Multiple Swellings Research Articles

086. Combination of Mustarde Flap and Paramedian Forehead Flap in Nasal Non-Melanoma Basal Cell Carcinoma: A Case Report

Background: Basal cell carcinoma (BCC) is a non-melanocytic skin cancer, specifically an epithelial tumor originating from basal cells. The National Comprehensive Cancer Network (NCCN) states that the primary goal of treating BCC is to eliminate the tumor to prevent its locally invasive and damaging characteristics while preserving function and aesthetic appearance as much as possible. This case report details a patient who experienced a defect on the nose due to surgery. Case: A sixty-year-old male patient came to our center with a lump on the right side of his nose, which had developed about 1.5 years prior to his admission. Over the last year, the initially small lump progressively enlarged in both size and depth, becoming ulcerated and necrotic. Clinical examination showed multiple lumps on the right side of the nose with a necrotic edge and ulceration, but without any signs of bleeding. Laboratory tests showed normal results. Conclusion: Facial defects caused by BCC may require various reconstruction approaches depending on the size and location. A combination of skin flap techniques, such as the paramedian forehead flap and Mustardé flap, shows outstanding functional and cosmetic outcomes.

078. Malignant Peripheral Nerve Sheath Tumor Masquerading as Neurofibromatosis Type 1 in A 47-Year-Old Female: A Rare Case of Diagnostic Dilemma and Management Challenge

Background: Malignant Peripheral Nerve Sheath Tumor (MPNST) is a rare soft tissue sarcoma, often associated with Neurofibromatosis Type 1 (NF1), and can arise from benign neurofibromas. MPNST typically presents with rapidly enlarging masses, pain, or neurological deficits, but can sometimes be mistaken for benign lesions, delaying diagnosis. This case report discusses a 47-year-old female with NF1 whose benign lesion progressed into MPNST. Case: A 47-year-old female presented with a complaint of pus discharge from a lump in her buttock over the past four days. The lump had progressively enlarged for two years before discharging pus. The patient also described multiple lumps on her body since childhood, characteristic of NF1, but noted that only the lump on her buttock had grown significantly and hardened over time. Patient is unable to walk due to her condition since two years ago. Initial histopathological examination indicated benign neurofibroma, but two months later, the patient underwent surgical excision of the tumor as the primary treatment, and the specimen was examined for pathology and showed MPNST. Conclusion: MPNST should always be considered in NF1 patients with rapidly enlarging, firm masses, even when initial pathology indicates a benign process. Timely diagnosis and surgical intervention are critical for optimal outcomes.

Primary Small Cell Carcinoma of Left Maxillary Sinus: A Case Report of Rare Tumor on Rare Location

Introduction: Primary extrapulmonary small cell carcinoma (EPSCC) is a rare and aggressive tumor with diverse clinical manifestations. In the realm of head and neck pathology, EPSCC most commonly presents in the larynx or oral cavity. Sinonasal small cell neuroendocrine carcinoma represents a particularly infrequent and aggressive neoplasm affecting the nasal cavity and paranasal sinuses. Case Presentation: Here in, we are presenting a case of a 40-year-old nonsmoking male with left maxillary sinus EPSCC, demonstrating extensive local invasion and regional lymphadenopathy. The patient presented with nasal obstruction, ocular swelling, visual loss, and multiple neck swellings. Diagnosis was challenging, requiring a multidisciplinary approach and histopathological confirmation. Immunohistochemistry revealed positive cytokeratin AE1/AE3 and synaptophysin markers validating the diagnosis of small cell carcinoma. Conclusion: This case underscores the diagnostic complexities and highlights the importance of swift intervention and a multidisciplinary treatment approach for optimizing patient outcomes in rare and aggressive tumors like EPSCC. Early detection and prompt management are crucial in resource-limited settings to mitigate morbidity and mortality.

Mesenteric Dedifferentiated liposarcoma presenting as a massive abdominal lump: A Rare Case

This case study examines a sixty five-year-old male presenting with a distended abdomen, lower back discomfort, and dyspnea on lying down, progressing over three months. Physical examination revealed multiple hard palpable lumps in the abdomen. Initial radiological evaluation indicated a connective tissue tumor, leading to a trucut biopsy revealing a spindle cell neoplasm of uncertain malignant potential. The tumor was found to be resistant to immunotherapy and neoadjuvant chemotherapy. Surgical resection unveiled multiple mesenteric tumors along the small bowel and also involving the descending colon, diagnosed as a dedifferentiated liposarcoma. Liposarcoma encompasses five histological subtypes, with dedifferentiated being the least common and comprised of poorly differentiated cells. Although liposarcomas typically originate from the retroperitoneum, the occurrence of dedifferentiated liposarcoma in the small bowel mesentery is exceedingly rare. This case report aims to underscore this uncommon occurrence, discuss diagnostic and treatment strategies, and advocate for further research into targeted therapies addressing specific immunohistochemistry markers to enhance outcomes for such patients, who generally face a grim prognosis Keywords – dedifferentiated liposarcoma , mesenteric tumors, spindle cell malignancy, mesenchymal tumors of GIT.

Bilateral tuberculous dactylitis of both hand and feet in a female toddler: a case report on a rare presentation of skeletal tuberculosis in children

BackgroundEven though tuberculosis is a common disease among children in developing countries, tuberculous dactylitis is an uncommon form of Skeletal tuberculosis specially with involvement of both the hands and feet.Case PresentationA one-and-a-half-year-old previously healthy female Ethiopian toddler presented to our pediatric outpatient clinic with a history of two-month duration of painful multiple swellings over both her hands and feet. The swelling involved the proximal phalanx of the left index finger, dorsum of the right hand, and dorsum of both feet over the first metatarsal bone. Physical examination, radiologic findings, and histopathology suggested tuberculous dactylitis. The patient was treated with anti-tuberculosis drugs for one year and she showed clinical and radiologic improvement and recovery.ConclusionTubercular dactylitis should be considered in the differential diagnosis of children from endemic areas presenting with bone and joint pain or swelling. Our experience of a twelve-month course of antitubercular treatment, which is in line with WHO recommendations, for skeletal tuberculosis, showed excellent outcomes.

Nevus Unius Lateris (NUL) in a Theree-Year-Old Child Treated by Tretinoin 0.025%, Desoxymethasone 0.25%, and Urea 20% Cream

Background: Linear verrucous epidermal nevus is the most frequent variant of the epidermal nevus classification. Linear verrucous epidermal nevus is characterized by the proliferation of epithelium arranged in a configuration that follows Blaschko's line. Nevus unius lateris (NUL) is a variant of the verrucous epidermal nevus, which has a unilateral distribution of lesions. Lesions are usually found at birth or in the first year of life as brown to grey verrucous papules or papillomatous plaques. The management of NUL is challenging as the results are varied and there is a high risk of recurrence. Purpose: to report a case of NUL and its management, especially in children. Case: A 3-year-old girl presented with brownish spots and multiple small lumps on the left buttock that have extended to the left leg since she was 9-days-old. On dermatologic examination, there were numerous hyperpigmented verrucous papules and plaques along the Blaschko line over the affected area. In this case, the diagnosis of NUL, is based on clinical symptoms and dermoscopy examination showed multiple large brown oval or round structures with hyperpigmented brown border. The patient was treated with combination topical therapy of tretinoin 0.025%, corticosteroid desoxymethasone 0.25%, and urea 20% cream, and the lesion improved within four weeks. Discussion: Epidermal nevus is often cosmetically disturbing. The treatment is still challenging and various, including surgical and non-surgical, but none is ideal and could potentially recur over months or years. dst.

Multiple Nasal Swellings and An Unusual Diagnosis: Extramedullary Plasmacytoma

Multiple Nasal Swellings and An Unusual Diagnosis: Extramedullary Plasmacytoma

Medical management of cutaneous lymphoma and associated ileus in a labrador dog

A 6-year-old male Labrador dog was presented to the Small Animal Medicine unit of the Veterinary Clinical Complex, Veterinary College and Research Institute, Orathanadu with a history of hair loss and multiple skin lumps all over the body. The dog was treated for atopic dermatitis past three weeks. Clinical examination revealed generalized alopecia, lymphadenopathy and nodule-like skin lumps were noticed all over the body. Hemato-biochemical analysis revealed anaemia, lymphocytosis and hypoproteinemia. FNAC of skin lump revealed cutaneous lymphoma. Radiography and ultrasonography examination revealed no evidence of metastasis. The dog was treated with modified Wisconsin Madison protocol. On the 15th week of protocol dog showed a distended abdomen and constipation, further abdominal ultrasonography revealed a distended loop and ileus. Hence the present case was diagnosed as vincristine-associated ileus in a dog. Neostigmine was administered to restore the intestinal motility. The dog showed uneventful recovery from cutaneous lymphoma and as well as vincristine-associated ileus.

MULTIPLE GIANT CHALAZIA IN HYPERIMMUNOGLOBULINEMIA E SYNDROME: A CASE REPORT

Introduction : Hyperimmunoglobulinemia E syndrome (HIES) is a rare primary immunodeficiency disorder that manifests as elevated level of serum immunoglobulin E (IgE) higher than 1.000 IU/mL and multisystem disorder characterized by recurrent skin and pulmonary abscesses caused by autosomal dominant or recessive disorder with gene mutation. We present a case of multiple giant chalazion ina patient with HIES.
 Case Illustration : A 15-year-old boy was referred to Ophthalmology Department with multiple giant lumps on the left eyelid for the last 2 weeks. He had a history of recurrent multiple lumps on the left lower eyelid in the last 1 year. He was diagnosed with HIES since 8 years ago. He had normal visual acuity of both eyes. Multiple giant chalazion were observed on the left upper and lower eyelid. The patient also presented with scalp and neck infection. Laboratory studies showed elevated total serum IgE level of 53,032 IU/mL and eosinophilia.
 Discussion : Ocular manifestations in HIES patients are not common. Some cases reported chalazia, keratoconus, and blepharitis. Surgical incision drainage was performed in our patient. Medications and surgical intervention had produced only transient improvement. The patient was treated conservatively. Riskof chalazia recurrence remains unknown as reported cases presented with diverse clinical presentation and follow-up serum IgE evaluation is not routinely performed.
 Conclusion : Recurrent multiple giant chalazia may occur as an ophthalmic feature of HIES. HIES should be considered and investigated in patients presenting with recurrent giant chalazia.

MULTIPLE GIANT CHALAZIA IN HYPERIMMUNOGLOBULINEMIA E SYNDROME: A CASE REPORT

Abstract
 Introduction : Hyperimmunoglobulinemia E syndrome (HIES) is a rare primary immunodeficiency disorder that manifests as elevated level of serum immunoglobulin E (IgE) higher than 1.000 IU/mL and multisystem disorder characterized by recurrent skin and pulmonary abscesses caused by autosomal dominant or recessive disorder with gene mutation. We present a case of multiple giant chalazion ina patient with HIES.
 Case Illustration : A 15-year-old boy was referred to Ophthalmology Department with multiple giant lumps on the left eyelid for the last 2 weeks. He had a history of recurrent multiple lumps on the left lower eyelid in the last 1 year. He was diagnosed with HIES since 8 years ago. He had normal visual acuity of both eyes. Multiple giant chalazion were observed on the left upper and lower eyelid. The patient also presented with scalp and neck infection. Laboratory studies showed elevated total serum IgE level of 53,032 IU/mL and eosinophilia.
 Discussion : Ocular manifestations in HIES patients are not common. Some cases reported chalazia, keratoconus, and blepharitis. Surgical incision drainage was performed in our patient. Medications and surgical intervention had produced only transient improvement. The patient was treated conservatively. Riskof chalazia recurrence remains unknown as reported cases presented with diverse clinical presentation and follow-up serum IgE evaluation is not routinely performed.
 Conclusion : Recurrent multiple giant chalazia may occur as an ophthalmic feature of HIES. HIES should be considered and investigated in patients presenting with recurrent giant chalazia.

A Curious Case of Multiple Lower Limb Swellings.

A Curious Case of Multiple Lower Limb Swellings.

Juvenile Hyaline Fibromatosis- Child with Scalp Swellings

Juvenile hyaline fibromatosis is a recessive autosomal hereditary disorder characterized by abnormal growth of hyalinized fibrous tissue. Its clinical presentation is manifested by benign skin lesions, bone lesions, joint contractures, and gingival hyperplasia. The underlying cause is an abnormal growth of hyalinized fibrous tissue with cutaneous, mucosal, osteoarticular, and systemic involvement. This report presents a case of a 4-year-old male child; with complaints of multiple painful body swellings and pus discharge from scalp swellings for the past two years admitted at Dr. Ruth Pfau Civil Hospital, Karachi, 2021. This patient had right occipital scalp swelling of 10x 10 cm due to which surgery was done and the excision was successful. Other findings included stiff joints, skin overgrowth over the scalp and back + buttocks, multiple firm cystic swellings on the scalp, back, trunk, and whole body involving the face (nose), anal region, gum hypertrophy, and various papules over the nose.

Do Posterior Neck Lumps Need Ultrasound Evaluation: A Case Series of 623 Neck Ultrasound Studies at a Single Institution.

Neck lumps are a common presentation to primary care services. The aetiology of posterior neck lumps is poorly explored in the literature, and therefore remain a concern to patients and clinicians. This often results in an urgent referral for ultrasound assessment. The authors of this study sought to evaluate the aetiology of posterior neck lumps from a radiological perspective, to assess whether ultrasound can be used as a useful adjunct, rather than a first-line urgent investigation. A retrospective case series was carried out, examining all primary care referred ultrasound studies for assessment of posterior neck lumps, performed at a single institution in Essex, United Kingdom, over a period of over 10 years dating between 2nd February 2012 to 8th November 2022. Data was collected on: patient age at the time of study, patient sex, whether the lump was single or multiple as palpated and documented by the primary care physician, size of the lump to the nearest 0.5 cm as documented on ultrasound using the longest dimension, sonographic diagnosis and any follow up imaging (not limited to ultrasound). A total of 623 neck ultrasounds were performed on 615 adults. Of the overall radiological diagnoses made from the 623 scans, 555 (89.09%) scans were benign, 63 (10.11%) scans had no lump found on sonography, and 3 (0.48%) scans showed malignancy. In the remaining 2 (0.32%) scans, the lump was deemed indeterminate. The most common aetiologies for benign lumps were due to: normal lymph nodes (n = 263; 42.21%), lipomas (n = 152; 24.39%), and benign dermal cysts (n = 105; 16.85%). All 3 malignant cases had co-existing anterior and posterior neck lumps. Given that the overwhelming majority of posterior neck lumps in our study had benign findings, we propose that patients with solitary or even multiple posterior neck lumps alone, regardless of size can either be investigated routinely or can be reassured depending on other clinical examination characteristics. Patients who have the presence of co-existing anterior and posterior neck palpable neck lumps justifies urgent or 2-week wait radiological investigation.

Paediatric Clear Cell Sarcoma of Scalp Masquerading as Benign Sebaceous Cyst: A Diagnostic Dilemma

Clear Cell Sarcoma of Soft Tissue (CCSST) is a rare and aggressive tumour comprising 1% of all soft tissue sarcomas. They tend to recur locally and have a high predilection for regional, as well as, distant metastases. These tumours usually occur in a young age group; however, their presentation in childhood is extremely rare. They are also known as Malignant Melanoma (MM) of soft parts due to similar histological and Immunohistochemical (IHC) features with MM. Distinguishing between them is very difficult morphologically. Both exhibit high lymph node metastases and positive staining for S-100 protein, Melanoma antigen (Melan-A) and Human Melanoma Black-45 (HMB-45). Here, the authors reported an unusual case of an 11-year-old male child who presented with a slowly progressing scalp swelling that was misdiagnosed as a sebaceous cyst radiologically and on Fine Needle Aspiration Cytology (FNAC), which later turned out to be CCSST on histopathology. Unfortunately, the patient was lost to follow-up, but later presented with multiple cutaneous swellings, emphasising the tumour’s aggressive nature. The index case is being reported as an exception to its age of occurrence and unusual presentation that posed a diagnostic dilemma, leading to a delay in treatment. The treatment for CCSST involves wide surgical resection with negative margins, and adjuvant therapy may be considered based on resection outcomes. In conclusion, the present case underscores the diagnostic challenges posed by CCSST, particularly when it occurs in atypical age groups and locations. Timely recognition and differentiation from similar entities, such as MM, are crucial for appropriate management and improved outcomes.

Lymphoproliferative Disorder in an Esophageal Cancer Patient Treated with Pembrolizumab.

A 75-year-old man diagnosed with esophageal cancer and lung metastasis received a combination of fluorouracil, cisplatin, and pembrolizumab. During pembrolizumab maintenance therapy, lymphoproliferative lesions at the lips and mouth and multiple lymph node swellings appeared. Histologically, Epstein-Barr virus (EBV)-encoded RNA was positive, and EBV-DNA was detected in the blood. The patient was diagnosed with other iatrogenic immunodeficiency-associated lymph proliferative disorders (OIIA-LPDs) related to EBV activation induced by pembrolizumab. Rituximab was administered, resulting in the improvement of the OIIA-LPD. The emergence of an OIIA-LPD merits close attention in patients receiving immune checkpoint inhibitors.

Steatocystoma multiplex suppurativa: a case report

Introduction: Steatocystoma multiplex (SM) suppurativa is an inflammatory variant of SM, a benign hamartomatous disorder of pilosebaceous unit that usually occurs in early adulthood. Treatment responses are often disappointing due to widespread lesions and late diagnosis. This case report aimed to describe a male diagnosed with SM suppurativa to increase the knowledge and management of SM suppurativa. Case: A 23-year-old male came with multiple lumps on his neck, chest, back, and extremities over the last four years. On dermatological examination, yellow to skin-colored papules, nodules, and cysts, 0.3 to 2 cm in diameter, were observed with erythematous-to-hyperpigmented macules and scars over the lesions. Histopathological examination of the lesion showed cysts with pilosebaceous-like lining and sebaceous glands adhered to the cyst’s wall. The patient diagnosed with steatocystoma multiplex SM suppurativa was treated only with a topical antibiotic and corticosteroid. Discussions: Although the histopathological findings showed pathognomonic findings for SM, SM suppurativa was established as the working diagnosis based on the clinical and dermoscopic findings of inflammatory lesions. The biopsy of noninflammatory lesions might cause no sign of inflammation in the histopathological findings. Conclusions: Dermoscopic findings showed a yellow structureless area with diffuse erythematous borders and histopathological findings of a pilosebaceous-like layer with sebaceous glands adhering to the cyst wall and chronic inflammation is the hallmark of SM suppurativa.

MULTIPLE EYELID LUMPS IN INFANT WITH DYSLIPIDEMIA IN RESOURCE-LIMITED SETTING ANAMBAS ARCHIPELAGO DISTRICT

Objective: Present a case of recurrent multiple eyelid lumps in the infant with dyslipidemia in the limited resources area. Case Report: A case report on a three-year-old child who had several painless red tumors in his eyelids and was well-nourished. The patient had a similar complaint three times in the last seven months in different sites. No history of atopy, chronic blepharitis, trauma, or eyelid surgery. Laboratory findings showed elevated levels of cholesterol. Warm compresses, antibiotic topical, and erythromycin 50 mg/kgbw/day divided into three doses were the patient's initial therapeutic interventions. For managing dyslipidemia we planned to modification of lifestyle, diet, and activities for two weeks, then evaluate the level of cholesterol. We evaluated and educated the patient’s parent to refer him to an ophthalmologist for further management. However, we had difficulty referring patients to the provincial hospital with an ophthalmologist due to the islands’ geographical location, infrequent and weather-affected transportation, as well as family economics. Discussions: A hordeolum is a common inflammation of the eyelid margin. Recurrence of hordeolum is usually associated with underlying causes such as systemic disease. Dyslipidemia leads to hypersecretion of meibum which will cause highly concentrated meibum in Meibomian glands, that leads to blockage of ducts of Meibomian glands and Meibomian gland dysfunction (MGD). Initial treatment of hordeolum is indeed conservative, typically limited to the application of warm compresses several times a day and topical antibiotics. Conclusions: Dyslipidemia is usually associated with recurrent hordeolum. The management of hordeolum is conservative.

Munchmeyer's Disease - Fibrodysplasia Ossificans Progressiva: A Rare Case Report

Munchmeyer's disease or Fibrodysplasia ossificans progressiva (FOP) is a rare, disabling connective tissue disorder involving malformation of the big toes and progressive heterotopic ossifications, which evolves in flare-ups and leads to disabling joint stiffness. We report the case of a 20-month-old infant who presented with multiple painless swellings of spontaneous and progressive onset on the back, elbow and lower limbs. These swellings were associated with bilateral hallux valgus. The radiological and CT scan findings were highly suggestive, and the diagnosis was confirmed by genetic study, which identified a mutation in the ACVR1 gene, confirming Fibrodysplasia ossificans progressiva syndrome. Epidemiological, etiopathogenic, diagnostic, evolutionary and therapeutic aspects are discussed through a review of the literature.

Collision dynamics of high-order localized waves in a novel [formula omitted]-dimensional integrable Boussinesq model

The pursuit of finding precise solutions for complex nonlinear systems in high dimensions has long been a significant goal in the fields of mathematics and physics. This paper focuses on investigating a novel equation, referred to as the (3+1)-dimensional Boussinesq equation, which accurately describes the behavior of gravity waves on the surface of water. Using the Hirota bilinear method, the study successfully derives multiple-soliton and multi-breather solutions for the Boussinesq equation. Moreover, it presents mixed solutions that combine solitons and breathers under specific parameter conditions. By considering the long wave limit for these solitons, rational and semi-rational solutions for the equation are obtained. These rational solutions encompass line rogue waves and lump waves, while the semi-rational solutions emerge from the interaction between line rogue waves and solitons. Additionally, employing symbolic computation, the paper introduces a class of multiple lumps for the (3+1)-d Boussinesq equation, showcasing intriguing triangular formations and circular patterns. Overall, the findings of this research enhance our understanding of unique nonlinear phenomena and offer valuable theoretical support for future experimental investigations.

Multiple nodular swellings with gingival hyperplasia and joint contractures.

Multiple nodular swellings with gingival hyperplasia and joint contractures.