on Chr7 (40.2 Mb) with 9 genes that significantly correlated with LVPW;d was identified. A suggestive 92.6 Mb QTL on Chr3 with Snapin , Tpm3 , and Wars2 correlated with EF% and FS% (p < 0.05). Conclusions: Our study found cardiomyopathy-associated traits are segregated among BXD family and these traits vary among BXD lines. Multiple associated QTLs demonstrate that the BXD family is suitable to map gene variants and identify genetic factors and modifiers that influence cardiomyopathy phenotypes.

Characterization of Acinetobacter baumannii Filamentous Cells by Re-Scan Confocal Microscopy and Complementary Fluorometric Approaches

The spread of Acinetobacter baumannii in clinical settings is a great concern at the time being, given the epidemic potential and the capacity to elude the effects of drugs of this bacterial species. How A. baumannii achieves its resistance determinants is not yet exactly understood, hence the need for new studies aimed at resolving its structure and functions. In this work, we employ Re-scan Confocal Microscopy (RCM), an emerging super-resolution technique, for investigating the morphology of this pathogen. Interestingly, about 1.5% of the imaged cells were found to be filamentous without internal division septa, in both logarithmic and stationary phases, which, to our knowledge, has not been previously reported. Since filamenting represents one of the first mechanisms adopted by bacteria to resist antibiotic effects, we also focus on evaluating the sensitivity of A. baumannii to colistin. For this, the LIVE/DEAD ratio is assessed by means of a fluorometric approach based on SYTO9 and KK114 dyes, two stains that we also used for RCM imaging. Their dual role demonstrated here can potentially be exploited in-tandem in multimodal systems for imaging and fluorometry.

Approach to Cystic Lesions in the Abdomen and Pelvis, with Radiologic-Pathologic Correlation

Cystic lesions found in and around the peritoneal cavity can often be challenging to diagnose owing to significant overlap in imaging appearance between the different entities. When the cystic lesion can be recognized to arise from one of the solid abdominal organs, the differential considerations can be more straightforward; however, many cystic lesions, particularly when large, cannot be clearly associated with one of the solid organs. Cystic lesions arising from the mesentery and peritoneum are less commonly encountered and can be caused by relatively rare entities or by a variant appearance of less-rare entities. The authors provide an overview of the classification of cystic and cystic-appearing lesions and the basic imaging principles in evaluating them, followed by a summary of the clinical, radiologic, and pathologic features of various cystic and cystic-appearing lesions found in and around the peritoneal cavity, organized by site of origin. Emphasis is given to lesions arising from the mesentery, peritoneum, or gastrointestinal tract. Cystic lesions arising from the liver, spleen, gallbladder, pancreas, urachus, adnexa, or soft tissue are briefly discussed and illustrated with cases to demonstrate the overlap in imaging appearance with mesenteric and peritoneal cystic lesions. When approaching a cystic lesion, the key imaging features to assess include cyst content, locularity, wall thickness, and presence of internal septa, solid components, calcifications, or any associated enhancement. While definitive diagnosis is not always possible with imaging, careful assessment of the imaging appearance, location, and relationship to adjacent structures can help narrow the differential diagnosis. Online supplemental material is available for this article. ©RSNA, 2021.

The Role of Tissue Harmonic Ultrasonography and Computerized Tomography in the Diagnosis of Intraabdominal Cystic Lesions

Aim: Abdominal Ultrasonography (US) and Computed Tomography (CT) examinations are imaging methods frequently used in Radiology Clinics. During these examinations, cystic lesions are frequently detected in the abdomen. It is an important problem to identify and characterize the clinical significance of these cysts.Methods: The findings of 145 patients who underwent abdominal imaging in the US and CT units of the Istanbul Training and Research Hospital Radiology Clinic and were found to have cystic lesions were analyzed retrospectively. The CT findings of cystic lesions detected in the abdominal organs or the abdominal cavity were reviewed, and the contribution of the new US image acquisition method, Tissue Harmonic Imaging (THI), to the characterization of cysts was examined.Results: A total of 145 patients, 56 men (39.3%) and 89 women (60.7%) with cystic lesions in the abdomen, were included. We detected cystic lesions most frequently in the kidneys (n:68, 46.89%) and second most frequently in the liver (n:65; 44.82%). In addition, we detected cystic lesions in the spleen in 5 cases (3.44%), in the pancreas in 7 cases (4.82%), and in the abdominal cavity in 5 cases (3.44%). In all our cases, cystic lesions could be visualized in both THI imaging and CT examination.Conclusion: THI examination provides valuable information in characterizing cystic lesions, especially by showing the wall feature of the cyst, the internal septa and the presence of intra-cystic solid component, while CT examination especially shows the wall calcification and the presence of air in the abscess, as well as the intramural solid component.

MRI features and clinical outcomes of unexpected uterine sarcomas in patients who underwent high-intensity focused ultrasound ablation for presumed uterine fibroids

Objective To investigate the MRI features and clinical outcomes of unexpected uterine sarcomas in patients after high-intensity focused ultrasound (HIFU) ablation for presumed uterine fibroids. Materials and methods 15,759 consecutive patients who came for HIFU treatment, from November 2008 to September 2019, for presumed uterine fibroids were retrospectively reviewed. All the patients had completed a pre-HIFU MRI. All MRI images were independently analyzed and interpreted by two radiologists in every center. Results According to the T2WI MRI features of hyperintensity, accompanied by irregular margins, necrosis or cystic degeneration, multi-lobulated lesion with internal septation, 46 patients were suspected to be uterine sarcomas before HIFU. Eleven patients were histologically diagnosed as uterine sarcomas after laparotomy. Among the 15713 patients who received HIFU treatment for presumed uterine fibroids, 8 patients were found to have occult recurrence during the follow-up period, and 6 were confirmed histologically as uterine sarcomas after laparotomy. The incidence rate of uterine sarcomas was 0.108% (17/15759). Among them, 12 cases were low-grade endometrial stromal sarcoma (LG-ESS) and 5 cases were uterine leiomyosarcoma (LMS). No histological dissemination of the sarcoma was detected in patients with unexpected uterine sarcomas. Conclusion Although some MRI features of uterine sarcomas and uterine fibroids overlapped, MRI is valuable in distinguishing between uterine fibroids and uterine sarcomas. HIFU does not seem to cause histological dissemination of the sarcoma, but follow-up visits should be strictly adhered to in order to detect unexpected uterine sarcomas at an early stage and to treat them in a timely manner.

Effect of the Internal Septum Extract of the Walnut Kernel on the Mesenchymal Stem Cells Cycle and MSCs-derived Insulin-Producing Β-cells Differentiation and Glucose Uptake

Background: For years, scientists have been striving to identify compounds to improve the characteristics and functions of cells for therapeutic applications. Objectives: This study aimed to evaluate the effect of the aqueous decoction of the internal septum of the walnut kernel (DISWK) on the survival, total antioxidant capacity (TAC), and cell cycle of rat bone marrow-derived mesenchymal stem cells (rBM-MSCs). We also evaluated the expression of genes involved in pancreatic insulin-producing β-cell (IPCs) commitment and glucose uptake in MSCs-derived IPCs. Methods: The rBM-MSCs were isolated, and then the cytotoxic and antioxidant effects of DISWK on the cells were examined by the MTT and TAC assays, respectively. Moreover, the influence of DISWK on the rBM-MSCs cell cycle was evaluated by PI-staining and flow-cytometry analysis. Next, the rBM-MSCs were transdifferentiated into IPCs treated with DISWK. Finally, Ins1/2, Insr, Glut1, Glut4, and Pdx1 genes expression was investigated in the DISWK-treated IPCs by qRT-PCR. Results: The results indicated that DISWK significantly reduced the viability of rBM-MSCs in a dose- and time-dependent manner and decreased their TAC in long-term cultures. Moreover, it suppressed the rBM-MSCs cell cycle at S and G2 phases. The gene expression analysis showed that DISWK significantly upregulated Ins1/2, Insr, and Glut1 genes and downregulated Pdx1 gene in the rBM-MSCs-derived IPCs. Conclusions: Decoction of the internal septum of walnut kernel suppresses the MSCs cell cycle and may prevent IPCs development via inhibiting Pdx1. It may also help glucose uptake by upregulating Ins1/2, Insr, and Glut1 genes expression in MSCs-derived IPCs.

Lymphangioma of popliteal fossa masquerading as Baker\u2019s cyst

BackgroundLymphatic malformations are the second most common vascular malformations after venous malformations. These slow-flow lesions occur most often in the paediatric population and seldom in the extremities. We report a case of lymphangioma at the popliteal fossa in an adult who underwent complete surgical resection.Case presentationA 30-year-old male presented to the department of orthopaedics with a swelling in the right calf region. Clinically, it was suspected to be a Baker’s cyst. Ultrasound showed a multiloculated anechoic cystic lesion in the inferior aspect of popliteal fossa along the intermuscular plane with multiple internal septations. Infected Baker’s cyst was considered, and MRI was suggested for further evaluation. On MRI, the lesion measured 7.2 × 4.6 × 5.8 cm, appeared as a low signal on T1 and high signal on STIR and T2, with multiple internal septations and was situated in the inferior aspect of the right popliteal fossa along the intermuscular plane between the lateral head of gastrocnemius and soleus muscles. No obvious synovial extension. A post-contrast study showed minimal peripheral and septal enhancement. Neither internal enhancing solid components nor significant internal derangement of the knee was observed. Diagnosis of lymphangioma was considered based on the imaging features and ruling out the common differentials for cystic lesions around the knee. Wide local excision was performed. Histopathological evaluation showed multiple irregularly dilated lymphatic channels lined by flatted epithelium. The lymphatic channels were seen to be surrounded by thick fibro collagenous cyst wall with scattered congested blood vessels, skeletal muscle fibre and chronic inflammatory cells.ConclusionLymphangioma must be included in the differential diagnosis of any cystic lesion if the lesion appears multiseptated and/or infiltrative. At the popliteal fossa, it presents as a multiseptated cyst with no synovial continuity or internal derangement of the knee.

Rare Case of Severe Hypercalcemia Secondary to Atypical Sestamibi Negative Parathyroid Cystic Adenoma

Primary hyperparathyroidism (PHPT) is defined as excessive secretion of parathyroid hormone (PTH) originating from the parathyroid gland. The most common cause is a single parathyroid adenoma which is typically solid. Cystic parathyroid adenomas (CPA) are the cause of about 1–2% of cases of primary hyperparathyroidism. It is known that cystic parathyroid adenomas are a result of degeneration of an existing parathyroid adenoma. SestaMIBI is an imaging study based on uptake of radioactive technetium99 and used to localize parathyroid adenomas. We describe an unusual case of severe hypercalcemia secondary to 99mTc sestaMIBI negative atypical parathyroid cystic adenoma. A 56-year-old male presented to our facility with nausea and vomiting. His past medical history included hypertension and hepatitis C with no history of fractures or kidney disease. Physical examination was normal. Upon admission the patient was afebrile with blood pressure of 170/120 mmHg and heart rate of 62 bpm. Chemistry showed Calcium of 14.5 mg/dL (8.6–10.2mg/dL), phosphorus 2.2 (2.7–4.5) mh/dL, magnesium 1.8 (1.7–2.6)mg/dL, intact PTH of 375 (15–65) pg/mL, PTH-related peptide <2.0 pmol/L(<2 pmol/L), 25-OH vitamin D of 19 ng/ml (30–80), Creatinine 1.22 (0.7–1.2)mg/dL, alkaline phosphatase 95 (40–129) units/L. He was started on aggressive hydration, calcitonin 4 units/kg, 4 mg of IV Zolendroninc acid. Neck sonogram revealed a large, complex, predominantly anechoic lesion with solid vascular components and thick internal septations in the inferior and medial aspect of the right thyroid lobe measuring 3 x 2 x 5.5 cm. Findings were confirmed with CT of the neck. Since Sestamibi scan (planar and SPECT/CT) did not show uptake in parathyroid glands, the cyst was thought to be of thyroid origin. Fine needle aspiration was not able to detect cellular material, but PTH was >100 pg/ml on the FNA sample. Otolaryngology service was consulted for parathyroidectomy. During the surgical treatment, the right upper parathyroid gland was removed with no changes in serum PTH. Next, the cystic lesion was removed with normalization of serum PTH (from 218 pg/ml to 35.2 pg/ml respectively). Intraoperative frozen section analysis was read as a cystic parathyroid adenoma. The final pathology report revealed cystic parathyroid tissue favoring parathyroid adenoma with focal atypia. Hypercalcemia resolved. Conclusions: Atypical cystic parathyroid adenomas are a rare cause of PHPT. 90% of parathyroid cysts are nonfunctional. Above mention is a case of a patient presenting with hypercalcemic crisis secondary to cystic parathyroid adenoma, which posed a diagnostic challenge as both neck ultrasound and 99mTc sestaMIBI scan were inconclusive. These findings should trigger suspicion for functional parathyroid lesions. Cystic components should be evaluated for PTH levels and if significantly elevated should be treated as a parathyroid adenoma.

Morphological analyses of the adult and juvenile stages of the stalked jellyfish Craterolophus convolvulus (Johnston, 1835) (Cnidaria: Staurozoa: Stauromedusae: Craterolophidae) using micro-CT

Investigations on the internal anatomy of stalked jellyfishes (Staurozoa) are crucial for species descriptions and systematic studies on this taxon. Contrast-enhanced X-ray micro computed tomography (micro-CT) has increased the opportunities for morphological descriptions of soft-bodied invertebrates in the last decade, but only few studies have focused on cnidarian taxa so far. We performed a micro-CT-based morphological study on the staurozoan Craterolophus convolvulus (Johnston, 1835) including the juvenile stage of the species for the first time. Virtual sections allowed for the analysis of specific anatomical details and revealed stage specific differences. For example, the peduncle length was longer in relation to the calyx length, the arrangement of arms in pairs was more pronounced, and the number of secondary tentacles and adhesive pads was lower in the juvenile specimen. Longitudinal virtual sections revealed the internal septa (claustra) with triangular lower edges in the adult and semicircular lower edges in the juvenile specimen. The primary tentacles, only present in the juvenile stage, had distinct distal swellings and adhesive pads at their stem bases. For both stages, our results revealed an internal canal system at the tip of the arms previously described as “intertentacular lobules”. Virtual sections also clarified the organization of gonads in densely folded gonad bands, which form sac-like pouches with small pathways. Even though our micro-CT data allowed for the discrimination of different tissues such as epidermis, gastrodermis, mesoglea, gonads, and muscles, their resolution was not sufficient to depict micro-anatomical details of gametes and nematocysts, which can be relevant for morphological studies on stauromedusae. Thus, micro-CT cannot replace histological standard techniques, but allow for a better spatial understanding of anatomical details and morphological features, facilitating taxonomic and phylogenetic studies on Staurozoa and other soft-bodied cnidarians.

Multimodal imaging in a case of macular vortex vein varix

Variceal dilations of vortex vein are not uncommon in eyes with high myopia. However, its occurrence in emmetropic eyes and posterior location has rarely been reported. We report a case of 55-year-old man who presented with a reddish orange sub-retinal lesion at the macula with subtle pulsation and collapse on pressure indentation. The lesion appeared hyerfluorescent on early frames of FFA with persistent silhouette in the late frames. ICGA showed dilated and tortuous vascular complex with hyperfluorescence in the mid phase without any evidence of late leakage. On SD–OCT the lesion appeared as a hypo-reflective sinusoidal space extending from the Hallers layer to the choriocapillary bed with distortion of the overlying RPE. The En-face Angio-OCT imaging was suggestive of a flow void sinusoidal tract with internal septa. The clinical features and collaborative findings on multimodal imaging were suggestive of variceal dilatation of the vortex vein ampulla.

Proposed ultrasound algorithm to differentiate thyroglossal duct and dermoid cysts

Objective1) To assess reproducibility of the previously established SIST score. 2) To determine inter-observer agreement in using ultrasound (US) characteristics to differentiate thyroglossal duct cyst (TGDC) from dermoid cysts (DC) 3) Improve the method used to pre-operatively differentiate TGDC from DC. Study designRetrospective chart review. SettingTertiary care pediatric hospital. Subjects and MethodsAn electronic medical record was queried to identify children with midline neck masses who underwent pre-operative neck US and had a histopathologic diagnosis of either TGDC or DC. Two pediatric radiologists, blinded to the pathologic diagnosis, evaluated the US images and documented the presence of pre-determined characteristics of each mass. Potential differentiating factors were analyzed for their predictive power. The SIST (septations, irregular walls, solid components = TGDC) score was determined as well as inter-observer agreement. Using the characteristics that had significant predictive power, we used the data to develop an algorithm to improve predicting cyst type. ResultsPathologically, there were 47 TGDC and 25 DC. The inter-observer agreement about the pathologic diagnosis between the two radiologists was substantial, K = 0.66. Overall, the SIST score predicted the correct diagnosis 67% of the time. Radiologist 1 and radiologist 2 were more accurate than the SIST score alone, making the correct diagnosis 96% and 86% of the time, respectively. In our study, we found that the most important US characteristics in differentiating TGDC and DC are: internal Septations, depth relative to Strap muscles, Shape and Solid parts (4 S algorithm). The SIST score criteria were individually shown to be significant and sensitive in recognizing DC, however, they were not specific and often misclassified TGDC as DC. We developed a new sequential filtering algorithm that more accurately differentiates cysts. This new algorithm uses step-wise filtering of characteristics, first for Septations, then for depth to Straps, then Shape of the cyst and lastly Solid parts (4 S algorithm). This algorithm correctly categorized cyst type in 100% of patients in our study. ConclusionsPre-operatively differentiating TGDC and DC continues to be a challenge. Using our 4 S algorithm, we can more definitively differentiate TGDC from DC compared to the SIST score. All SIST score characteristics were significant and sensitive in detecting dermoid cysts, however, not very specific. The radiologists’ judgment and accuracy was better than the SIST score. The 4 S algorithm uses sequential filtering of important characteristics: Septations, depth to Straps, Shape of cyst and lastly Solid parts to improve diagnostic accuracy.

Unusual presentation of pancreatic tumor

A 47 year-old female presented with a reducible bulging mass at umbilicus. Physical examination showed no jaundice, no abdominal pain, but the abdomen was distended due to obesity. Under the impression of umbilical hernia, herniorrhaphy was arranged. However, a large cystic mass was observed through the fascia defect during operation. Pancreatic cystic tumor was suspected and CT was arranged after herniorrhaphy. CT demonstrated a giant (28x26cm) lobulated cystic mass was found mainly in central abdomen with internal septa. Distal pancreatectomy with splenectomy was performed and pathology showed mucinous cystic neoplasm (MCN) with low-to intermediate grade dysplasia. The post-operative course was uneventful and her body weight decreased from 90 to 75 kilograms. Pancreatic tumor usually presented with symptoms such as abdominal pain, back pain, or jaundice. Umbilical hernia is an unusual presentation of pancreatic tumor, and it might be neglected in obese patient. Sophisticated investigation of the etiology of increased intraabdominal pressure and careful inspection during herniorrhaphy may help us not to lose the diagnosis of pancreatic tumor in such an unusual presentation.

Radiological differences in computed tomography findings and texture analysis between cystic lymph node metastases of human papillomavirus-positive oropharyngeal cancer and second branchial cysts.

PurposeThe study aimed to analyse radiological differences in computed tomography (CT) findings and texture analysis between cystic lymph node metastases (CNM) in human papillomavirus (HPV)-positive oropharyngeal cancer (OPC) and second branchial cleft cysts (2nd BC).Material and methodsPatients with pathological evidence of CNM-HPV-OPC and 2nd BC, who underwent contrast-enhanced CT, were retrospectively evaluated. The evaluated characteristics include age, sex, and CT findings. CT findings included the maximum and minimum transverse diameters, maximum caudal diameter, thickness of the peripheral wall, presence of internal septation, presence of surrounding fat stranding, location, and 40 texture parameters.ResultsA total of 13 patients had CNM-HPV-OPC (19 lesions), while 20 patients had 2nd BC (20 lesions). Patients with 2nd BC were significantly younger than those with CNM-HPV-OPC (p < 0.001). In terms of diameter, 2nd BC lesions were significantly larger than the CNM-HPV-OPC lesions (p < 0.001). CNM-HPV OPC lesions had significantly thicker walls than 2nd BC lesions (p < 0.001). CNM-HPV-OPC lesions had significantly higher association with internal septations than 2nd BC lesions (p < 0.001). Second BC lesions were significantly less common at level III than CNM-HPV-OPC lesions (p = 0.047). Among the 40 texture parameters measured, 8 had significant differences (p ≤ 0.001).ConclusionsThere were significant differences in CT findings and textural parameters between CNM-HPV-OPC and 2nd BC lesions. These results may help in differentiating one from the other.

Role of Dynamic Contrast Enhanced Magnetic Resonance Imaging and Mammogram in Evaluation of Breast Lesions with Pathological Correlation

Background: To perform mammography and dynamic contrast enhanced MRI in patients with clinically suspicious breast lumps and correlating the findings with pathology in patients of positive imaging. Subjects and Methods: total of 40 patients evaluated through MRI BI-RADS lexicon (General Electric Medical Systems) at 1.5T in combination with dynamic kinetic analysis of time and signal curves for lesion characterization. Results: The mean age was 44 years, maximum of patients (n=22) belongs to age group of 41-60 years (52.5%). Five lesions showed dark internal septations, as benign. 11 lesions (33.5%) showed heterogenous enhancement, as malignant. Early rim enhancement is observed in 3 lesions (9%). Out of which two of them were proven to be malignant and one lesion was an infective abscess. Invasive Duct Cell Carcinoma was the common histology in the malignant lesions, observed in 13 out of 18 (72.2%). Fibroadenoma was the common benign breast lesion, observed in 8 out of 19 (42.1%). In 4 post operative patients, 2 (50%) were post operative fibrosis, 1 (25%) was recurrence and 1 (25%) was post operative collection. In 18 malignant lesions, 11 patients (61.1%) had skin retraction, 10 patients (55.5%) had skin thickening, 9 patients (50%) had axillary lymphadenopathy, 2 patients (11.1%) had nipple retraction, and one patient (5.6%) had pectoralis involvement. In our study, MR imaging alone has Sensitivity of 88.8%, specificity of 86.3%, PPV of 84.2%, and NPV of 90.4% with Accuracy 87.5%. Conclusion : The dynamic contrast enhanced MRI is important tool to evaluate the postoperative breast in differentiating between benign postoperative changes. By combining kinetic analysis with morphological analysis it add benefit to categorise the breast lesions into benign and malignant with increased confidence levels. CE-MRI with both morphology and kinetic curve assessment has a Sensitivity of 94.5%, Specificity of 100% with Accuracy of 97.5%.

Inflammatory pseudo-tumoral primary hepatic tuberculosis: a surgeons dilemma

Pseudo-tumor hepatic tuberculosis is a rare entity. Tuberculosis involving the liver in the absence of active pulmonary tuberculosis is very uncommon. It is characterized by non-specific symptoms and radiological polymorphism. This case report illustrates the difficulty in reaching the correct diagnosis in case of hepatic masses, which are most often confused with carcinoma of the liver, primary or metastatic and hence, in the past referred to as pseudo-tumoral hepatic tuberculosis. We report a case of an inflammatory pseudo-tumor of the liver due to tuberculosis in a 6 years child. Computer tomography showed evidence of a large heterogenously enhancing predominantly cystic multiseptated mass in left lobe of liver with peripheral nodular enhancement and persistent enhancement of internal septations and nodular solid components. Hence malignant tumor was initially considered in view of the radiological findings. Alpha fetoprotein was within normal limits. The patient was treated surgically by debridement of left lobe of liver.

Resolving the systematics of Richtersiidae by multilocus phylogeny and an integrative redescription of the nominal species for the genus Crenubiotus (Tardigrada)

The family Richtersiidae, although established recently with the use of phylogenetic methods, was considered potentially paraphyletic at the time of its erection. Until now, the family comprised four genera, Richtersius, Diaforobiotus, Adorybiotus and a newly erected genus Crenubiotus. However, the genetic characterisation for the latter two genera was very limited or absent. To address concerns about the phylogenetic affinity of these two genera, we present a multilocus phylogeny of the families Richtersiidae and Murrayidae based on four molecular markers (18S rRNA, 28S rRNA, ITS-2 and COI). Our results show a distinct evolutionary lineage composed of Adorybiotus and Crenubiotus, which is sister to Murrayidae. In order to accommodate the phylogenetic and morphological distinctiveness of this lineage, we erect a new family, Adorybiotidae fam. nov. The new taxon differs morphologically from other families in the superfamily Macrobiotoidea by a unique combination of traits: (1) the presence of tubercles/cushions with aggregations of microgranules on their surfaces present on all legs and on the dorso-caudal cuticle, (2) a system of internal septa in claws, and (3) buccal apparatus morphology. Moreover, in order to stabilise the taxonomy and nomenclature in the genus Crenubiotus, we redescribe its type species, Crenubiotus crenulatus, by means of integrative taxonomy and designate a new neotype based on a population from the original terra typica.

A case of giant orbital conjunctival cyst mimicking lymphatic malformation.

A conjunctival inclusion cyst is a colorless or whitish translucent cystic lesion, frequently occurring on the conjunctiva. Here, we describe a patient with a giant conjunctival cyst, mainly existing in the orbit, which clinically resembled lymphatic malformation. A 34-year-old male complained of a subconjunctival mass on his left infero-medial side persisting since childhood. It had gradually enlarged over the 3 months before the initial visit. He had no history of trauma, surgery, or conjunctivitis. The mass was dark red, with superficial dilated blood vessels. Magnetic resonance imaging showed a well-circumscribed mass in the inferior orbit, measuring 12 × 25 mm, which had an internal septum. The lesion was completely resected without rupture of the mass through a transcutaneous approach. Histopathologically, the mass was a cyst composed of columnar epithelium with goblet cells and lymphoid follicles adjacent to the wall. In conclusion, a giant orbital conjunctival cyst and a lymphatic malformation should be differentiated at diagnosis.

Cystic lymphangioma of the jejunal mesentery in a young adult: a rare case report

Lymphangioma is an uncommon congenital malformation of the lymphatic system that manifest as a benign tumor. They are most commonly seen in children and rarely in adults. Lymphangiomas in the peritoneal cavity are extremely rare in adults, comprising of less than 1% of all lymphangiomas. We report a case of 18-year-old healthy female who was diagnosed with cystic mesenteric lymphangioma of the small intestine on CT scan as a part of her routine health check-up. CT scan reported a large well-defined cystic mass in mesentery of the small intestine filled with a hyper dense fluid. The lesion had thin capsule and internal septa. Radiological diagnosis was confirmed intra-operatively on laparoscopy. The patient underwent laparotomy with resection of the cyst and the involved jejunum segment followed by end to end anastomosis. The specimen was sent for histo-pathological examination and the findings were consistent with the diagnosis of cystic lymphangioma of the jejunal mesentery. Cystic mesenteric lymphangiomas are rare entities in a clinical setting that can be easily missed on clinical examination or may present as asymptomatic disease. CT scan is the gold standard investigation for diagnosis of mesenteric lymphangiomas. The preferred surgical approach depends on the location of the lesion, the clinical features and the spread of the lesion to surrounding structures.

Laparoscopic Excision of Recurrent Pelvic Lymphocyst Following Pelvic Lymph Node Dissection for Clear Cell Carcinoma of Ovary

Study ObjectiveDemonstration of safe laparoscopic technique for definitive excision of recurrent pelvic lymphocyst developing following pelvic lymph node dissection for clear cell carcinoma of the ovary; overcoming the additional surgical challenges of close proximity to vital anatomical structures and dense post-operative adhesions.DesignSurgical video detailing a systematic approach to laparoscopic excision of pelvic lymphocyst - describing individual surgical steps and highlighting relevant anatomy.SettingSurgery was undertaken by a gynae-oncology consultant with one surgical assistant. The patient was positioned in modified Lloyd-Davis – with table height and stack adjusted for optimal ergonomics.Patients or ParticipantsA 68 year old lady underwent total abdominal hysterectomy, bilateral salpingo-oophrectomy and omentectomy in April 2018 for stage 1A clear cell carcinoma of ovary; followed by completion laparoscopic pelvic and para-aortic lymphadenectomy. The patient subsequently developed a right pelvic lymphocyst, causing pain. Pre-operative imaging described a 3.9 × 3.3 × 3 centimetre right pelvic lymphocyst, with internal septations and thick wall. Two attempts at percutaneous drainage were unsuccessful due to difficulty penetrating the cyst capsule and loculated interior.InterventionsLaparoscopic excision of pelvic lymphocyst was undertaken. Pneumoperitoneum was maintained at a pressure of 12mmHG throughout. The pelvic peritoneum overlying the lymphocyst was opened and plane developed using a combination of monopolar, bipolar and advanced energy devices. The ureter and iliac vessels were systematically identified to avoid inadvertent injury; and avascular pelvic spaces developed to aid cleavage of the capsule with minimal blood loss.Measurements and Main ResultsNo intra or post-operative complications occurred. Histopathology confirmed a benign lymphocyst. At post-operative review, the patient reported resolution of pain and improved mobility.ConclusionThis video demonstrates a safe laparoscopic approach to excision of a densely adherent pelvic lymphocyst, abutting important pelvic structures – facilitated by the step-wise identification of pelvic anatomy and relevant pelvic spaces.

S1543 Flank Pain: A Common Presentation of a Rare Disease

INTRODUCTION: Lymphangiomas are benign lesions believed to arise from malformations of sequestered lymphatic tissue. Less than 1% occur intraabdominally, and of these, only 0.8-1% arise from the gallbladder. Most arise in children less than five years old, but they often go unrecognized until adulthood when masses enlarge to cause symptoms. CASE DESCRIPTION/METHODS: A 28-year-old female with history of recurrent urinary tract infections (UTIs) presented to the hospital with three days of worsening right flank pain, polyuria, nausea, vomiting and chills. Exam noted costovertebral angle tenderness. Urinalysis was positive for >50 white blood cells, leukocyte esterase, and nitrite. Comprehensive metabolic panel, acute hepatitis panel, and pancreatic enzymes were normal. The patient was given ceftriaxone and discharged on cefdinir for treatment of acute pyelonephritis. Her polyuria improved, but she continued to experience nausea, vomiting, chills, right flank pain and developed a new right upper quadrant pain. CT scan of the abdomen revealed a decompressed gallbladder with significant wall edema. Abdominal ultrasound noted large multiloculated fluid collection in the gallbladder fossa (Figure 1). MRCP found marked thickening of the gallbladder wall and fluid signal with internal septations (Figure 2). The findings were consistent with gallbladder lymphangioma. Laparoscopic cholecystectomy was performed uneventfully. Intra-operatively, a lobulated cystic structure was noted in the gallbladder fossa (Figure 3). Pathology confirmed gallbladder lymphangioma. She had an uneventful post-operative course and was discharged home. DISCUSSION: Lymphangiomas are rare benign tumors with variable clinical presentations ranging from asymptomatic to nonspecific symptoms such as nausea, vomiting, and abdominal discomfort. Until recently, it was difficult to diagnose without pathology, but this paradigm has changed with advanced imaging such as MRI/MRCP which can depict the location of the mass relative to the gallbladder. Complete surgical resection is the standard of care, as unperturbed growth can cause disruption of surrounding structures and vessels. Our case highlights a common presentation of a rare entity. The presence of a more common co-existing diagnosis of UTI added to the difficulty in detecting her rare pathology. This emphasizes the import of maintaining a broad differential diagnosis, especially when symptoms do not resolve with standard care.Figure 1.: Grayscale and color doppler sonographic imaging of the gallbladder shows multiloculated cystic mass with mild hyperemia along the contracted gallbladder wall.Figure 2.: Axial T2-weighted magnetic resonance imaging shows high-signal-intensity gallbladder wall edema (red asterick) with low-intensity signal internal septations and lobulated irregular mucosa (yellow arrow).Figure 3.: Gross appearance of lobulated cystic structure (green arrow) near gallbladder fossa on laparoscopy.