Left Sixth Rib Research Articles

LIMITATIONS IN THE USE OF SUBCUTANEOUS DEFIBRILLATOR IN PATIENTS WITH LOW BODY MASS INDEX

Abstract Introduction Subcutaneous defibrillator is an effective and widely used tool in clinical practice but the presence of large fluctuations in the body mass index and the reduction of subcutaneous tissue may limit its application to all patients. Case Report In 2014, a 51–year–old woman underwent implantation of a dual–chamber transvenous defibrillator with left subclavian vein approach in secondary prevention for long Qt syndrome (LQT3). About 6 years after implantation she presented a ventricular lead breakage due to subclavian crush syndrome and was subjected to multiple inappropriate shocks due to lead failure. For this reason, the transvenous defibrillator was replaced with a single–chamber pacemaker for atrial stimulation and a subcutaneous defibrillator was implanted (Fig.1). In the following years the patient lost 14 kg and in the first months of 2022 she complained of the onset of stabbing pain in the precordial region near the upper face of the left sixth rib on the midclavicular line (Fig.2). Over the months, this symptomatology has become increasingly limiting and poorly responsive to normal analgesics but only to opiates; furthermore the pain has also occurred after a few weeks at the left parasternal level along the course of the distal portion of the subcutaneous catheter. For this reason, after discussing the case with the patient, we proceeded to implant a new transvenous lead via left subclavian vein and upgrade to a dual–chamber defibrillator. Subsequently, in the same operating session, the subcutaneous defibrillator was removed, finding only a modest traction resistance of the catheter in the parasternal area, resolved with the use of a 10 French introducer used as a sheet to debride the course of the same from the fibrotic adhesions (Fig .3). In the days following the procedure, the patient reported a progressive total disappearance of the pain symptoms. Reassessed after one year, the patient reports subjective well–being with total absence of chest pain and good quality of life. Conclusions The subcutaneous defibrillator represents an important resource for the management of the main ventricular arrhythmias, especially in patients with a high risk of infection and with a long life expectancy. The presence of a stable amount of subcutaneous tissue is a necessary condition to guarantee the tolerance of the lead over time and to avoid chronic pain situations that can lead to its removal.

Management of Rib Avascular Necrosis Complicated by Osteomyelitis in a Patient With Sickle Cell Anemia

Abstract Introduction Avascular necrosis of the rib is a rare presentation of sickle cell anemia's vaso-occlusive crisis. This report describes the case of a 45-year-old man known to have sickle cell anemia presenting with rib avascular necrosis complicated by osteomyelitis. The patient came to the outpatient department with left lateral chest wall pain. Antibiotics produced no improvement. A computed tomography scan of the chest revealed a left sixth rib fracture with a thick fluid collection consistent with pus. The patient was taken to surgery and underwent necrotic bone debridement and pus drainage. The patient showed improvement and became afebrile after the surgery. Conclusion The lack of distinct clinical indicators and low occurrence of rib avascular necrosis can lead to misdiagnosis and mismanagement of the disease.

PSAT218 Technetium 99m-Methyl Diphosphonate (99mTc MDP) Radioguided Surgery in Patient With Tumor-Induced Osteomalacia (TIO)

Abstract Introduction TIO is a rare paraneoplastic syndrome of excess FGF23 secretion by mesenchymal tumors that results in myopathy, pain, weakness and osteomalacic fractures. Tumors are small and often difficult to locate, frequently delaying diagnosis. Surgery is considered definitive therapy, but recurrences remain common due to incomplete tumor resection. We present a novel approach of using Gallium (Ga) 68 DOTATATE PET/CT to identify the culprit tumor preoperatively followed by intraoperative 99mTc MDP radioguided surgical resection. Case Report A 41-year-old female presented with a four-year history of progressive weakness, fatigue, muscle and bone pain, and multiple subacute rib fractures and bilateral hip fractures with minimal trauma. On exam, she had proximal muscle weakness and walked with an antalgic gait aided by crutches. Laboratory evaluation revealed serum phosphorus of 2.1 mg/dL (2.5-4.5), tubular reabsorption of phosphate (TRP) of 78.9% (>85%), elevated alkaline phosphatase of 209 IU/L (31-125), 1,25 dihydroxy vitamin D [1,25 (OH)2 D] of 17 pg/ml (18-72) and serum FGF23 610 RU/ml (<180). Serum calcium, parathyroid hormone (PTH), estimated GFR and 25 hydroxy vitamin D were normal. Testing for genetic causes of hypophosphatemia was negative. With biochemical and genetic testing consistent with TIO, functional imaging was performed. Ga 68 DOTATATE PET/CT identified a single, 1.8 cm non-expansile sclerotic focus along the anterior left sixth rib with moderate uptake. She denied any recent trauma to the site. She was referred to thoracic surgery for a left sixth rib resection. Intraoperatively, she received 8.1 mCi Tc99m-MDP intravenously and the margin of the tumor was localized using a gamma probe allowing complete resection. Surgical pathology confirmed a 2.0 cm phosphaturic mesenchymal tumor (PMT)with widely negative margins. Postoperatively, her muscle strength, fatigue and ambulation improved significantly within six weeks and her serum phosphorus, TRP, 1,25 (OH)2 D normalized. Discussion Localization of PMTs is difficult because tumors are small and can be located anywhere in the body. Functional imaging using somatostatin analogs such Ga 68 DOTATATE PET/CT exploits the presence of somatostatin receptors expressed by many PMTs. Complete resection of PMTs can be challenging because they tend to be locally infiltrative along bone trabeculae. 99mTc MDP is a radiotracer localized to bone in proportion to osteoblastic activity as seen at sites of bony remodeling or bone metastasis. Accurate tumor localization and complete resection with widely negative margins are imperative for definitive treatment and cure. This case is unique in utilizing Ga 68 DOTATATE PET/CT for localization of the PMT paired with intraoperative 99mTc MDP in conjunction with a gamma camera for identifying tumor margins facilitating complete tumor resection and cure of the patient. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

FAMILY MATTERS: CHEST PAIN AS THE INITIAL PRESENTATION OF EARLY-ONSET METASTATIC PROSTATE CANCER

FAMILY MATTERS: CHEST PAIN AS THE INITIAL PRESENTATION OF EARLY-ONSET METASTATIC PROSTATE CANCER

Chondromesenchymal hamartomas in a 24-year-old male mimicking a posterior mediastinal tumor and a 5-month-old boy with postoperative disseminated intravascular coagulation: two case reports

BackgroundChondromesenchymal hamartoma of the chest wall is a rare, benign disease that usually presents at birth or in early infancy. It typically involves one or more ribs, forming a unilateral or bilateral extrapleural mass. Patients may be asymptomatic or complain of mild respiratory distress depending on tumor size and location. To the best of our knowledge, only two of the approximately 100 cases reported so far are adults.Case presentationWe present two cases of chondromesenchymal hamartoma. The first case involved the left fifth rib in a 24-year-old male, in close proximity to the fifth vertebral body in the left posterior mediastinum, mimicking a posterior mediastinal tumor on imaging. The tumor was excised via thoracoscopy and the patient had an uneventful postoperative course. The second case was that of a 5-month-old boy, who had a tumor involving the left fifth and sixth ribs which caused thoracic cage collapse. Following en bloc resection of the tumor and the involved rib segments, the patient was transferred to the intensive care unit for treatment of pulmonary infection and disseminated intravascular coagulation (DIC). He was discharged from the hospital in stable condition 11 days later. On histopathology, the tumor was found to be a chondromesenchymal hamartoma with immature spindle-shaped mesenchymal cells, plate-like hyaline cartilage, areas of woven bone formation, endochondral ossification and calcification, osteoclastic giant cells, and secondary aneurysmal bone cysts.ConclusionsAlthough the presently reported cases have morphological characteristics similar to previously reported ones, they had distinct radiological and clinical characteristics. Patient 1 is only the third report of an adult with chondromesenchymal hamartoma. His case was characterized by its radiological appearance mimicking a posterior mediastinal tumor. Patient 2 represents the first documentation of DIC as a postoperative complication following excision of a chondromesenchymal hamartoma. We present these two cases to provide clinicopathological insights regarding this extremely rare tumor that are relevant to both pathologists and clinicians.

SUN-935 Invasive Neuroendocrine Breast Carcinoma Presenting as Liver Metastases

Introduction:Primary neuroendocrine carcinoma of the breast is rare and must be differentiated from metastatic neuroendocrine carcinoma from the gastrointestinal tract.Clinical Case:A 66-year-old white female presented to the outpatient clinic complaining of abdominal fullness with unintentional weight loss of over 30 pounds over 3 months. She had no nausea, vomiting, diarrhea, or constipation. During initial evaluation, she had hepatomegaly with the liver edge palpable 4 cm below the costal margin. Laboratory studies are within normal limits except for elevated alkaline phosphatase at 369 U/L (n<130 U/L).A CT scan of the abdomen and pelvis with contrast showed extensive malignant lesions involving the liver consistent with prior hepatocellular carcinoma versus metastatic disease. Patient had a colonoscopy and esophagogastroduodenoscopy in an attempt to identify a primary gastrointestinal malignancy, but both studies were unremarkable. Ultrasound guided biopsy of the liver masses revealed malignant cells with morphologic features that were suggestive of metastatic neuroendocrine carcinoma.The patient was started on monthly intramuscular octreotide 30 mg. She had a Gallium-68 dotatate scan showing increased uptake in the area of several large heterogeneous necrotic tumors throughout the liver, and in the left sixth posterolateral rib. The maximum uptake was noted in a 3.7 cm x 3.5 cm ovoid mass in the right breast. The patient admitted to noticing a mass in her right breast which decreased in size after her initial dose of octreotide. She had not had a mammogram in several years and refused a breast exam during initial evaluation. The patient was sent for mammography and ultrasound as well as for biopsy of the breast lesion.Results of the breast biopsy showed intermediate grade neuroendocrine tumor of the breast. The patient underwent right total mastectomy with lymph node staging, and intraoperative pathology identified neuroendocrine carcinoma of intermediate grade in the right breast and right axillary lymph nodes, and macrometastatic carcinoma in a right axillary tail lymph node. Immunohistochemistry showed the malignant cells were chromogranin and synaptophysin positive. They were also estrogen receptor positive. The cells were negative for progesterone receptor and human epidermal growth factor receptor 2.The patient follows up regularly with oncology and continues to receive monthly doses of octreotide. She was also started on exemestane and had Yittrium-90 radioembolization of liver metastases.Conclusion:Patients with neuroendocrine carcinoma of the breast rarely present with clinical conditions related to hormonal hypersecretion as in neuroendocrine carcinoma of the GI tract but respond to treatment with somatostatin analogs.

New methods for sex estimation using sternum and rib morphology.

Sex estimation of skeletal remains is of great importance in the fields of physical and forensic anthropology. Since skeletons are often incomplete, it is essential to estimate sex from as many skeletal remains as possible. The aim of this study was to establish new methods for estimating sex using the morphology of the sternum and the fifth to ninth ribs. We considered two conditions of skeletal preservation: All skeletal elements measured are available, or only a single element is available. Traditional or virtual measurements were carried out on three samples: (1) A skeletal sample from the Hamann-Todd Human osteological collection, Cleveland Museum of Natural History, USA (N = 413), was used to create prediction equations for sex estimation. (2) A recent, CT-based sample from Israel (N = 33) was used to cross-validate the accuracy of the prediction equations. (3) A skeletal sample from the Anthropological Collection at Tel Aviv University (N = 15) was used to test the validity of the virtual measurements. Reliability and validity analyses were carried out via intraclass correlation coefficient analysis. Prediction equations for sex were created using logistic regression. The measurements were found to be highly reliable and valid. Success rates for sex estimation were high (> 80%) and correspond well between the skeletal and recent samples, especially for the left sixth, left eigth, and left ninth ribs. To conclude, measurements of the sternum and ribs are valuable for estimating sex and can be carried out using either traditional or virtual tools. Of all the skeletal elements examined in this study, the sternum, left sixth, left eighth, and left ninth ribs were found to be the most reliable skeletal elements for estimating the sex of an individual.

MEDICAL MANAGEMENT OF BILATERAL FLAIL CHEST CAUSED BY PROLONGED CPR

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Flail chest is a life-threatening condition caused by blunt trauma to the chest resulting in fractures of three or more consecutive ribs in two or more places with paradoxical motion. We present a rare case of bilateral flail chest secondary to trauma from manual CPR that recovered without surgical intervention. CASE PRESENTATION: A 65-year-old man presented to our hospital with MI, complicated by VF and cardiac arrest. He was emergently intubated and after 42 minutes of manual CPR he had ROSC. Several attempts at weaning the AC/PC were unsuccessful due to agitation, desaturation, tachypnea. CT chest showed acute fractures of lateral right fourth, anterior right fifth, anterior right sixth, lateral left fourth, anterior left fifth, and anterior left sixth ribs in addition to inward movement of the chest. There was a conservative strategy due to the high risk of bleeding on Ticagrelor and persistent fever (pan-sensitive MSSA on respiratory culture). Pain was managed with Precedex, Hydromorphone, and Midazolam drips then transitioned to Propofol and Gabapentin. He was then started on Oxycodone and Seroquel. On hospital day 25 the patient was weaned off Propofol, was A&O, and transitioned to tracheostomy collar/Fentanyl Patch. DISCUSSION: It is believed that the mortality from flail chest is secondary to complications rather than the flail chest itself, although visceral chest wall injuries such as pulmonary contusions and hemothorax are common. Nevertheless, without proper sedation/pain management (successive use of analgesics/sedatives with different pharmacological properties), and cautious attention to possible complications (VAP, mucous plugging, pulmonary contusions), this patient may have suffered from increased M&M.Pain control was difficult in an awake state; hence he was placed on Propofol for almost the entirety of his stay. At one point he was receiving high dose Hydromorphone, Oxycodone, Precedex, and Propofol. While there may be significant morbidity and additive effect of multiple opioids/sedatives, it was only with meticulous and slow discontinuation of these sedatives that the patient was able to successfully wake up with good pain control and relatively minimal delirium. While epidural/paravertebral blocks were considered, the patient’s DAPT precluded the their use. Secondly, because of the patient’s unusual distribution of fracture, regional anesthesia, would have also been difficult and short-lived. Early tracheostomy was warranted in this situation for comfort, pulmonary toilet, reduction of dead space, and sedative needs. CONCLUSIONS: Rib fractures and flail chest can produce significant morbidity for the elderly. Pain control, pulmonary toilet, and volume expansion measures are critical to reducing complications and further M&M. While surgical fixation continues to be controversial, medical management of even the most severe cases of flail chest can be successful. Reference #1: Phillips B, Murray E, Holzmer S . Bilateral Flail Chest: A review. Journal of Trauma and Orthopaedic Surgery.April - June 2017;12(2):2-7. Reference #2: Dehghan N, de Mestral C, McKee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:462. Reference #3: R.S. Hoke, D. Chamberlain. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation, 63 (2004), pp. 327-338. DISCLOSURES: No relevant relationships by Hany Abdallah, source=Web Response no disclosure on file for Leila Hosseinian

A RARE MALIGNANCY

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Ewing's sarcoma is a malignant neoplasm which arises from the skeletal bones. It most commonly affects children and young adults with a female preponderance. Ewing’s sarcoma of the rib is a rare enity as long bones are usually affected . CASE PRESENTATION: A 24 year-old male presented with complaints of shortness of breath , cough and left chest pain for 1 month. He also had episodes of seizures since last 3 years. He had multiple soft cutaneous nodules and macular patches over chest , back and upper limbs. There was bulging of left anterior chest wall with shifting of trachea as well as apex beat to right. There was increased vocal fremitus as well dull percussion note on left. There were reduced breath sounds with increased vocal resonance on left. Routine blood investigations were within normal limits. Chest X -ray revealed a homogeneously white left hemithorax with shifting of mediastinum to the right. Pleural fluid cytology had features suggestive of small round cell tumor. CECT thorax revealed a large heterogeneous mass in the left hemithorax with shifting of mediastinum to right and lytic destruction of left 6 th rib. There was minimal left pleural effusion with nodular pleural deposits. USG guided trucut biopsy from the left lung mass revealed small cell neuroendocrine carcinoma. The tumour was CD 99, Synaptophysin, CD 56 , FLI-1 - positive and negative for CK, CK7, TTF-1 and chromogranin. Dermatology opinion favoured the skin nodules to be neurofibromatosis. So a final diagnosis of Ewing’s sarcoma left sixth rib with Neurofibromatosis and seizure disorder was made. The patient received Vincristine , Adriamycine and Cyclophosphamide (VAC),alternating with Ifosfamide and Etoposide as well as was planned for radiotherapy DISCUSSION: Ewing sarcoma is an uncommon disease, which usually arises from the skeletal bones. It constitutes approximately 10 % of all primary malignant bone tumours. Only 40 % of such cases are seen in flat bones like innominate, ribs, scapula and sterum #1.A characteristic chromosomal translocation, (11; 22) (q24; q12) can be detected in 90% of cases .Patients with Ewing's Sarcoma of the ribs present with breathlessness, weight loss and painful chest wall mass. #2 pleural effusion as in our case, is an unusual finding #3 . The tumour has propensity to spread inwards towards the thoracic cavity and thus,may manifest as an extra pleural mass.our case unique in a wayas it had several other associated finding like neurofibromatosis,seizure disorder as well as skin lesion although such association are not commonly reported CONCLUSIONS: This case showcases the significance of IHC an important tool in diagnosis of lung malignancies and lays stress on excluding extrathoracic involvement in all such cases. Reference #1: MirraJM. Bone tumors: clinical, radiologic, and pathologic correlations. Philadelphia: Lea&Febiger, 1989; 1087-1117. Reference #2: Gladish GW, Sabloff BM, Munden RF, Truong MT, Erasmus JJ, Chasen MH. Primary thoracic sarcomas. Radiographics 2002 May-Jun;22(3):621-637 Reference #3: Wolf G, Aigner RM, Schwarz T. Massive pleural effusion with dyspnea in a 17-year-old boy as the first sign of ewing sarcoma. J Pediatr Hematol Oncol 2002 Jun-Jul;24(5):420 DISCLOSURES: No relevant relationships by UMER AHMED SYED, source=Web Response

When and why was the phrenicoabdominal branch of the left phrenic nerve placed into the esophageal hiatus in German textbooks of anatomy? An anatomical study on 400 specimens reevaluating its course through the diaphragm

BackgroundThe phrenicoabdominal branch of the left phrenic nerve passes between muscle fiber bundles within the costal part of the diaphragm near the pericardium. In most German textbooks of anatomy, however, its passage is described to be found in the esophageal hiatus. The aim of this study was to reevaluate its topography relative to the diaphragm in a multicentric study and to identify the initiation of this description. MethodsIn this multicentric study, the most dorsomedial branch of the left phrenic nerve was identified as the phrenicoabdominal branch in 400 embalmed anatomic specimens of Caucasian origin. The distance between its passage and the apex of the pericardium, the left border of the esophageal hiatus, and the inner aspect of the left sixth rib was measured on the cranial aspect of the diaphragm. Textbooks on human anatomy published in German language between 1700 and 2018 were reviewed for their description of the passage of the left phrenicoabdominal branch through the diaphragm. ResultsThe first statement on the passage of the left phrenicoabdominal branch through the esophageal hiatus was given in 1791 by Sömmering. Since then, in German textbooks of anatomy, a duality in the description of the passage of the left phrenicoabdominal branch persists. In none of the individuals examined in this study, the left phrenicoabdominal branch passed through the esophageal hiatus. In 99.5% of all cases, it pierced the costal part of the diaphragm dorsal to or at the same level as the apex of the pericardium. The mean distances (standard deviations) were 3.4 (±1.5) cm to the apex of the pericardium, 5.8 (±2.2) cm to the esophageal hiatus, and 5.5 (±1.6) cm to the inner aspect of the left sixth rib. ConclusionThe findings on the position of the left phrenicoabdominal branch relative to the diaphragm help to improve topographical knowledge and prevent inadvertent nerve injury during surgical interventions on or near the diaphragm. Further to this, these results may form a substantial basis to adopt the correct description of the passage of the left phrenicoabdominal branch to anatomical textbook knowledge.

Successful downstaging of isolated bony metastatic prostate cancer after metastasectomy and androgen deprivation therapy

Isolated bony metastasis from prostate cancer is extremely rare, thus, the efficiency of its surgical resection remains unclear. We present a case of isolated left sixth rib metastasis from prostate cancer that was treated with metastasectomy and androgen deprivation therapy. Salvage radical prostatectomy was conducted subsequently, successfully downstaging the tumor.

An unusual case of rib anomalies in number and morphology with association of vertebral and sternum anomalies: Computed tomography diagnosis

A significantly less number of ribs with multiple developmental anomalies in ribs, spine, and sternum is very rare anomaly. We report a case of a 50-year-old man with 15 number of ribs, absent first, second, fourth, seventh and eleventh ribs on the left and absent first, third, eight and tenth ribs on the right side, along with a bifid anterior end of the left sixth rib, fused posterior ends of right fifth and sixth ribs, and bilateral hypoplastic 12th ribs. These anomalies were also associated with thoracolumbar block and hemivertebrae as well as a small sternum. All findings were identified incidentally on computed tomography. No similar type of rib anomalies was found in previous literature. We discuss the details of this case, and suggest a perspective of morphology and developmental biology.

Costal Cartilage Fractures and Disruptions in a Rugby Football Player

Costal cartilage fracture of the rib cage, or costochondral, is a rare sporting injury. For contact athletes, the instability of the rib cage may lead to potential serious complications, similar to rib fractures or thorax disruption. Most authors recommend initial conservative treatment with surgery reserved for only recalcitrant cases. We report a case of an amateur American male rugby football player who sustained a costal cartilage fracture and disruption involving the anterior left fifth and sixth rib costal cartilages. The case highlights the difficulty in establishing the diagnosis based on clinical examination and standard radiographs alone. Computed tomography was used to assist in diagnosing this destabilizing injury to the rib cage. Costal cartilage fractures and disruptions in athletes are rarely reported in the literature and can have serious implications for the athlete's ability to return to play if the rib cage is destabilized.

Fatal hemorrhage from an undiagnosed rectal carcinoma in a case of Diogenes syndrome

Case report A 61-year-old male was found dead at his home address after a strong putrefactive odor was noted. The decedent was lying on a couch, with his underpants pulled down to his knees, and a blood stained towel located beneath his buttocks. A large amount of blood had dried over his exposed groin region and thighs. Inspection of the house revealed blood-stained towels, underwear, and newspaper pages strewn on the floor in various rooms, with trails of blood droplets on the floor in the hallways and in various rooms. Several chairs had blood stained impressions where he had been sitting (Fig. 1). The toilet bowl and seat were also covered in blood. The house was noted to be quite untidy with rotting food and empty drink and take-away food containers throughout. The decedent was described as a ‘‘very private person’’ who had been unwell in recent times with loss of weight. There was a family history of bowel cancer, however, the decedent had no significant medical history. On external examination the decedent appeared older than his stated age, cachectic with moderate scleral jaundice. Changes of early decomposition were noted. The most striking external feature was the presence of copious amounts of fresh blood draining from the anus covering his buttocks and inner thighs (Fig. 2). On internal examination, the most significant finding was a blood filled rectum associated with a large (60 9 80 mm) ulcerated carcinoma at the recto-anal verge which had infiltrated through the full thickness of the rectum (Fig. 3). Metastatic deposits were noted in the liver (Fig. 4) which weighed 5,551 g, lung, lymph nodes, and left sixth rib. These were confirmed histologically to be metastatic deposits of moderately well differentiated adenocarcinoma. Death was attributed to hemorrhage from a rectal adenocarcinoma exacerbated by end stage metastatic liver disease.

Pyothorax-associated lymphoma: complete remission achieved by chemotherapy alone

We present the case of a patient with malignant lymphoma resulting from chronic pyothorax after artificial pneumothorax for pulmonary tuberculosis. The 81-year-old female patient had a medical history of artificial pneumothorax from left pulmonary tuberculosis when she was 23 years old and subsequent chronic pyothorax. She had become aware of pain in the left back from October 2008. Chest computed tomography revealed a tumor measuring 61 mm × 27 mm behind the left sixth and seventh ribs. After biopsy revealed pyothorax-associated lymphoma, 4 courses of R-CHOP therapy were administered, leading to complete remission. No recurrences were noted during follow-up over a 4-year period after the initiation of therapy.

Solid variant of aneurysmal bone cyst of the thoracic spine: a case report.

IntroductionThe solid variant of aneurysmal bone cyst is rare, and only 13 cases involving the spine have been reported to date, including seven in the thoracic vertebrae. The diagnosis is difficult to secure radiographically before biopsy or surgery.Case reportAn 18-year-old Hispanic man presented to our facility with a one-year history of left chest pain without any significant neurological deficits. An MRI scan demonstrated a 6 cm diameter enhancing multi-cystic mass centered at the T6 vertebral body with involvement of the left proximal sixth rib and extension into the pleural cavity; the spinal cord was severely compressed with evidence of abnormal T2 signal changes. Our patient was taken to the operating room for a total spondylectomy of T6 with resection of the left sixth rib from a single-stage posterior-only approach. The vertebral column was reconstructed in a 360° manner with an expandable titanium cage and pedicle screw fixation. Histologically, the resected specimen showed predominant solid fibroblastic proliferation, with minor foci of reactive osteoid formation, an area of osteoclastic-like giant cells, and cyst-like areas filled with erythrocytes and focal hemorrhage, consistent with a predominantly solid variant of aneurysmal bone cyst. At 16 months after surgery, our patient remains neurologically intact with resolution of his chest and back pain.ConclusionsBecause of its rarity, location, and radical treatment approach, we considered this case worthy of reporting. The solid variant of aneurysmal bone cyst is difficult to diagnose radiologically before biopsy or surgery, and we hope to remind other physicians that it should be included in the differential diagnosis of any lytic expansile destructive lesion of the spine.

Cronkhite-Canada syndrome associated with rib fractures: a case report

BackgroundCronkhite-Canada syndrome (CCS) is a rare multiple gastrointestinal polyposis. Up till now, many complications of CCS have been reported in the literature, but rib fracture is not included.Case PresentationWe report a case of a 58-year-old man who was admitted to our hospital with a 6-month history of frequent diarrhea, intermittent hematochezia and a weight loss of 13 kg. On admission, physical examination revealed alopecia of the scalp, hyperpigmentation of the hands and soles, and dystrophy of the fingernails. Laboratory data revealed hypocalcaemia and hypoproteinemia. Esophagogastroduodenoscopy, video capsule endoscopy and colonoscopy revealed various sizes of generalized gastrointestinal polyps. Histological examination of the biopsy specimens obtained from the stomach and the colon showed adenomatous polyp and inflammatory polyp respectively. Thus, a diagnosis of CCS was made. After treatment with corticosteroids for 24 days and nutritional support for two months, his clinical condition improved. Two months later, he was admitted to our hospital for the second time with frequent diarrhea and weight loss. The chest radiography revealed fractures of the left sixth and seventh ribs. Examinations, including emission computed tomography, bone densitometry test, and other serum parameters, were performed, but could not identify the definite etiology of the rib fractures. One month later, the patient suffered from aggravating multiple rib fractures due to the ineffective treatment, persistent hypocalcaemia and malnutrition.ConclusionsThis is the first case of a CCS patient with multiple rib fractures. Although the association between CCS and multiple rib fractures in this case remains uncertain, we presume that persistent hypocalcaemia and malnutrition contribute to this situation, or at least aggravate this rare complication. Besides, since prolonged corticosteroid therapy will result in an increased risk of osteoporotic fracture, CCS patients who accept corticosteroid therapy could be potential victims of rib fracture.

Polyostotic fibrous dysplasia of the ribs: An unusual cause of chest pain and dyspnea

Fibrous dysplasia is a benign bony abnormality that may be monostotic or polyostotic and is not included in the differential diagnosis of chest pain and dyspnea, since it is typically asymptomatic. A 36-year-old man presented with left-sided chest pain and dsypnea for three months. Chest X-ray and chest computed tomography scan revealed a large solid mass arising from the anterior parts of the left fourth, fifth, and sixth ribs and compressing the adjacent lung parenchyma. The tumor was completely removed surgically and histopathologic examination was consistent with fibrous dysplasia without malignant transformation. This report demonstrates that polyostotic dysplasia of the ribs may cause chest pain and dyspnea and present radiographically as a large mass.

Renal Involvement in Multicentric Castleman Disease With Glomeruloid Hemangioma of Skin and Plasmacytoma

A 47-year-old man presented with fever of unknown origin, generalized weakness, edema, and renal failure. He had left-sided pleural effusion, generalized lymphadenopathy, multiple nontender cutaneous nodules, hepatomegaly, renal failure, and hypergammaglobulinemia. Axillary lymph node biopsy showed findings consistent with Castleman disease of the hyaline vascular type associated with interfollicular plasmacytosis. A renal biopsy performed in view of proteinuria and acute renal failure showed hypercellular glomeruli with capillary loop thickening and double contours consistent with membranoproliferative glomerulonephritis. Skin nodule biopsy showed a glomeruloid hemangioma characterized by dermal proliferation of capillary loops in a nodular manner resembling a glomerulus. He experienced clinical and biochemical remission with steroids. Discontinuation of steroid therapy was associated with recurrence of renal failure, reappearance of nodules, lymphadenopathy, and appearance of bony lytic lesions. Biopsy of bony lytic lesions showed plasmacytoma. The patient achieved complete remission on treatment with steroids and cyclophosphamide and is free of symptoms at the end of 40 months of follow-up. To our knowledge, this is the first case report of the occurrence of membranoproliferative glomerulonephritis, glomeruloid hemangioma of the skin, and plasmacytoma in a patient with multicentric Castleman disease without human immunodeficiency virus infection.

Costal osteochondroma presenting as haemothorax and diaphragmatic laceration

We report the unusual case of an 11-year-old girl who suffered a large haemothorax and lacerated left hemidiaphragm because of a costal osteochondroma arising from the left sixth rib near the costochondral junction. Surgical excision of the osteochondroma was performed and the lacerated diaphragm was repaired.