Intramuscular Nodules Research Articles

Diagnosis and Treatment of Vesico-Peritoneal Fistula after Robotic Surgical Treatment of Deep Endometriosis

<h3>Study Objective</h3> Demonstrate the diagnosis and surgical treatment of vesico-peritoneal fistula after robotic surgical treatment of deep endometriosis. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient is placed in the semi-gynecological position on both surgical approaches. <h3>Patients or Participants</h3> A 38-year-old woman reports right iliac fossa pain, dysuria, and deep dyspareunia for 4 years. A 3 cm hard and painful nodule was palpable in the right iliac region of abdominal wall. MRI shows a 3.0 × 1.4 × 1.3 cm retrocervical lesion and irregular thickening of the uterosacral ligament insertion, suggestive of deep endometriosis. A 2.7 cm endometrioma on left ovary. And a 6 × 3 × 1.5 cm intramuscular nodule on the inferior abdominal aspect that affects virtually the entire muscle thickness. <h3>Interventions</h3> Robotic-assisted laparoscopic resection of pelvic endometriosis and abdominal wall nodules, with abdominal mesh placement. On the 7th postoperative day, the patient developed acute abdominal pain due to abdominal wall abscess and bladder catheter mechanical obstruction. Collection drainage was US-guided, but patient kept having recurrent urinary tract infections. CT showed a fistulous path communicating the bladder dome and the extraperitoneal space, and cystoscopy confirmed the fistula. Robotic-assisted laparoscopy was performed, Retzius space was developed for better exposure of the bladder and fistulous tract, with subsequent resection of the fistula and partial cystectomy with resection of the necrotic segment and part of synthetic mesh. <h3>Measurements and Main Results</h3> We obtained efficient diagnosis and treatment. The patient had complete resolution of the symptoms. <h3>Conclusion</h3> Vesico peritoneal fistula is a rare entity of epithelialized communication between peritoneal cavity and bladder, and it is usually associated with postoperative complications. As it has no specific symptoms, diagnosis is difficult.

Cytomorphological spectrum of cysticercosis: A study of 26 cases.

Cysticercosis is a systemic parasitic disease caused by the larval stage of Taeniasolium. It is the most common parasitic disease worldwide. Fine needle aspiration cytology can play an important role in prompt recognition of this disease. To study the role of FNAC in the diagnosis of cysticercosis. This study included 26 patients with parasitic infestation who presented with palpable subcutaneous and intramuscular nodules at different sites. Their clinical presentations and fine needle aspiration cytomorphological features are reported. The age range of these patients was 7-60years. The majority were males. The most commonly affected site was head and neck followed by upper extremity. Most of the cases were clinically misdiagnosed as lipomas, neurofibromas, lymphadenitis, epidermal inclusion cyst, sialadenitis, and soft tissue tumours. The aspirate was clear fluid in the majority of cases. All of the cases revealed fragments of bladder wall with associated granulomas in seven cases and giant cells in four cases. However, none of the case revealed hooklets. Fine needle aspiration cytology can provide a simple, minimally invasive, low-cost, outpatient diagnostic technique for the diagnosis of cysticercosis, as cytological diagnosis is quite clear when the actual parasitic structures are identified in the smear.

Abdominal wall endometriosis: Is structure in imaging related to nodule localisation? A retrospective study

Objective:Investigate the relationship between the structure of abdominal wall endometriotic nodules in MRI and their localisation in abdominal wall layers in order to better understand nodule origins.Design:Women who had an MRI prior to surgical treatment of an abdominal wall endometriotic nodule between 2005 and 2016.Population:Thirty-six patients including four patients with two nodules.Methods:MRI images were reviewed. Each nodule was analysed according to its structure (fibrous, cystic, mixed), localisation (subcutaneous fat, intra muscular, intermediary position), and size.Results:Forty nodules were analysed in MRI with no relationship found between localisation and nodule structure ( p = 0.48). 87.5% of mixed nodules were revealed to have a cystic superficial rim extending towards the subcutaneous fat layer. This finding suggests that the glandular part of the nodule is the active part of the disease from which nodule progression occurs. Intermediary and intramuscular nodules were respectively statistically larger than subcutaneous fat nodules indicating a relationship between nodule size and localisation (35 mm (22–53) vs 17 mm (17–23)) ( p = 0.03).Conclusion:Despite differences in environments surrounding the nodules, no significant relationship between nodule structure in imaging and abdominal wall localisation was found. Data from mixed nodules indicate however the possible role of nodule environment on structure and that the mechanism of nodule growth may be linked to development of cystic superficial rims, at the forefront of disease progression, abdominal wall nodules growing from deep to superficial. Studies are required to further investigate our findings and enable greater understanding of the origins of AWE.

Fine Needle Aspiration Cytology of Cysticercosis: A Study of 30 Cases.

Cysticercosis is a systemic parasitic disease caused by larval stage of Taenia solium. It is the most common parasitic disease worldwide. It is potentially a dangerous systemic disease with variable clinical manifestations. It can be diagnosed by radiological imaging and serology but demonstration of parasitic larva by cytology or histopathology is still the gold standard. Fine needle aspiration cytology (FNAC) plays an important role in prompt diagnosis of this disease.Aim:To study the role of FNAC in the diagnosis of cysticercosis.Materials and Methods:This study included 30 patients presenting with palpable subcutaneous and intramuscular nodules at different sites. Fine needle aspiration was performed on these lesions and cytological features were analyzed. Subsequent excision biopsy was evaluated wherever possible.Results:Thirty patients in the age group of 7–80 years presenting with subcutaneous and intramuscular nodules at various sites were studied. Majority of the patients were males. The most commonly affected sites were upper and lower extremities and abdominal wall. Most of the cases were clinically misdiagnosed as lipomas, neurofibromas, lymphadenitis, epidermal inclusion cyst, sialadenitis, and soft tissue tumors. On cytological examination of aspirate from the lesions, fragments of parasite were seen in a background of mixed inflammatory cell infiltrate. Histopathological correlation was available in 17 cases.Conclusion:FNAC is a simple, sensitive, cost-effective, and rapid diagnostic tool for diagnosis of cysticercosis as cytological diagnosis is quite clear where the actual parasitic structures are identified in the smear.

Spontaneous Resolution of Idiopathic Panniculitis: Role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Diagnosis and follow-up.

We present the case of a-55-year-old female patient who presented with dry cough. High-resolution computed tomography chest revealed multiple nodules in both lungs. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) was done to look for the unknown primary. It showed hypermetabolic bilateral lung nodules, subcutaneous nodules involving lower limbs, an intramuscular nodule, enlarged paratracheal, and right axillary nodes. There was no primary tumor seen. The biopsy of subcutaneous nodule revealed panniculitis with the foreign body granuloma. Follow-up scans after 6 and 9 months showed spontaneous resolution of all lesions except for few right axillary nodes. There was no active treatment given, and the patient remains asymptomatic on follow-up. Here, PET/CT played a role in excluding a primary tumor, guiding the biopsy, and follow-up.

IMAGING DIAGNOSIS-ULTRASONOGRAPHIC APPEARANCE OF SKELETAL MUSCLE METASTASES IN A DOG WITH HEMANGIOSARCOMA.

A 13-year-old spayed female German shepherd dog was presented for acute onset of lethargy, anorexia, and disseminated erythematous skin lesions. Thoracic radiographs and abdominal ultrasonographic findings were consistent with metastatic hemangiosarcoma. Multiple, ill-defined, irregularly shaped hypoechoic nodules were also detected within the thoracic and abdominal wall. Hemangiosarcoma metastases to the skeletal muscle were confirmed based on histopathological examination. Multivisceral involvement was also confirmed by necropsy. Metastatic neoplasia should be considered as a differential diagnosis for dogs with ill-defined, irregular, hypoechoic, intramuscular nodules.

Cysticercosis presented with nodules diagnosed on fine-needle aspiration cytology

Cysticercosis is a parasitic disease caused by the larval form of the cestode worm Taenia solium. It is commonly manifested as subcutaneous, intramuscular, eye, or brain nodules. We report two cases in an 8-year-old male child who presented with a cheek nodule, and another in a 25-year-old man who presented with a flank swelling. Both cases were diagnosed by fine-needle aspiration cytology. The use of fine-needle aspiration cytology highlights the cytomorphological diagnosis of cysticercosis in subcutaneous and intramuscular nodules.

Fine-needle aspiration cytology of subcutaneous cysticercosis: A series of five cases

Taenia solium, a potentially dangerous parasite, causes human cysticercosis that can cause a gamut of manifestations affecting the various systems of the body. Sometimes, parasitic infestations present as only superficial palpable subcutaneous or intramuscular nodules that are usually mistaken for lymph nodes or benign tumors like lipoma, neurofibroma, or epidermal inclusion cysts. Fine-needle aspiration cytology (FNAC) has emerged as a useful tool in the diagnosis of these superficial parasitic lesions. It also helps in avoiding unnecessary open biopsy to obtain a diagnosis. We, herein, report a series of five cases of subcutaneous cysticercosis at different sites (axilla, chest wall, abdominal wall, lateral neck, and cheek) misdiagnosed as lipomas and lymph nodes and finally diagnosed on FNAC.

Fine needle aspiration cytology of subcutaneous cysticercosis: a study of 16 cases

Background: Cysticercosis is an important parasitic infection more prevalent in developing countries. Fine needle aspiration cytology (FNAC) is an easy, low cost and fairly accurate method in diagnosing the disease. The main objective is to study the clinico-cytological profile of patients diagnosed with cysticercosis cellulosae. Methods: The present study was descriptive observational cross sectional study done over a period of four years during which FNAC was done in patients presenting with subcutaneous and intramuscular nodules at various sites. After detailed clinical history and clinical examination, the character of aspirate was noted. In each case, three alcohol fixed smears were prepared, first smear was stained with Papanicolaou stain, second with Giemsa stain and third one was kept unstained for any further required stain. Subsequent excision biopsy was also performed in patients suspected to have cysticercosis. Results: A total of 16 cases of cysticercosis were diagnosed on FNAC and subsequently confirmed by excision biopsy over a four year period. Out of the 16 cases 11 (68.7%) were females and 5 (31.3%) were males. The mean age at diagnosis was 24 years. Most common site of involvement was upper extremity followed by neck. In most cases provisional clinical diagnosis was lipoma. In 10 cases out of 16 cases, actual parasitic structures were demonstrated. Only one case showed presence of hooklet. 5 cases showed presence of only acellular granular material with no parasite. The background population in most of the cases were predominantly eosinophils, lymphocytes, neutrophils with multinucleated giant cells in some cases. Conclusions: The high accuracy coupled with low cost and quick results make FNAC an important outpatient procedure for diagnosis of cysticercosis. In any soft tissue nodular swelling, possibility of cysticercosis must be kept in mind, especially in endemic areas.

A cytological study of palpable superficial nodules of parasitic origin: a study of 41 cases.

Background. Few parasitic infestations present as only superficial palpable subcutaneous or intramuscular nodule. The current study highlights the role of FNAC in the diagnosis of superficial palpable parasitic lesions. Methods. This was a retrospective study in which we reviewed the FNAC record of all patients over a period of two years from September 2011 to August 2013. During this period, FNA was performed on 5954 cases which presented as superficial palpable lump at various sites of body. There were 41 cases diagnosed as parasitic lesion or suspicious of parasitic lesion on cytology which were included in the study. Results. In the present study, most of the patients were children and young adults. The lesions were located over trunk in 18 (43.9%) cases, extremities in 12 (29.3%) cases, and head and neck region in 11 (26.8%) cases. Out of 41 cases, 27 (65.8%) cases were confirmed on cytology and/or histopathology as parasitic lesions, including 21 (51.2%) cases of cysticercosis, 5 (12.2%) cases of filariasis, and one (2.4%) case of hydatid cyst. Cytological findings of remaining cases were suggestive of parasitic lesion. Conclusion. Careful assessment of cytological material is helpful to detect parasite or inflammatory response to parasite even in asymptomatic patients.

Principles of biopsy in suspected lung cancer: priority still based on invasion in the era of targeted therapy?

There are multiple ways to obtain a biopsy for patients with suspected lung cancer under clinical circumstances. Diagnostic goals described previously in literature should be achieved preferably by using the safest, least invasive, and least costly biopsies. Insight into molecular profile and era of targeted therapy challenged the previous concepts on tumor biopsy. Distinct principles of biopsy should be revisited to adopt the advances in clinical research. A 53-year-old gentleman with 10-year history of dust exposure consulted to our hospital because of bloody sputum. PET/CT scanning revealed a 3.2-centimeter mass with an increased (18)F-FDG uptake in right upper lung lobe, metabolically active lesions in multiple stations of mediastinal or bilateral hilar lymph nodes and an intramuscular nodule in the left gluteus maximus. He underwent transthoracic core needle biopsy of the lung mass, resection of intramuscular nodule, bronchoscopy and right upper lung lobectomy in sequence. The final diagnosis was considered as systemic lipid deposition. Principles of biopsy in suspected lung cancer should be prioritized in sequence based on weight in clinical management, acquisition of tissue, invasion, efficiency and cost.

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma: characterization of five cases

To describe the imaging and histopathology of pseudomyogenic hemangioendothelioma. Five cases of pseudomyogenic hemangioendothelioma, which presented over the last 5 years, were retrieved from the files of the Royal National Orthopaedic Hospital. The imaging and histopathology were reviewed in all cases. Magnetic resonance imaging, which was available from all cases, was assessed for the following features: the number of lesions, location in soft tissue (superficial and or deep/subfascial) and bone, and the signal characteristics and morphology of individual lesions. Immunohistochemistry was performed in all cases to characterize the lesions. Four of the five patients had multiple lesions involving a single limb. Bone was involved in 3 of the 5 individuals. All tumors diffusely expressed ERG and cytokeratins AE1/3, but not MNF116. CD31 was weakly positive in 4 cases. INI-1 expression was retained in all cases. Imaging features included ill-defined, infiltrative lesions in subcutaneous fat with extension to the adjacent skin, poor- to well-defined intramuscular nodules and predominantly intracortical focal bone lesions with rare medullary involvement. Pseudomyogenic hemangioendothelioma represents a distinct recently characterized tumor type presenting in young adults, with a tendency towards multicentric bone and soft tissue involvement.

Fine Needle Aspiration Cytology of Cysticercosis

Sir Cysticercosis is an infection of the larvae of Taenia solium and it is endemic in Latin and Southern America, Africa, and rural areas of eastern Europe and Asia. In India, it is common in northern parts, with variable clinical manifestations depending on the sites of involvement and most common sites involved are subcutaneous and muscle tissues, followed by the eye and brain [1]. Humans are considered as incidental hosts or accidental hosts, as they can be infected either by drinking contaminated water of by eating uncooked vegetables infected with eggs [1]. Gill et al., concluded that FNAC in cysticercosis was a low-cost outpatient procedure with rapid and definitive diagnosis. FNAC is helpful in identifying the parasite and its structure; however, sometimes, the presence of eosinophils, histiocytes in palisading clusters or singly, along with typical granular dirty background, provide a clue to suspicion of parasitic infestation [2]. A 27-year-old female patient presented with a swelling on the right arm, of three weeks duration. The swelling was subcutaneous, soft, non tender and it measured 2.5 × 2 cm in size. A clinical diagnosis of lipoma was made. FNAC was done using 22 G needle, which yielded clear fluidy aspirate. The smears were air dried as well as wet fixed in 95% ethyl alcohol and stained with Giemsa and haematoxylin and eosin stain. Smears showed fragments of fibrillary bluish material with interspersed small nuclei and at places, they showed a honeycomb appearance. The background comprised of mixed inflammatory cells infiltrate consisting of neutrophils, eosinophils, lymphocytes, and histiocytes surrounding the fibrillary material, along with granulomas [Table/Fig-1a,​,bb,​,cc,​,d].d]. A final diagnosis of subcutaneous cysticercosis was made. [Table/Fig-1a]: Bladder wall of Cysticercus (Giemsa x100) [Table/Fig-1b]: Wall of Cysticercus with surrounding mixed inflammatory infiltrate and epithelioid cell granuloma (Inset). (Giemsa x100) [Table/Fig-1c]: Fibrillary stroma with interspersed small variable shaped oval nuclei (H&E x100) [Table/Fig-1d]: Fibrillary stroma with interspersed small oval nuclei and honeycomb appearance. (Giemsa x400) The diagnostic role of FNAC in cysticercosis was first described in 1989 by Kung et al.,[3]. FNAC is a widely acceptable method and aspiration of clear fluid is a strong indicator of a parasitic infection in a palpable subcutaneous or intramuscular nodule, which provides a clue for the diagnosis of cysticercosis [4]. The possibility of cysticercosis should be kept in during assessment of all inflammatory and cystic swellings [2]. FNAC smears showing mixed inflammatory cells infiltrate along with giant cells in varying proportions should be viewed with high index of suspicion, as smears of parasitic origin, even in the absence of identifiable parasitic fragments and aspirated fluid, should be processed completely and should not be discarded as nonspecific [5]. A diagnosis of cysticercosis is vital, as it calls for a diligent search for the parasite in vital organs, where it causes significant morbidity and can even prove to be fatal [5].

Cytomorphological spectrum of subcutaneous and intramuscular cysticercosis: A study of 22 cases

Background:Cysticercosis is more common than usually thought. Fine needle aspiration cytology (FNAC) plays an important role in prompt recognition of this disease.Aims:To study the role of FNAC in the diagnosis of cysticercosis.Materials and Methods:Twenty-two patients with subcutaneous and intramuscular nodules, who were clinically diagnosed as tuberculous lymphadenitis, reactive lymphadenitis, lipoma, neurofibroma and cysticercosis were included in the present study.Results:In nine cases, a definitive diagnosis of cysticercosis was obtained in the form of fragments of parasite bladder wall and, biopsy confirmed the diagnosis. In the rest 13 cases, larval fragments could not be identified on the aspirates and the diagnosis of parasitic inflammation was suggested on the basis of other cytomorphological findings. Follow-up biopsy confirmed the diagnosis of cysticercosis.Conclusions:FNAC in cysticercosis is a low-cost outpatient procedure. The cytological diagnosis is quite straightforward in cases where the actual parasite structure is identified in the smears. However, in other cases, presence of eosinophils, histiocytes which may be in palisaded clusters or not, a typical granular dirty background, etc., are the features which should always alert the pathologist to this possibility.

Cysticerci in Palpable Nodules Diagnosed on Fine Needle Aspiration Cytology

Cysticercosis is the larval manifestation of the cestode T. solium. It commonly presents as subcutaneous and intramuscular nodules which is often clinically misinterpreted as benign mesenchymal lesions and lymph nodes. Cysticerci in subcutaneous nodules can be diagnosed rapidly and with considerable accuracy by FNAC. This study highlights the cytomorphological features of subcutaneous cysticercosis diagnosed by FNAC. Forty three patients with palpable nodules diagnosed as cysticercosis or suspected as cysticercosis by FNAC between August 2005 to July 2008 were included in the study. Excision biopsy was done in 12 cases where definitive evidence of parasite was not found. Solitary nodules were present in 36 (83%) patients and multiple nodules were present in seven (17%). In 31 cases (72.09%) definite evidence of cysticercus was found. In 12 cases (27.9%) a suggestion of parasitic inflammation was made based on other cytomorphological features which was confirmed by biopsy in eight cases. Human cysticercosis commonly presents as subcutaneous nodules which can be diagnosed with considerable accuracy by FNAC. Definite evidence and suggestion of parasitic inflammation on cytology obviates the need for subsequent histopathological examination.

Fine needle aspiration in the diagnosis of subcutaneous cysticercosis

Human cysticercosis commonly manifests as subcutaneous and intramuscular nodules. The current study highlights the role of fine needle aspiration cytology (FNAC) in the diagnosis of subcutaneous cysticercosis. One hundred and twenty two patients with subcutaneous swellings, diagnosed as cysticercus or suspicious of parasitic inflammation on FNAC, were included in the present study. The relevant clinical data, cytomorphological findings, and histopathological findings, wherever available were evaluated. In 57 cases, a definite evidence of cysticercus was obtained in the form of fragments of parasite bladder wall, hooklets, or intact larva. Out of these, biopsy correlation was available in 10 cases, eight of which failed to reveal any parasite. In 65 cases, larval fragments could not be identified on aspirates, and the diagnosis of parasitic inflammation was suggested on the basis of other cytomorphological findings, which are discussed. In 22 of these cases, a biopsy correlation was available, which revealed definite parasitic elements in six cases and the remaining 16 cases were reported as suggestive of parasitic cysts. Thus, to conclude, FNAC is a reliable and cost effective procedure for the diagnosis of subcutaneous parasitic nodules. It obviates the need for a subsequent histopathological examination, as the parasite may not be demonstrated even on biopsy specimens.

筋肉内腫りゅう型サルコイドーシスの１例

A 55-year-old woman first noticed palpable nodules in the left lower extremity. Two months later, she noticed another nodule on the other side and visited our hospital.On physical examination, she had scatterd intramuscular nodules without pain or muscle atrophy.MR imaging showed multiple nodules in the involved muscles. These structures were typical stripe sign with high signal on T1 and T2 weighted images at the peripheral portion, and low signal on all the sequence at the central structure. High uptake nodules were detected on Galium scintigraphy. Chest X ray did not show features of bilateral lymphadenopathy (BHL). Biopsy spicement of the palpable intramuscular nodule showed glanulomas composed of epitheliod cells without caseous necrosis. This was diagnosed as nodular muscular sarcoidosis. This case proved that MR imaging is very helpful for diagnosing muscular sarcoidosis from the pathological features of the nodules.

Intramuscular onchocercoma. Case report

Onchocerciasis is characterized by the presence of numerous microfilariae in the skin, formation of subcutaneous nodules and eye lesions that can lead to blindness. We present a case, rather uncommon in our environment, in which an incomplete life cycle of the parasite, led to a single intramuscular nodule. The clinical symptoms and histological features are described, together with the treatment, using Ivermectin.

An ultrastructural study of spontaneous cell death in a mouse mastocytoma with particular reference to dark cells.

The morphology and frequency of the various types of cell death occurring spontaneously in a mouse mastocytoma growing as intramuscular nodules were investigated. In addition to necrosis and apoptosis, which have been well documented in malignant neoplasms in the past, a third morphological pattern of cell death, the formation of dark cells, was observed. Necrosis first appeared in confluent patches about 5 days after tumour inoculation, and these increased in size as the tumours grew. Apoptosis, on the other hand, was present at all stages of tumour growth, and remained at a reasonably constant level. Dark cells were first observed at about 6 days, and increased in numbers thereafter. Dark cells were characterised by overall cellular condensation and gross swelling of mitochondria. Their cytoplasm became squeezed out between adjacent cells and then fragmented. Remnants of dark cells were eventually phagocytosed and degraded by macrophages. The distribution of dark cells in the tumours suggested that crowding and compression may contribute to their development.