Management Conundrum Research Articles

Navigating Uncharted Territory: High-Grade B-Cell Lymphoma Coexisting with Warthin Tumor – Lessons Learned from an Unusual Encounter

Abstract Introduction/Objective High-grade B-cell lymphomas (HGBCL) coexisting with Warthin tumors (WT) are infrequently encountered, yet each case offers valuable insights. This introduction sets the stage by highlighting the rarity of such occurrences and emphasizing the importance of thorough evaluation in diagnosing and managing salivary gland neoplasms. Methods/Case Report We present the case of a 78-year-old man with longstanding bilateral parotid gland masses, initially presumed to be benign WT based on prior biopsies. However, surgical intervention unmasked a surprising twist – concurrent presence of HGBCL within the WT. This rare juxtaposition posed a diagnostic and management conundrum, underscoring the importance of thorough evaluation and consideration of atypical presentations. Pathological examination revealed a landscape of large-sized cells with aberrant expression profiles, including CD20, Pax-5, BCL2, and MUM-1 positivity, along with a MYC rearrangement. Despite the rarity of this phenomenon, the case serves as a poignant reminder of the necessity for comprehensive assessment in seemingly benign conditions. Results (if a Case Study enter NA) N/A Conclusion By dissecting this unique encounter, we glean invaluable lessons in diagnostic vigilance, emphasizing the need for heightened awareness and multidisciplinary collaboration in the management of salivary gland neoplasms. This case underscores the significance of recognizing unusual presentations and leveraging them to refine diagnostic and therapeutic approaches, ultimately enhancing patient outcomes and guiding future clinical practice.

Edward’s syndrome neonate, a management conundrum of an anaesthesiologist

Chromosomal disorders manifest with multiple congenital anomalies, which is associated with high morbidity as well as mortality. Trisomy 18 also known as Edward’s syndrome is a rare chromosomal disorder. We report a case of Edwards’ syndrome in a 15-day-old female neonate, with typical syndromic features. Infant’s clinical condition was superimposed by respiratory distress, necessitating a comprehensive, multidisciplinary management involving neonatologist, anesthesiologists, and orthopedic specialists. Considering the intricacies of Edwards’ syndrome and hence contributing to refining protocol for enhanced care and meticulous support. Furthermore, emphasizes the requirement for further research to advance understanding of the clinical condition and propagate future management.

BIOPATCH GRAFTING OF LARGE OR RECALCATRANT OSTEOCHONDRAL DEFECTS OF THE TALUS

IntroductionLarge osteochondral defects (OCD) of the talus present a difficult management conundrum. We present a series of Maioregen xenograft patches applied through an open approach, early lessons from the technique and good early outcomes, in patients who are otherwise looking at ankle salvage techniques.Results16 patients underwent open patch procedures, performed by a single surgeon, over a 30 month period. 12 males, and 4 females with age at presentation from 21–48. The majority were young, male, in physical employment with active sporting interest. MoxFQ, and E5QD were collected preop, 3, 6, 12 month postoperatively. There were significant improvements in ROM, pain, and scores in the cohort. 3 cases returned to Theatre, 1 for a concern about late infection, which settled with good outcome, and a further 2 with metalwork / adhesions.ConclusionEarly results suggest that this patch technique may be useful in prolonging the longevity of the TTJ, where micro fracture has failed, or the lesion is so large that it would likely be futile. Patients rescoped demonstrated good integration of the patch material, with stability and functional improvement. There may be a place for this technique in the management of large lesions, particularly in young patients where preservation is desired over joint salvage.

Morular Metaplasia of the Endometrium: A Case Report and Literature Review: Care Pathways based on Molecular Biology

Background: Endometrial morular metaplasia, a clinical conundrum from a diagnostic and management angle given its rarity and low oncogenic potential has been linked to endometrial hyperplasia and carcinoma. Case report: A 77-year-old woman with no significant past medical history was found to have an asymptomatic thickened endometrium on pelvic imaging, after presenting with lower abdominal pain, 3 yrs ago. Diagnostic hysteroscopy identified an endometrial polyp within a pyometra. Histopathology showed focal complex hyperplasia without atypia with superimposed morular metaplasia (EMM) amongst negative microbiology. Following conservative management with a Multidisciplinary Team (MDT) overview, as per her choice with 6-monthly follow-up hysteroscopies, endometrial biopsies, and a short use of the Mirena IUS (discontinued due to poor tolerance), histopathology shows resolved hyperplasia with persistent EMM. She is considering a hysterectomy. Discussion: Current evidence suggests that a sub-type of EMM, a likely histological manifestation of beta-catenin (CTNNB1) gene mutation: could be a precursor of endometrial hyperplasia and low-grade endometrioid-endometrial carcinoma sub-type. Though low-grade in nature, the increased recurrence risk raises significant concerns. Management options which include conservative, hormonal, and surgery have been described in the literature. A few cases of premenopausal women have been managed conservatively, with one resulting in a pregnancy. However, due to the lack of a natural history timeline, the optimal frequency of endometrial sampling when uterine-sparing, is unclear, leading to a management conundrum. Conclusion: Management of morular endometrial metaplasia can be difficult but must reflect the woman’s choice with an MDT overview. Immuno-histochemical tools utilizing new molecular biological advances can simplify the diagnostic and prognostication processes, aiding clinical management.

1197 Cataplexy - Management Conundrums

1197 Cataplexy - Management Conundrums

Clinical Problem Solving: Management Conundrums in Tuberculous Meningitis

Tuberculosis involving the central nervous system is a treacherous disease. Resistant TB, vasculitis, raised intracranial pressure, and paradoxical response add to the problems faced by the patient. Adverse effects of drugs, interactions, and uncertainties in management mean that a multidisciplinary approach involving infectious diseases physician, neurologist, and microbiologist is needed for optimal management.

Diagnosis and management of pancreatic cystic lesions for the non-gastroenterologist.

Although most pancreatic cystic lesions do not progress to cancer, they create concern for patients and their primary care physicians. The lack of consensus guidelines on diagnosis and surveillance of these lesions can lead to a management conundrum. We review current guidelines on diagnosis and management.

Archetypal representations of dilemmas concerning invasive alien species management—A case of invasive Lantana camara in the protected areas of Nilgiri Biosphere Reserve, India

AbstractThis multi‐site case study on the invasive alien plant Lantana camara in protected areas of Nilgiri Biosphere Reserve, India, addresses the reasons for inadequate institutional responses from stakeholders in managing the species despite the seriousness. The study uses thematic analysis and qualitative systems approach. The themes are converted into a qualitative‐system‐dynamics model and are then abstracted into system archetypes. The study identified three major themes: the dilemma involving stakeholders, the dilemma of alternative and commercial use of Lantana, and the Lantana management conundrum. The study translated these dilemmas into four generalisable archetypes: ‘drifting goals’, ‘modified‐shifting‐the‐burden’, ‘fixes‐that‐fail’ and ‘substitution rebound’. The latest is a novel contribution to the systems literature. Practically, the study helps understand the recurring undesired behavioural patterns in invasive species management and suggests policy and governance changes to tackle them. The study also points towards building stakeholder relationship protocols, focussing on fundamental solutions and having clear Lantana management targets.

Aortic regurgitation in athletes: the challenges of echocardiographic interpretation

BackgroundBicuspid aortic valve (BAV) is the most common congenital cardiac defect and prone to premature degeneration causing aortic regurgitation (AR). The assessment of AR in athletic individuals poses several challenges as the pathological left ventricle (LV) remodelling caused by AR may overlap with the physiological remodelling of intense exercise. The purpose of this study is to highlight these challenges, review the existing literature and discuss how to tackle these conundrums. As a real-world example, we compare the resting transthoracic echocardiographic (TTE) findings in a cohort of individuals with BAV and AR, sub-grouped into “highly active” or “lightly active”.MethodsAdult male subjects with an index TTE performed at a tertiary referral centre between 2019 and 2022 were included if the TTE confirmed a BAV and at least moderate AR. Further strict inclusion criteria were applied and parameters of valve disease severity was made in accordance with existing guidelines. Subjects completed a physical activity questionnaire over the telephone, and were classified into either group 1: “highly active” or group 2: “lightly active” based on their answers. Demographics and TTE parameters were compared between the two groups.Results30 male subjects (mean age 44 ± 13 years) with BAV-AR were included – 17 were highly active, and 13 lightly active. There was no significant difference in age (group 1, 45 ± 12.7 years vs. group 2, 42 ± 17 years; p = 0.49), height (p = 0.45), weight (p = 0.268) or severity of AR, when quantitative assessment was possible. Group 1 had a significantly higher stroke volume (131 ± 17mls vs. 102 ± 13 mls; p = 0.027), larger LV volumes, diastolic dimensions and significantly larger bi-atrial and right ventricular size. This LV dilatation in the context of AR and athleticism poses a diagnostic and management conundrum. Despite this, none of these 17 highly active individuals demonstrated any of the traditional criteria used to consider surgery.ConclusionThere is significant overlap between the physiological adaptations to exercise and those caused by AR. Multi-modality imaging and stress testing can aid clinicians in diagnostic and management decisions in exercising individuals when there is discordance between AR severity and symptoms.

Vascular Access: A Clinical Conundrum in Endovascular Management of Iliac Pseudoaneurysm

Vascular Access: A Clinical Conundrum in Endovascular Management of Iliac Pseudoaneurysm

Trouble in paradise: When two species of conservation and cultural value clash, causing a management conundrum.

Threatened species throughout the world are in decline due to various causes. In some cases, predators of conservation or cultural value are causing the decline of threatened prey, presenting a conservation conundrum for managers. We surveyed marine turtle nests on K'gari (formally known as Fraser Island), Australia, to investigate dingo predation of green and loggerhead turtle nests, where each of these species is of conservation value. Our monitoring revealed that 84% of nests were predated by dingoes. Only 16% of nests were not consumed by dingoes, and only 5.7% of nests were confirmed to have successfully hatched. Up to 94% of nests were consumed in some areas, and predation rates were similar across different dingo packs. Information on the available numbers of nests and dingoes in the area indicated that turtle nests alone are sufficient to support extant dingoes over the summer. These results indicate that marine turtle eggs represent a previously unquantified but important food source for dingoes on K'gari, and that turtle nests at this rookery site are under serious threat from dingoes. This research should highlight the importance of prioritising the protection of turtle nests from dingoes or risk losing the entire rookery forever in the near future.

Children and Adolescents With Hybrid Diabetes: A Management Conundrum

ObjectiveHybrid diabetes (HD); ie, insulin resistance with positive diabetes-associated autoantibodies (DAAs) is increasing in children. We aimed to compare the characteristics of children with HD with those with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) at diagnosis and after 2 years. MethodsA retrospective review of patients aged 0 to 19 years, with C-peptide and 4 DAA measurements available, who were diangosed with new-onset diabetes from 2016 to 2020 were included in the analysis. ResultsOverall, 102 subjects were included, 32 with T1DM, 21 with HD, and 49 with T2DM. Amongst the groups (T1DM vs HD vs T2DM), there were differences in the proportion of non-Hispanic Whites (81.3% vs 47.6% vs 16.4%, P < .001), frequency of family history of T2DM (37.5% vs 100% vs 85.4%, P < .001), acanthosis nigricans (0% vs 42.9% vs 93.9%, P <.001), median body mass index z-score (−0.55 vs 1.8 vs 2.4, P <.001), and median C-peptide (0.4 ng/mL vs 0.9 ng/mL vs 2.4 ng/mL, P <.001). At 2 years, differences were seen in median body mass index z-scores (0.3 vs 1.9 vs 2.3, P <.001), mean HDL-cholesterol (58.0 mg/dL vs 48.2 mg/dL vs 39.5 mg/dL, P <.001), and the use of basal insulin (100% vs 100% vs 74.4%, P <.001). ConclusionPhenotypic and metabolic differences were seen in youth with T1DM, HD, and T2DM at diagnosis and follow-up. At 2 years, all subjects with HD remained insulin dependent whereas some with T2DM were not, indicating the need for targeted interventions to address the etiopathogenesis.

HRAS-mutated primary thyroid malignant melanoma or medullary thyroid carcinoma with melanocytic dedifferentiation? A singular case with an ontogeny-phylogeny quandary.

Melanotic pigment in the thyroid is practically synonymous with chronic minocycline therapy and rare cases of melanotic medullary thyroid carcinoma. However, primary melanoma of the thyroid has not been reported yet. We report a rare case of a 25-year-old male with a locally aggressive thyroid mass and distant metastases at presentation. Radiologically, a 8.3×7.6-cm nodule was identified in the right thyroid lobe. Fine-needle aspiration cytology (FNAC) showed discohesive atypical plasmacytoid cells with prominent nucleoli and no cytoplasmic pigmentation. Serum calcitonin levels were normal. A trucut biopsy showed a malignant tumor with a similar cytomorphology, including marked nuclear pleomorphism. In addition, intracytoplasmic melanin was seen in <1% of cells. Tumor cells were immunonegative for AE1/AE3, TTF1, synaptophysin, and chromogranin while positive for SOX10, S100P, HMB45, and Melan A, confirming the diagnosis of malignant melanoma, without any detectable MTC component in the biopsy. An HRAS G13R mutation was detected on NGS, which, intriguingly, is a known mutation in MTC, and exceedingly rare in melanocytic lesions. No other clinically or radiologically apparent primary lesion was identified elsewhere in the patient. The unusual histology and hitherto unreported molecular findings make this case of primary thyroid melanocytic neoplasm worth reporting. Abstruse origin of melanoma cells in the thyroid gland with molecular signature suggestive of MTC in our case raises a nomenclature and management conundrum, prompting us to revisit the "ontogeny recapitulates phylogeny" theory.

Anomalous aortic origin of right coronary artery from left coronary cusp: a management conundrum: a case report

BackgroundCoronary artery anomalies are characterized by an abnormality in the course or origin of three main coronary arteries. There needs to be more scientific evidence to promptly treat coronary artery anomalies with poorly understood prognostic implications, especially anomalous aortic origin of the right coronary artery from the left coronary cusp.Case presentationA 58-year-old Caucasian female presented multiple times over 6 months with atypical chest discomfort and palpitations. The treadmill exercise test demonstrated exercise-induced non-sustained ventricular tachycardia. A coronary angiogram revealed no obstructive coronary artery disease and an anomalous aortic origin of the right coronary artery from the left coronary cusp with an interarterial course. She was managed conservatively with medications, despite persistent recurrent symptoms.ConclusionIt is essential to identify subtle symptoms and insidious onset of anomalous aortic origin of the right coronary artery symptoms as seen in our patient, which can contribute to significant morbidity. There are discrepancies in existing guidelines between different cardiovascular societies in managing selected subgroups of patients with anomalous aortic origin of the right coronary artery who do not have high-risk features, but continue to remain symptomatic.

Takotsubo Syndrome and Complete Heart Block: A Diagnostic and Management Conundrum.

There is increasing evidence that Takotsubo cardiomyopathy behaves more like a highly variable and dangerous syndrome than an isolated cardiomyopathy. In this case report, we describe a case of Takotsubo cardiomyopathy complicated by complete heart block. We discuss the potential mechanisms for its etiology and examine the need for pacemaker placement.

Bringing Risk Parity To The DeFi Party: A Complete Solution To The Crypto Asset Management Conundrum

Bringing Risk Parity To The DeFi Party: A Complete Solution To The Crypto Asset Management Conundrum

The management and governance conundrum in South African public schools: principals’ perspectives

The introduction of school governing bodies (hereinafter SGBs) changed the roles and functions of principals dramatically when this new approach to school governance and professional management (referred to as a participatory decision-making approach) was activated when the South African Schools Act 84 of 1996 (hereinafter SASA) was implemented in January 1997. Consequently, the principal is no longer the only decision-maker in the school. The principal as the protagonist in school management and governance (implementing SGB policy) is the role-player most affected by the introduction of the participatory decision-making approach. In this article, we discuss principals’ perspectives regarding the shared participatory decision-making approach and the effects thereof on the relationship between the principal and the SGB. In this regard, it is important to note that the perceptions the two parties have of each other are established by the SGB’s encroachment on the professional management functions of the principal and vice versa. The research findings concluded that the relationship between the principal and the SGB is often a relationship characterised by tension, no trust and irrational actions by the SGB. The relationship is further influenced by the functionality or lack of functionality of SGBs as well as prevailing socio-economic conditions and SGB members’ levels of literacy. On the other hand, principals who do not adapt to participatory decision-making, and who still implement an assertive autocratic management approach, also contribute to a turbulent relationship.

Benign fibroepithelial polyp of ureter masquerading as upper tract urothelial carcinoma: A management conundrum

Upper tract Urothelial Cell Carcinomas (UTUCs) account for only 5–7% of urothelial carcinomas. Of these only 25% are located in the ureter. The imaging characteristics of these tumors can mimic certain benign entities like fibroepithelial polyps. The gold standard treatment for invasive upper tract urothelial carcinomas, regardless of the tumor’s location in the UUT, is Radical Nephroureterectomy (RNU) with excision of a bladder cuff. We describe the case of a patient with postoperatively detected benign fibroepithelial polyp who presented with symptoms and findings mimicking features of an UTUC. In cases where the preoperative diagnosis is in doubt, which can be the case with ureteric fibroepithelial polyps, surgical treatment should be to attempt complete excision of the tumor with renal preservation to prevent unnecessary nephrectomy.

Renal cell carcinoma with tumour thrombus extending in duplicated inferior vena cava: A rarity with management conundrum

DIVC may play a role as a confounding factor in imaging diagnostic tests and also may represent a hazard for inadvertent injury and bleeding during surgery. Careful interpretation Radiological investigations help to define such anomalies and avoid significant morbidity during surgical exploration. We present a case of renal cell carcinoma involving Right kidney with tumor thrombus extending into both venae cava. Triphasic Contrast-Enhanced Computerized Tomography (CECT) scan of abdomen with three-dimensional reconstruction showed duplicated left sided IVC, Heterogeneously enhancing intraluminal soft tissue density filling defect was seen along the entire length of right renal vein, also crossing the midline to the left sided duplicated IVC -s/o tumour thrombus. Patient underwent right radical nephrectomy with tumour thrombectomy. Cavotomy was done at the junction of right renal vein and right IVC. Entire thrombus was delivered intact. Histopathological examination showed papillary renal cell carcinoma (type II) stage pT3bN1Mx. IVC thrombus showed clusters of malignant cells of same morphology as tumor entangled in thrombus. The patient is doing well at 3 months of follow-up.

Comorbid Vulvar Lichen Sclerosus and High-Grade Squamous Intraepithelial Lesions: A Management Conundrum.

This study aimed to determine if treating lichen sclerosus (LS) with high-potency topical corticosteroids (TCS) increases the risk of high-grade squamous intraepithelial lesion (HSIL) recurrence in patients with comorbid vulvar LS and HSIL. This is a retrospective study of patients with comorbid vulvar LS and HSIL treated with TCS between 2015 and 2020. Patients with clinically diagnosed or biopsy-proven LS and biopsy-proven HSIL of the vulva were included. Clinical data included demographics, tobacco use, immune-modifying conditions, specimen pathology, treatment types, and HSIL recurrence. Bivariate analysis was performed to compare demographic and clinical characteristics between patients with and without HSIL recurrence. Twenty-six patients with comorbid LS and HSIL were identified. The median age was 66.0 years and median time in treatment for LS was 5.5 years. Thirteen (50%) had recurrence of HSIL and 13 (50%) did not have recurrence. Exposure to high-potency TCS was present in 20 (77%) patients, with 17 (65%) having use of more than 1-year duration and 9 (35%) having use at the time of HSIL diagnosis. When comparing the groups with and without HSIL recurrence, there was no significant difference in high-potency TCS exposure, duration of use, or use at time of HSIL diagnosis. High-potency TCS use for the treatment of LS did not seem to increase the risk of HSIL recurrence in patients with comorbid vulvar LS and HSIL. This suggests that high-potency TCS can be appropriately used for the treatment of LS even when HPV-associated disease is present.