Left-sided Chest Research Articles

MANAGEMENT OF A CASE OF BREATHLESSNESS IN EMERGENCY ROOM - A CASE REPORT

In a busy emergency room many patients are coming with breathlessness because of a variety of aetiology including respiratory system, cardiovascular system, central nervous system, metabolic, trauma, foreign body in airway etc. Nearly most of them can be managed in emergency room with rationale approach, but some cases require further approach with advanced investigation and further workup to stabilise the patient. In this case report, we are mentioning in detail about management of a case of breathlessness presented to our emergency room with breathlessness, decreased chest expansion on left side of chest and decreased air entry on base of left lower chest required intercostal drainage and diagnosed having malignant hilar mass. After stabilisation he was sent to oncology department for further management.

481 Mass compromising left atrium

Abstract A 47-year-old woman presented to the ER with a sudden-onset left side chest pain of less than one hour in duration that started at rest. The pain was severe and radiated to the left shoulder. This was accompanied with symptoms of shortness of breath and sweating but no similar episodes in the past. There was no significant history of coronary artery disease or any other illness in the family. She had dyslipidemia and a smoking habit of 1 pack/day for the previous 10years. In the ERt, she was hemodynamically stable and her physical examination was within normal limits. ECG showed ST-segment elevation in the inferior leads. No prior ECG was available for comparison. She underwent emergent PCI which showed spontaneous proximal segment circumflex (dominant) artery dissection with TIMI angiographic flow grade 0. All other coronaries were patent with TIMI III flow and no atherosclerotic changes. PCI was carried out, but unfortunately, it was complicated with coronary rupture having to implant a drug eluting stent in order to seal the vessel rupture, with optimal final result (TIMI 3). An urgent TTE was performed for evaluation of the patient due to persistence of chest pain after coronariography, revealing an echogenic mass at the left atrium suggesting extracardiac hematoma vs. left atrium dissection. TC scan confirmed space compromise of the left atrium by a mass, without being able to rule out active bleeding. The patient was transferred to our center for emergent CABG surgery. Upon arrival, the patient had persistent chest pain, sinus tachycardia, and hypertension. Intraoperative TOE findings consisted of a mass compromising left atrium and minimal pericardium effusion. Comprehensive study identified a mobile intimal flap of the atrial wall that was creating a false chamber. Intraoperative surgery findings were compatible with a huge left atrial desiccant hematoma . Two orifices were performed on the epicardium of the inferior and lateral border of the left atrium, in order to drain the retained blood and lavage. No active bleeding was evidenced. TTE control evidenced disappearance of the left atrium mass a The patient had a satisfactory evolution and discharged without complications. Even though left atrial desiccant hematoma is a rare STEMI complication , in this patient, we concluded the etiology was iatrogenic due to the performance of PCI. Conclusion Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. Its diagnosis requires a high index of suspicion. Predisposing factors and catheterization, surgical or pathologic findings should be reviewed in order to identify the pathogenic mechanism . Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, blunt chest trauma and iatrogenic PCI are related to its development. Abstract 481 Figure. MASS COMPROMISIN LEFT ATRIUM

Larrey diaphragmatic hernia in an adult

Introduction. Larrey hernia is a very rare type of the left sided parasternal congenital hernia with the incidence of 1?3% of all anterior diaphragmatic hernias. Case report. The paper describes Larrey congenital diaphragmatic hernia in an adult female patient, aged 70 years. Seventeen years earlier, the patient had had problems with intermittent left side chest pain, hypertension, dyspnea, shortness of breath, fatigue, and abdominal discomfort. She had no past surgical history, and no traumatic rupture of the diaphragm. An open surgical repair was conducted, reducing the herniated organs back into the abdominal cavity, and closing the diaphragmatic defect, repaired with a non-absorbable suture. During the immediate postoperative period, as well as six months later, the patient had a remarkable postoperative recovery. Conclusion. Larrey hernia represents an extremely rare kind of the anterior diaphragm hernias, which can be symptomatically manifested in older persons over 65 years of age. The treatment in the cases of asymptomatic and symptomatic Larrey hernias is a surgical intervention.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women's Chest Pain Registry.

Background/AimsChest pain in patients with obstructive coronary artery disease (OCAD) is affected by several social factors. The gender-based differences in chest pain among Koreans have yet to be investigated.MethodsThe study consecutively enrolled 1,549 patients (male/female, 514/1,035; 61 ± 11 years old) with suspected angina. The predictive factors for OCAD based on gender were evaluated.ResultsMen experienced more squeezing type pain on the left side of chest, while women demonstrated more dull quality pain in the retrosternal and epigastric area. After adjustment for risk factors, pain in the retrosternal area (odds ratio [OR], 1.491; 95% confidence interval [CI], 1.178 to 1.887) and aggravation by exercise (OR, 2.235; 95% CI, 1.745 to 2.861) were positively associated with OCAD. In men, shorter duration (OR, 1.581; 95% CI, 1.086 to 2.303) and dyspnea (OR, 1.610; 95% CI, 1.040 to 2.490) increased the probability for OCAD, while left-sided chest pain suggested a low probability for OCAD (OR, 0.590; 95% CI, 0.388 to 0.897). In women, aggravation by emotional stress (OR, 0.348; 95% CI, 0.162 to 0.746) and dizziness (OR, 0.457; 95% CI, 0.246 to 0.849) decreased the probability for OCAD.ConclusionsThis is the first study to focus on gender differences in chest pain among Koreans with angina. Symptoms with high probability for OCAD were different between sexes. Our findings suggest that patient’s medical history in pretest assessment for OCAD should be individualized considering gender.

Repeated Thrombolytic Treatment for Recurrent Pulmonary Thromboembolism: A Report of 2 Cases and a Literature Review.

We present 2 cases of pulmonary thromboembolism (PTE). The first case, a 50-year-old man, was admitted to the emergency department because of sudden onset dyspnea and left side chest pain. He was diagnosed with intermediate-risk (submassive) PTE, and thrombolytic treatment was commenced. The patient fully recovered, but 5 days later, he was diagnosed with a new, high-risk PTE. The second patient, a 23-year-old woman, presented with syncope, dyspnea, and chest pain for 2 days. She was diagnosed with high-risk (massive) PTE. Thrombolytic treatment was commenced, and the patient fully recovered, too. But the later patient was also diagnosed with a new PTE 4 days later. We applied repeated thrombolytic treatment in the patients due to repeated PTE. The first patient fully recovered and was discharged from the hospital, but the second patient died because of gastrointestinal bleeding and renal insufficiency. A repeated thrombolytic treatment could be an alternative treatment for these patients, considering treatment's risks.

First Case of an Accidental Penetrating Chest Wall Vascular Trauma by a Sikh Ceremonial Dagger

A 21-year-old male Sikh presented with accidental penetrating injury to left side of chest by his dagger (Kirpan). He sustained a large hematoma along the left lateral chest wall. On post contrast arterial phase, a focal contrast blush was seen within the large hematoma suggestive of active bleeding into the hematoma from a branch of axillary artery. We performed CT-guided surface marking of the site of bleeding vessel on the chest wall and centered our incision on the mark. Emergency surgery to remove the large clots and repair the bleeding artery was performed. This case can raise awareness about the possible cause of thoracic injury in Sikh patients carrying the dagger and the utility of CT-guided surface marking to localize the bleeding point in a huge hematoma.

Autobullectomy: A rare case of spontaneous resolution of infected giant bullae

Introduction: Bullous lung disease is a common presentation in patients with chronic obstructive pulmonary disease (COPD). The giant pulmonary bulla occupies one third of involved hemithorax and characterized by the existence of centrilobular emphysema in non bullous lung. Sometimes air reabsorbs spontaneously leading to shrinkage and regression of bulla known as autobullectomy. Mechanism of autobullectomy remains unclear. Here, we report a patient with infected bulla who experienced complete resolution after antifungal treatment. Case History: A 63 year old mal with history of twenty pack years of tobacco smoking came to the pulmonary outpatient department with complains of left side chest pain, cough with mild expectoration and low grade fever since five days. Patient also had blood tinged sputum since three days. His chest X-Ray PA view showed a thin walled cavity with air fluid level on the left upper zone with a few calcified parenchymal foci. Patient had symptomatic improvement after two weeks of antifungal treatment. Repeat skiagram chest and CECT chest showed complete resolution of bulla. Discussion: There are two hypotheses which can explain occurrence of bulla: Conclusion: Spontaneous resolution of giant bulla also known as autobullectomy is an ignorant event and follows an infection trigger. The early suspicion and diagnosis by the treating physician can avert the need for a surgical bullectomy in these patients and decline the morbidity and mortality. Our case is of interest not only because of the rarity with which spontaneous regression has been reported in the literature but also because the source of infection was fungal.

ISOLATED CONGENITAL ABSENCE OF THE LEFT PULMONARY ARTERY WITH LUNG HYPOPLASIA

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Unilateral absence of the pulmonary artery (UAPA) is a rare congenital defect with significant physiologic sequelae. Here, we describe a patient presenting with congenital isolated left-sided UAPA. CASE PRESENTATION: A 27-year-old African male presented with six weeks of flu-like symptoms. He was born in Sierra Leone and immigrated to the United States at age 17. To evaluate his persistent cough and left side chest discomfort, a chest x-ray was obtained, showing significant opacification of the left hemithorax with left pneumothorax initially concerning for necrotizing pneumonia. He was placed on broad spectrum IV antibiotics and admitted. A follow-up computerized tomography of the chest found significant hypoplasia of the left lung with changes consistent with chronic infection, a significantly hypoplastic left pulmonary artery (PA), and hyperexpanded right lung. An echocardiogram found the right PA to be 1.8 cm in diameter compared to the left PA at 1.1 cm. His antibiotic regimen was changed to Augmentin to cover community-acquired pneumonia and he was discharged with plan to follow up with Cardiothoracic Surgery. DISCUSSION: UAPA is a rare condition that typically presents with associated congenital heart defects. Isolated presentation is even rarer, especially on the left side. During embryogenesis, the extrapulmonary PAs arise from the sixth aortic arch. Improper development, possibly due to persistence of a ductus arteriosus, leads to agenesis of the ipsilateral PA. While revascularization from collateral circulation arising from other arteries is possible, typically, inadequate blood flow to the ipsilateral lung during fetal development leads to hypoplasia of the lung.A UAPA essentially cuts pulmonary circulation in half, resulting in a diversion of cardiac output to the remaining PA. Studies in pigs have shown medial hypertrophy of the larger PAs in the unaffected lung and increased muscularity of the smaller arteries. Pulmonary hypertension developed in 44% of all patients with associated right ventricular hypertrophy. This can ultimately lead to right heart failure and eventually death.While many present in infancy, it is not uncommon for patients to remain asymptomatic until adulthood, when they may present with dyspnea on exertion, hemoptysis, or recurrent pulmonary infections. Patients often have a hypertrophied contralateral lung to compensate for the hypoplastic affected lung, leading to a mediastinal shift towards the affected lung. Despite this compensation, patients often have decreased pulmonary function. CONCLUSIONS: Isolated left UAPA results in left lung hypoplasia secondary to lack of blood flow during development. The diversion of cardiac output through the remaining PA may result in pulmonary hypertension and right-side heart failure. Pulmonary function is usually decreased despite contralateral lung compensation. Reference #1: Steiropoulos P. Unilateral pulmonary artery agenesis: a case series. Hippokratia. 2013;17(1):73–6. Reference #2: ADJ TH, NA B, Ottenkamp J. Isolated unilateral absence of a pulmonary artery: a case report and review of the literature. Chest. 2002;122(4):1471–7. Reference #3: Kruzliak P, Syamasundar RP, Novak M, Pechanova O, Kovacova G. Unilateral absence of pulmonary artery: Pathophysiology, symptoms, diagnosis and current treatment. Arch Cardiovasc Dis. 2013;106:448–54. DISCLOSURES: My spouse/partner as a Employee relationship with SAS Please note: >$100000 Added 02/28/2018 by Audrey Hopping, source=Web Response, value=Salary No relevant relationships by Vikas Pathak, source=Web Response No relevant relationships by Christine Zhou, source=Web Response

Filarial pleural effusion without peripheral blood or pleural fluid eosinophilia

Lymphatic filariasis is a tropical parasitic disease and is endemic in India. It is present in various forms but its manifestation as pleural effusion is rare. Here, we describe a...

Risk of splenic injuryassociated with fracture of 9th, 10thand 11thribsin blunt trauma

Spleen is the intra abdominal organ most frequently injured in blunt trauma ,suspension of splenic injury should be raised in any patient with blunt trauma to the abdomen and lower left side of chest(blow,fall,or sport related injury.{3}This study was done in the emergency department (ED)in ALHussein teaching hospital (ALNassiria) during 2 years( between 15thmarch2007 to 14thfeberory 2009) 96patients [ 62malesand34females].Patients present as a trauma to the abdomen and/or lower chest. 74 of those patients have rupture spleen with fracture of left lower ribs proved by chest x-ray,abdominal US and C.T scan. To evaluate percentage of splenic injury associated with fracture of left lower ribs we did such study. About 54%of those patient get splenic injury associated withfracture of 3 lower ribs and 24% of patient get splenic injury associated with fracture of 9th&10thribs and about 11% associated with single rib fracture especially10th rib and about 11% have no splenicinjury although they have fracture ribs.Patient with fracture of lower 3 ribs have high risk of splenic injury about double risk from those who have 2lower rib fracture .and triple to those who have single rib fractureespecially 10th rib which regarded most effective rib in splenic injury ,and about 11% 0f patients have no association splenic injury even some of them with 3 ribs fracture.

Xanthogranulomatous pyelonephritis presenting as acute pleuritic chest pain: a case report

BackgroundXanthogranulomatous pyelonephritis is a rare and serious manifestation of chronic kidney inflammation that can be life-threatening if not recognized and treated appropriately, often with antibiotics and surgery. Affected patients are most commonly females in their fifth or sixth decade of life with a background of obstructive uropathy, nephrolithiasis, or recurrent urinary tract infections who present with vague nonspecific symptoms.Case presentationA 43-year-old woman of Russian ethnicity with a history of nephrolithiasis presented to our emergency department with new left-sided pleuritic chest pain amid a 6-week history of constitutional symptoms including fevers, night sweats, and 7 kg of weight loss. Workup for acute coronary syndrome and pulmonary embolism in our emergency department was negative. Given that she was clinically unwell, she was admitted to internal medicine to expedite workup for the cause of her symptoms. A broad differential diagnosis for various infectious, inflammatory/autoimmune, and neoplastic processes was considered. Based on classic radiographic and histopathologic findings, she was ultimately diagnosed with xanthogranulomatous pyelonephritis of her left kidney, which was a direct consequence of chronic inflammation. This inflammation exhibited spread to local tissues and across her left hemidiaphragm, resulting in a unilateral pleural effusion which explained her chest discomfort. She was treated with antibiotics administered intravenously and urgent total nephrectomy with a good functional outcome.ConclusionsOur case illustrates an uncommon but clinically important do-not-miss diagnosis that underlies a common clinical presentation of pleuritic chest pain. The case underscores the importance of maintaining a broad differential diagnosis and organized approach when treating patients with undifferentiated clinical presentations.

Chest Injury in a Soccer Player

HISTORY: A 24 year-old female collegiate soccer player presented 3 days after a collision injury. While playing soccer she was struck on the left side of chest by a male soccer player. Witnesses nearby told her they heard a pop at the time of collision. Since the game, she had been wrapping her chest with an ACE wrap and taking Tylenol 1000mg twice daily with mild relief. She denied hemoptysis but had some left sided chest tightness with walking about 100 feet. She complained of pain with deep inspiration and difficulty sleeping. She felt her pain was improving until she lifted her 2 year-old niece 1 day prior to presentation, when it acutely worsened. PHYSICAL EXAM: Examination in the clinic. Vital signs: Pulse 84 Blood pressure 110/80. Oxygen saturation was 98% on room air and with brisk walking. Trachea midline, jugular veins non-distended. Tenderness to palpation over ribs 4–6 in the mid-axillary line without ecchymosis or step-off appreciated. Normal respiratory effort. On auscultation, there were diminished breath sounds at the left apex. Pain noted with deep inspiration. Abdomen without obvious deformity or ecchymosis, nontender, normal bowel sounds, no hepatosplenomegaly. DIFFERENTIAL DIAGNOSIS: 1. Rib fracture 2. Rib contusion 3. Lung contusion 4. Pneumothorax TESTS AND RESULTS: 6/17/15 – CXR – Large left-sided apical pneumothorax measuring 3–3.5 cm (approximately 30-35%). – No rib fractures seen 6/18/15 – CXR status post CT-guided placement of chest tube – Much improved left-sided pneumothorax measuring 5 mm from the apex with small-caliber chest tube overlying 2nd-3rd intercostal space FINAL DIAGNOSIS: 1. Traumatic left-sided apical pneumothorax 2. Non-displaced left-sided rib fracture TREATMENT AND OUTCOMES: 1. CT-guided chest tube placement with removal after 2 hours. 2. Continue ACE wrap for comfort. 3. Rest with return-to-play progression over 5 weeks post chest tube. 4. Patient had return of mild chest pain 10 weeks after chest tube placement but repeat chest x-ray showed no return of pneumothorax. Progressed well back to playing soccer without further complication.

An Unusual Case of Pneumonia in a 20 Year Old

SESSION TITLE: Noninfectious “Pneumonia” SESSION TYPE: Case Report Slide PRESENTED ON: Sunday, April 17, 2016 at 01:00 PM - 02:00 PM INTRODUCTION: Carcinoid tumours are rare tumors of the lung and is usually detected in middle aged. It is extremely rare in young adults and children. 9 out of 10 lung carcinoids are typical. CASE PRESENTATION: 20 year old male presented with high grade fever, cough and purulent expectoration and severe breathlessness. He had history of Pneumonia 3 months back. He was hypoxic and examination revealed decreased intensity of breathsounds on left side of chest. CXR PA view revealed consolidation and suspected collapse of left lower lobe and lingula. He was initiated on CAP regimen and mucolytics and CXR repeated on next day showed a complete collapse of left lung. A CECT chest was done followed by bronchoscopy; which revealed an endobronchial lesion in left main bronchus. Biopsy of the tumour was consistent with atypical carcinoid. Left side pneumonectomy was performed and metastastic workup revealed lesions in liver for which he is presently undergoing treatment. DISCUSSION: Atypical Carcinoid tumours are extremely rare tumours in young adults and a strong index of suspicion is required for the diagnosis of the same in younger population. CONCLUSIONS: An early diagnosis is essential as the risk of metaststis is high in atypical carcinoids as compared to typical carcinoids. Almost all lung carcinoids detected during childhood and young adults are typical carcinoids. In our case an agressive atypical carcioid was the culprit. This case is discussed for the rarity of presentation. Reference #1: Pediatric case of the day. Neuroendocrine carcinoma (atypical carcinoid/Kulchitzky-cellcarcinoma II), Lee GH, Dietrich RB, Pais B, et al., Radiographics, 1994;14(1):188-91. Reference #2: Atypical carcinoid of the lung. A distinct clinicopathologic entity. T H Grote; W R Macon; B Davis; F A Greco; D H Johnson. Chest. 1988;93(2):370-375. doi: 10.1378/chest.93.2.370 DISCLOSURE: The following authors have nothing to disclose: Paramez Ayyappath, Shine Shukoor, Indira Kumari No Product/Research Disclosure Information

Case of Hydropneumothorax Following Multiple Episodes of Vomiting

SESSION TITLE: Cardiothoracic Disorders SESSION TYPE: Case Report Slide PRESENTED ON: Saturday, April 16, 2016 at 04:00 PM - 05:00 PM INTRODUCTION: Boerhaave’s syndrome1 first described by Hermann Boerhaave in 1724 and by Barret in 1946. It is the most serious and rapidly fatal perforation of gastrointestinal tract. Classical presentation of a patient with this syndrome is vomiting, chest pain, and subcutaneous emphysema (Mackler’s triad); however, this classical triad is rare to found. Unusual presentation with variety of features makes it challenge to diagnose. CASE PRESENTATION: A 52 year male presented with respiratory distress, left side chest pain, and fever for six days. All these symptoms proceeded by 5 episodes of vomiting. A chest x-ray done by some other physician, which revealed left side pleural effusion about 300 ml fluid was aspirated, but there was no improvement in symptoms. At this time we received patient in our hospital. Patient was dyspnoeic with a respiratory rate of 38 breaths/min, pulse of 114 beats/min, and blood pressure of 130/74 mmHg. Clubbing, cyanosis, lymphadenopathy, or subcutaneous emphysema were absent. Chest examination revealed findings suggestive of left hydropneumothorax. A provisional diagnosis of left hydropneumothorax (iatrogenic) was made. Initial investigations haemoglobin of 10.8 mg/dL, total leucocyte count 14,600/mm3 with 75% neutrophils. Serum electrolytes, blood urea, liver function test and electrocardiogram were with in normal limits. chest x-ray showed a left sided hydropneumothorax. The patient was put on oxygen, and broad-spectrum antibiotics. A contrast enhanced computed tomography (CECT) scan and barium swallow was done. CECT showed a left sided hydropneumothorax and pneumomediastinum. Barium study showed a leakage of contrast to the mediastinum. Patient was immediately shifted to Cardio Thoracic Surgery for operative intervention. DISCUSSION: Boerhaave’s syndrome is the spontaneous transmural rupture of lower oesophagus. In the lower part of oesophagus there is lack of striated muscle and the vertical arrangement of longitudinal muscles, so there is a structural weakness in this part. Conditions like vomiting, childbirth, heavy weight lifting may cause increase in intra oesophageal pressure and results in spontaneous rupture of lower part of oesophagus. clasical Mackler’s triad is rare to found. So this condition is often miss diagnosed. Emergency operative intervention is the treatment of choice in most patients with Boerhaave’s syndrome. Thoracotomy with primary repair of the oesophageal rupture along with drainage of the pleural cavity and mediastinum is recommended if diagnosis is made within 24 hours of onset of symptoms2. The technique of bypassing of oesophagus along with feeding jejunostomy is recommended in patients who present late. CONCLUSIONS: This was a case of left side hydropneumothorax with pneumomediastinum secondary to oesophageal rupture (Boerhaave’s syndrome). Reference #1: Barret NR. Spontaneous perforation of the oesophagus: Thorax 1946;1:48-54. Reference #2: Hutter JA, Fenn A, Braimbridge MV. Br J Surg 1985;72:208-9. DISCLOSURE: The following authors have nothing to disclose: Mohit Bhatia, J. K. Samaria, Anand Bansal No Product/Research Disclosure Information

Vitiligo restricted to Becker’s nevus: Is it an isotopic response?

Becker’s nevus commonly presents as a unilateral hyperpigmented, irregular macule or patch or verrucous plaque with a variable hypertrichotic element located on the shoulder, anterior chest or scapula, and back, and rarely, on the face, neck, and extremities. A number of cutaneous associations were reported with Becker’s nevus. However, coexistence of vitiligo and Becker’s nevus is a rare finding. We report such a finding in a 15-year-old boy who presented with Becker’s nevus on the left side of chest and upper arm and had developed depigmented lesions on the same site over the past 5 months. Diagnosis of both the types of lesions was confirmed by histopathology. Role of cytokines may be proposed in the development of vitiligo and other immunologically mediated diseases on the existing Becker’s nevus on the basis of the concept of ‘Wolf’s isotopic response’ and ‘Ruocco’s immunocompromised district’.

Superior advancement of the diaphragm and rectus muscle flap as an alternative to prosthetic chest wall reconstruction following the excision of huge lower chest wall tumor

Chest wall reconstruction (CWR) is desirable, especially after the excision of huge chest wall tumor, and using mechanical prostheses for the closure of defects is fraught with some complications. We present a case of a 45-year-old man with a 6-week history of recurrent left-sided lower chest wall mass. Chest examination showed a linear surgical scar 8 cm lower and lateral to the left nipple with an underlying huge mass, whose histology from the previous excisional biopsy revealed dermatofibrosarcoma protuberance. He had the excision of the chest wall tumor and subsequently the superior advancement of the diaphragm and using rectus muscle for the CWR. This method was effective in closing the defect without the known complications.

Unusual presentation of occult follicular carcinoma of thyroid: As thoracic wall lump

Occult thyroid carcinoma presenting with clinically apparent metastasis is rare and is a diagnostic challenge. Here we report a 68-year-old male who presented with a left side chest wall mass of one year duration. The mass showed rapid enlargement at the latter end of its course, following an initial asymptomatic period. Imaging studies showed a soft tissue mass eroding into several ribs. Wide local excision with primary reconstruction was performed. Histological studies and immune staining revealed metastasis from a follicular thyroid carcinoma. Total thyroidectomy followed, confirming the diagnosis. Post-operatively radio isotope ablation (I131) was done. A suppression dose of thyroxin was continued with regular thyroglobulin assays. Painful bone metastasis responded well to analgesics, bisphosphonates and external beam radiotherapy. Follicular carcinoma comprise 10–15% of thyroid malignancies. Localized thyroid carcinoma has a very good prognosis, 10 year survival rates reducing by 50% with metastatic disease. Commonly thyroid cancer presents as detectable thyroid nodules, 25% having metastasis. In contrast metastatic manifestations are reported in less than 5% of occult thyroid cancers.

Large Pleural Effusion and Mediastinal Mass: An Unusual Connection!

Question: A 50-year-old Hispanic man with history of smoking, chronic obstructive pulmonary disease, chronic pancreatitis, congestive heart failure, and recurrent deep vein thrombosis on anticoagulation therapy was admitted with worsening shortness of breath and upper abdominal and chest pain for 3 days. The patient had chronic abdominal pain, occasional productive cough and had lost 50-lb weight over the last 6 months. He denied fever, night sweats, difficulty swallowing, vomiting, or diarrhea. Initial vital signs were temperature 97.7 F, blood pressure 90/58 mm Hg, heart rate 89 bpm, respiratory rate 24/min, and SPO2 90% on 15 L oxygen via nonrebreather mask. The breath sounds were diminished and there was dullness to percussion on the left side of chest. Electrocardiogram showed a normal sinus rhythm at 100 bpm. A portable chest radiograph revealed a large left pleural effusion, small right pleural effusion, congestive heart failure, and globular cardiac silhouette (Figure A). Left thoracentesis was performed and 2 L of cloudy fluid was drained leading to improvement in patient’s symptoms and vital signs. A repeat chest radiograph confirmed interval decrease in size of left pleural effusion (Figure B). Initial laboratory tests showed hemoglobin of 12 g/dL (normal, 13–17), white blood cells of 19,000/mL (normal, 4000–11,000), pro-brain natriuretic peptide of 1100 pg/mL (normal, <450), and normal basic metabolic panel, liver tests, troponin, and serum lipase. Empiric antibiotics were initiated for presumed para-pneumonic effusion. A 2-D echocardiogram demonstrated normal ventricular ejection fraction, minimal pericardial effusion and a mass in the left pleural space compressing on the left atrium (Figure C, arrow). Non–contrast-enhanced computed tomography (CT) of the thorax revealed a large, predominantly cystic appearing middle mediastinal mass extending from the upper abdomen to the subcarinal level (Figure D, asterisk). What is the diagnosis? Look on page 319 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Dosimetric analysis of intensity-modulated radiotherapy and three-dimensional conformal radiotherapy for chest wall irradiation in breast cancer patients

AbstractBackgroundFor chest wall irradiation in breast cancer patients, three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) have made tremendous changes in treatment delivery.PurposeThe purpose of this study is to compare the dosimetric parameters in IMRT and 3DCRT plans.Materials and methodsIMRT and 3DCRT plans were generated for 25 randomly selected postmastectomy breast cancer patients. The prescribed dose (PD) was 50 Gray (Gy) in 25 fractions (#) at the rate of 2 Gy/# with 5#/week. Dose volume histogram was evaluated for planning target volume (PTV) coverage and dose to organs at risk (OARs). All the dosimetric parameters were compared using unpaired student’s t-test.ResultsPTV coverage was significantly better in IMRT, although the 90% of PTV was well covered by 90% of PD in all plans by both the techniques. Homogeneity index and conformity index were better in IMRT. V5 Gy and Dmean of contralateral lung, contralateral breast and heart (right side chest wall cases) were found to be lesser in 3DCRT compared with that in IMRT. However, there was no significant difference in V20 Gy of ipsilateral lung and V25 Gy of heart (left side chest wall cases) in all the plans by both the techniques.ConclusionAdequate target coverage was achieved by both the techniques, however, dose to OARs were lesser in 3DCRT plans as compared with that in IMRT plans. Thus, it can be concluded that 3DCRT is as efficient as IMRT for the chest wall irradiation.

Acute Intermittent Porphyria—A Diagnostic Dilemma

Porphyrias are metabolic diseases resulting from a partial deficiency of an enzyme in the heme biosynthetic pathway. AIP (deficiency of hydroxymethylbilane synthase) causes acute attacks due to secondary accumulation of heme precursors. It presents with abdominal pain, tachycardia, hypertension, hyponatremia, seizures, motor neuropathy, etc. Screening is done with qualitative urinary PBG and ALA. Urinary and fecal fractionated porphyrins and DNA testing provided the confirmation. Acute attacks are treated with IV hemin and glucose. Prevention of acute attacks is with smoking cessation and avoidance of inciting agents. A 11-year-old undernourished girl, on multiple antiepileptics, for 4 years (started for refractory seizures), presented with complaints of recurrent generalized abdominal pain with weight loss since the past 1 year, with constipation and poor oral acceptance since 10 days. Examination revealed tender epigastrium, decreased air entry on left side of chest, generalized muscle wasting, and paresthesias. Investigations revealed Hb 9 g/dl; TLC 8200/cu mm (77/ 20/01/02); platelets 1,84,000/cu mm; PS-normocytic normochromic; Na 131 meq/L; K 4 meq/L; Ca 8.9 mg/dl; PO4 3.3 md/dl; ALP 255 U/L; blood urea 49 mg/dl; serum creatinine 0.9 mg/dl; bilirubin 0.5 mg/dl; SGOT 54 U/L; SGPT 21 U/L; blood culture—no growth; HIV-NR; urine examination— normal; serum amylase 112U/L; serum lipase 71U/ L; lipid profile, carbamazepine level, and CXR—normal; PPD test –NR; GA for AFB—negative; USG abdomen, CECT abdomen, and brain—normal; CECT thorax-opacities and necrotic patches on left lower zone consistent with pulmonary tuberculosis; EEGpartial epilepsy with focus at right temporal lobe; serum lead level—normal; Urine for porphobilinogen, 5-ALA, and total porphyrins—positive; and NCV— Severe axonal motor and sensory neuropathy in all four limbs. A diagnosis of AIP with pulmonary tuberculosis with partial seizure with undernutrition was made. Antiepileptics were tapered gradually and gabapentine with modified ATT was started and the child responded very well. AIP should be kept in the differentials of chronic abdominal pain and patients with psychological symptoms.