Non-tender Swelling Research Articles

Magnetic Resonance Imaging of a Cystic Pilomatricoma in an Ankle Joint

Pilomatricoma, also known as calcifying epithelioma of Malherbe, is an asymptomatic, slow-growing, benign dermal neoplasm that originates from hair cortex cells. The most common sites are the head and neck (68.2%), followed by the trunk (14.4%) and the upper (15.3%) and lower (2%) extremities. The majority (60%-70%) of tumors develop in the first 2 decades of life. A typical pilomatricoma presents as a firm, calcified, dermal nodule appearing as a solid mass in subcutaneous tissue on computed tomography or magnetic resonance imaging.This article describes the case of a 42-year-old man who presented with nontender soft tissue swelling in the right ankle joint. Radiographs and magnetic resonance imaging findings showed an inflamed cystic mass with calcification in the lateral malleolar area of the right ankle joint. These atypical magnetic resonance imaging features around the ankle joint led to confusion with other disease entities, including chronic bursitis, pigmented villonodular synovitis, rheumatoid nodules, and gout. After complete excision of the mass, histological examination revealed a cystic pilomatricoma.Although rare, a cystic pilomatricoma should be considered in the differential diagnosis of soft tissue masses with calcification.

Aneurysm of External Jugular Vein Mimicking Hemangioma of Neck

Venous aneurysms are one of the rare causes of neck swellings. Among neck veins, external jugular vein aneurysms are uncommon. We present a case of a woman who presented with a nontender compressible swelling in the left lower neck region, which initially thought to be hemangioma, was later found to be external jugular vein aneurysm on Doppler ultrasound and CT angiography.

C3 An old friend, a new face: primary syphilis presenting as a bubo with balanitis and lymphocoele

BackgroundFollman balanitis as an initial presentation of primary syphilis is well described and syphilis is a known cause of lymphocoele. Inguinal buboes are commonly seen in chancroid and lymphogranuloma venereum...

Benign fibrous histiocytoma of the external auditory canal: Case report and literature review

Background: The benign fibrous histiocytoma (BFH) is a mainly dermal neoplasm composed of a mixture of fibroblastic and histiocytic cells. It is usually reported as occurring on the extremity, retroperitoneum or orbit but not commonly in the other head and neck regions.Methods: A ten-year old girl presented with a right external auditory meatal mass for 6 months. Clinical examination showed a small, firm non-tender swelling on the antero-inferior part of the cartilagenous external auditory canal. An excisional biopsy was performed without complication.Results: Clinical and histopathological examinations with immunohistochemical studies were consistent with the diagnosis of BFH of the external auditory canal. There was no local recurrence to date.Conclusions: BFH is an uncommon benign neoplasm of the head and neck and none has been previously described occurring in the external auditory canal. Complete local excision is the mainstay of treatment with excellent prognosis. DOI: http://dx.doi.org/10.3329/bjo.v18i1.10424 Bangladesh J Otorhinolaryngol 2012; 18(1): 77-80

Pseudoaneurysm of the Facial Artery After the Injection of Local Anesthetics

Generally, a true aneurysm is a dilatation of the vessel wall, whereas a pseudoaneurysm (PA) is a weakening or rent in a vessel wall, with contained rupture into the surrounding tissues. In the face, PAs of the facial artery are an extremely rare development after penetrating or blunt trauma. A 31-year-old woman presented with nontender, palpable, and firm lump that had been steadily increasing in size over a 4-week period. Examination confirmed a firm and spherical swelling in the left mandibular area, which was nonpulsatile. The patient presented with a mass on the upper part of her left chin 6 months after the injection of local anesthetics for dental treatment. After the procedure, a hematoma developed over the injection site, and it was treated with local ice. This case is unique in that the lesion seen using computed tomography and ultrasonography scanning had an unusual presentation. Ultrasonography revealed thrombi within the tumor, and color Doppler examination showed blood moving in the perivascular mass. During the operation via intraoral incision, a lesion was found as a dilation of the muscular branch of the facial artery. The facial artery was exposed, isolated, and tied off with a 2-0 white silk ligature. Histopathologic analysis determined that the content of the fragile cystic lesion was an organized thrombus and hematoma. As with any penetrating facial injury, local anesthetics can damage vessels and produce a PA. Therefore, we present a rare case of false facial artery aneurysm with no associated risk factors, which was nonpulsatile on presentation.

Subcutaneous Entomophthoromycosis mimicking soft tissue tumour: Report of two cases in Maharashtra, India

Entomophthoromycosis (subcutaneous zygomycosis) is a sporadic subcutaneous infection that is largely restricted to tropical areas of Africa, Asia, and South America. It presents in two clinically distinct forms. Subcutaneous zygomycosis, caused by Basidiobolus ranarum and rhinofacial zygomycosis caused by Conidiobolus coronatus. Neither of these two forms occur preferentially in patients with underlying disease or defective immunity1. Entomophthoromycosis is characterized by the formation of firm and nontender swellings, generally on the extremities, trunk, & rarely other parts of the body2. Subcutaneous zygomycosis can also mimic soft tissue tumors3. We present 2 cases with large, rapid-growing zygomycotic subcutaneous lesions, initially misdiagnosed as a soft tissue tumor, emphasizing importance of rapid & thorough diagnosis with a high index of suspicion, especially in endemic areas. Our experience with these cases highlights importance of awareness & early recognition of this condition to prevent disfigurement produced by advanced disease, misdiagnosis, & unnecessary delay in treatment. Subcutaneous zygomycosis should be considered in differential diagnosis of subcutaneous swellings, especially in tropical countries. Treatment should be given on histopathological diagnosis as fungus is difficult to grow in culture with immunology & serology having limited basis in use for diagnostic purposes.

Case report of traumatic abdominal wall hernia following blunt motorcycle handlebar injury and review of the literature

A 25-year-old man, riding a motorcycle, rammed into a moving car at a T junction and sustained a blunt lower-right abdominal injury with the handlebar of his motorbike. He developed a swelling at the point of impact for which he presented in hospital 10 days later. Clinical assessment revealed a healthy young man with a soft, nontender reducible swelling over the lateral half of the right inguinal area. A diagnosis of acute traumatic hernia was made. Abdominal ultrasonography revealed a wide-necked defect in the anterior abdominal wall over the right inguinal area with protruding bowel loops beneath an intact skin. He was planned for herniorrhaphy but has defaulted since then.

Subcutaneous zygomycosis of the cervicotemporal region: Due to Basidiobolus ranaram

Basidiobolomycosis is a rare chronic subcutaneous infection caused by Basidiobolus ranarum. The disease usually occurs in children, less often in adolescent and rarely in adults. Males are more frequently affected than females. We report a case of subcutaneous zygomycosis of head and neck region caused by B. ranaram, in an immunocompetent adult female presenting with nontender firm swelling over the nape of neck and temporo-parietal region. The diagnosis was confirmed by histopathology, microbiology (culture) and DNA sequencing of molecular technique (sequencing). The patient was successfully treated with amphotericin B and potassium iodide

A Case of Juvenile Sjögren's Syndrome with Interstitial Nephritis

Primary Sjögren's syndrome (SS) is a rare autoimmune disease, especially in children. Juvenile primary SS with interstitial nephritis is rare in Japan. We report on a 12-year-old girl in whom salivary gland swelling had recurred from the age of 5 years, SS was diagnosed at the age of 10 years, and interstitial nephritis developed at the age of 12 years. The patient presented with a chief complaint of swelling of both parotid glands. The patient had a history of recurrent parotitis from 5 years of age, with episodes recurring 5 to 6 times a year and resolving within 3 days each time. However, at the age of 11 years, the patient had continuous mild swelling of the parotid glands. Examination on admission showed bilateral nontender parotid gland swelling; mild swelling of the lower extremities, xerostomia, and xerophthalmia but no exanthem. Laboratory findings were as follows: serum protein, 10.1 g/dL; immunoglobulin (Ig) G, 3,828 mg/dL; antinuclear antibodies, 1,280-fold; anti-Ro/SS-A antibody, 512-fold; anti-Ro/SS-B antibody, 4-fold; creatinine, 0.45 mg/dL; blood β2-microglobulin, 2.2 mg/L (slightly elevated); and cystatin C, 0.86 mg/L. Urinalysis showed proteinuria and a β2-microglobulin concentration of 11,265 mg/L. Thus, this patient had low molecular weight proteinuria. Schirmer's test showed decreased tear secretion (5 mm), and fluorescein staining showed marked bilateral superficial punctate keratitis. A lip biopsy showed infiltration by small round cells (mild to moderate), interstitial fibrosis, loss of salivary gland parenchyma, and atrophy, with no obvious epimyoepithelial islands, leading to a diagnosis of SS. Light microscopic examination of the renal biopsy specimens showed expansion of mononuclear cell infiltration in the renal interstitium, inflammatory cell infiltration of interstitial areas with edema and mild fibrosis, and tubulitis and mononuclear cell infiltration that included many lymphocytes and plasma cells. There were no pathological findings of glomerulonephritis. Small arteries showed no obvious abnormalities. Immunofluorescent staining showed slight, nonspecific deposition of IgM, but no deposition of IgG, complement 1q, 3, or 4. On the basis of the renal biopsy showing nonspecific chronic interstitial nephritis, renal tubular atrophy, and interstitial enlargement, tubulointerstitial nephritis associated with SS was diagnosed.

Imaging characteristics of three primary muscular hydatid cyst cases with various patterns

A 65-year old man was admitted to our surgery clinic because of a cystic mass within his left thigh musculature. He had realized a progressively growing mass in his left thigh for three years. He was living in a village and had contact with both sheep and dogs since his childhood. There was no history of trauma, fever or weight loss. Laboratory results showed an erythrocyte sedimentation rate of 12 mm/h (Westergren) and a total leukocyte count of 7,000/mm3. A hemaglutination inhibition test revealed that the titer of antibodies to Echinococcus was 1:165. Physical examination revealed a diffuse, non-tender cystic swelling occupying nearly the entire anterior aspect of the thigh with the rigidity of the muscles. Chest X-ray was normal. Abdominal US revealed no abnormality. US and CT examinations were performed. US examination showed a 5 x 4 cm mass composed of multiple thin-walled cysts (Fig. 1a). These clusters of cysts were localized between the femur and vastus muscles, with no involvement of the muscle or bone. No calcifi cations were present. CT scan demonstrated the cystic structure close to vastus muscles (medius, intermedius, lateralis) (Fig. 1b). The lesion was defi ned as a type-II HC according to the Gharbi classifi cation. Introduction

Volar Plating for Unstable Proximal Interphalangeal Joint Dorsal Fracture-Dislocations

To report our results of open reduction internal fixation with volar mini plate and screw fixation for unstable dorsal fracture dislocations (DFDs) of the proximal interphalangeal (PIP) joint. We performed a retrospective review of 13 consecutive DFDs of the PIP joint treated with volar mini plate and screw fixation, measuring both clinical and radiological outcomes. The age range of our patients was 15 to 56 years (average, 33 y). Six injuries were related to work, 5 to sports, and 2 to motor vehicle accidents. Of the 13 DFDs, 6 were comminuted. Articular involvement ranged from 30% to 70% (average, 44%). The average time to surgery was 7 days (range, 0-23 d). Patients had follow-up of 12 to 60 months (average, 25 mo). Four patients had a postoperative course complicated by plate and screw removal at an average of 4 months later, either as part of a secondary procedure to improve range of motion or owing to patient request. All patients returned to their original occupation. Of the 13 patients, 11 were satisfied with the result, and 12 of 13 had either no or mild pain. All 13 DFDs united in good alignment but 3 showed degenerative changes. Average grip strength was 85% of the unaffected side, and average active PIP joint and distal interphalangeal joint motion arcs were 75° and 65°, respectively. Average Quick Disabilities of Arm, Shoulder, and Hand score was 4 (range, 0-9). All patients had non-tender swelling of the proximal interphalangeal joints but no signs of flexor tenosynovitis or infection. Fixation of unstable PIP joint DFDs via a volar approach is technically feasible with mini plates and screws. This treatment allows early active range of motion and provides good objective and subjective outcomes; however, noteworthy complications occurred in 39% of patients. Therapeutic IV.

Primary parotid gland lymphoma: a case report.

IntroductionMucosa associated lymphoid tissue lymphomas are the most common lymphomas of the salivary glands. The benign lymphoepithelial lesion is also a lymphoproliferative disease that develops in the parotid gland. In the present case report, we describe one case of benign lymphoepithelial lesion with a subsequent low transformation to grade mucosa associated lymphoid tissue lymphoma appearing as a cystic mass in the parotid gland.Case presentationA 78-year-old Caucasian female smoker was referred to our clinic with a non-tender left facial swelling that had been present for approximately three years. The patient underwent resection of the left parotid gland with preservation of the left facial nerve through a preauricular incision. The pathology report was consistent with a low-grade marginal-zone B-cell non-Hodgkin lymphoma (mucosa associated lymphoid tissue lymphoma) following benign lymphoepithelial lesion of the gland.ConclusionsSalivary gland mucosa associated lymphoid tissue lymphoma should be considered in the differential diagnosis of cystic or bilateral salivary gland lesions. Parotidectomy is recommended in order to treat the tumor and to ensure histological diagnosis for further follow-up planning. Radiotherapy and chemotherapy should be considered in association with surgery in disseminated forms or after removal.

Non-ossifying fibroma (metaphyseal fibrous defect) of the mandible

A 15-year-old young man was referred for evaluation of a non-tender swelling of the left mandibular angle region. A non-ossifying fibroma was diagnosed. The lesion was enucleated under general anesthesia. The postoperative course was uneventful. There have been no signs of recurrence, and there was complete bone regeneration in the region 24months after operation. This report also reviews other fifteen cases of non-ossifying fibroma in the mandible reported in the literature.

Synchronous malignant vagal paraganglioma with contralateral carotid body paraganglioma treated by radiation therapy

Paragangliomas are rare tumors and very few cases of malignant vagal paraganglioma with synchronous carotid body paraganglioma have been reported. We report a case of a 20-year old male who presented with slow growing bilateral neck masses of eight years duration. He had symptoms of dysphagia to solids, occasional mouth breathing and hoarseness of voice. Fine needle aspiration cytology (FNAC) performed where he lived showed a sinus histiocytosis and he was administered anti-tubercular treatment for six months without any improvement in his symptoms. His physical examination revealed pulsatile, soft to firm, non-tender swellings over the anterolateral neck confined to the upper-mid jugulo-diagastric region on both sides. Direct laryngoscopy examination revealed a bulge on the posterior pharyngeal wall and another over the right lateral pharyngeal wall. Magnetic resonance imaging (MRI), 99mTc-labeled octreotide scan and angiography diagnosed the swellings as carotid body paraganglioma, stage III on the right side with left-sided vagal malignant paraganglioma. Surgery was ruled out as a high morbidity with additional risk to life was expected due to the highly vascular nature of the tumor. The patient was treated with radiation therapy by image guided radiation to a dose of 5040cGy in 28 fractions. At a follow-up at 16 months, the tumors have regressed bilaterally and the patient can take solids with ease.

Diagnosing SAPHO Syndrome in Suspected Metastatic Bone Tumors

Abstract: A previously healthy 44-year-old woman who had been followed at different health care facilities for symptoms which had begun 3 years earlier was referred to our service for clinical evaluation. Her problems during the initial examination were pain in the sternoclavicular and sacroiliac joints as well as plantar pustulitis. Based on previous x-ray hyperostosis findings, metastatic bone tumors to the spine and first costocondral junctions bilaterally were suspected. A biopsy of the sternoclavicular lesion showed a nonspecific inflammation pattern. On the first physical examination we found a nontender swelling of the sternoclavicular junctions, necrosis of the plantar epidermis and pain at the sacroiliac joints. The patient was referred for bone scintigraphy and positron emission tomography-computed tomography (PET-CT) scan. The whole body bone scintigraphy using Tc-99m MDP showed increased accumulation of the radiotracer in the anterior chest wall and in the right sacroiliac joint. Metastatic bone tumor was not suggested, although exclusion of bone metastases was difficult. The PET-CT with F-18 FDG showed areas with low metabolic activity in the anterior chest wall (SUV Max: 1.96) and in the right sacroiliac joint (SUV Max: 2.18) making the diagnosis of malignancy and acute infection unlikely. The clinical symptoms, the typical skin lesions involving the soles of the feet and low hypermetabolic lesions on PET-CT made the final diagnosis of SAPHO syndrome.

Responsibility and reflection: Understanding our responses to perceived errors. A response to Woodward, Lemer and Wu

A fourth-year medical student in the USA assumed responsi-bility for a patient with esophageal cancer as a member ofa consultation team. In her initial examination, the student notedasymmetric, non-tender lower-extremity swelling. She docu-mented the edema in her note but did nothing additional with thisinformation. Her teamwas focusing on pain, and she assumed thattheprimaryteamwashandlingday-to-dayoncologicconcerns.Fivedays later, with a change of members in the primary team, a newintern noted the swelling, ordered an ultrasound, and a lower-extremity deepvenous thrombosiswasdiagnosed.Afamiliar seriesof events unfolded: the student recognized her lapse as an error;she felt deeply ashamed and guilty; she worried that her error hadled to a delay in diagnosis, and that this had caused preventableharm to the patient. She reported her error and sense of shame toher attending, and asserted the desire to disclose and apologize forthe mistake to the patient. The attending physician agreed thatwhile an error had been made, there were mitigating factors. Theattending shared her own experience of committing a moredevastating mistake as a young trainee. The student perceivedthese words as comforting and supportive, but the feelings ofshame persisted even after she disclosed the error to the patient.Internally, she vowed never to ignore asymmetric edema.Were there systemic factors that contributed to this error?Absolutely. None of the many other participating physicians hadreadthestudent’sdocumentationofthephysicalexamination,onlythe assessment and plan. The likely harried initial primary internhad not noted the edema himself. A change in teams broughta change in perspective, bringing new information to bear. Thestudent’sformal educationdid notemphasize asymmetric swellingas a never-miss symptom. As the first author of our article in thisissue of Social Science & Medicine ‘‘On the Prospects for a Blame-Free Medical Culture’’ (Collins, Block, Arnold, & Christakis, 2009),the student described above likely understood more than theaverage student in her position about blame and the systemicprevention of error. But this did nothing to prevent her fromexperiencing this mistake as deeply personal, and from acceptingcomplete responsibility for it herself.Inhighlightingthelimitedprospectsforablame-freeculture,ourgoal is not to prevent progress in the error prevention movement.

Cysticercosis of the Breast

Cysticercosis, although common in developing nations, is an uncommon cause of a breast lump. This article reports a case from India, where a young woman presented with a firm, nontender breast lump. Breast sonography imaging with a high-frequency transducer revealed a well-defined cystic lesion with an internal echogenic nodule and surrounding hypoechoic area. Subsequently, fine-needle aspiration cytology was performed, which confirmed the diagnosis of cysticercosis.

Responsibility and reflection: Understanding our responses to perceived errors. A response to Woodward, Lemer and Wu

A fourth-year medical student in the USA assumed responsi-bility for a patient with esophageal cancer as a member ofa consultation team. In her initial examination, the student notedasymmetric, non-tender lower-extremity swelling. She docu-mented the edema in her note but did nothing additional with thisinformation. Her teamwas focusing on pain, and she assumed thattheprimaryteamwashandlingday-to-dayoncologicconcerns.Fivedays later, with a change of members in the primary team, a newintern noted the swelling, ordered an ultrasound, and a lower-extremity deepvenous thrombosiswasdiagnosed.Afamiliar seriesof events unfolded: the student recognized her lapse as an error;she felt deeply ashamed and guilty; she worried that her error hadled to a delay in diagnosis, and that this had caused preventableharm to the patient. She reported her error and sense of shame toher attending, and asserted the desire to disclose and apologize forthe mistake to the patient. The attending physician agreed thatwhile an error had been made, there were mitigating factors. Theattending shared her own experience of committing a moredevastating mistake as a young trainee. The student perceivedthese words as comforting and supportive, but the feelings ofshame persisted even after she disclosed the error to the patient.Internally, she vowed never to ignore asymmetric edema.Were there systemic factors that contributed to this error?Absolutely. None of the many other participating physicians hadreadthestudent’sdocumentationofthephysicalexamination,onlythe assessment and plan. The likely harried initial primary internhad not noted the edema himself. A change in teams broughta change in perspective, bringing new information to bear. Thestudent’sformal educationdid notemphasize asymmetric swellingas a never-miss symptom. As the first author of our article in thisissue of Social Science & Medicine ‘‘On the Prospects for a Blame-Free Medical Culture’’ (Collins, Block, Arnold, & Christakis, 2009),the student described above likely understood more than theaverage student in her position about blame and the systemicprevention of error. But this did nothing to prevent her fromexperiencing this mistake as deeply personal, and from acceptingcomplete responsibility for it herself.Inhighlightingthelimitedprospectsforablame-freeculture,ourgoal is not to prevent progress in the error prevention movement.

Chondroid syringoma diagnosed by fine needle aspiration cytology

Chondroid syringoma is a rare benign skin adnexal tumor of eccrine/apocrine origin affecting commonly the head and neck region. It used to be previously called as mixed tumor of skin because of the presence of both the epithelial and mesenchymal components. There are only few case reports describing the fine needle aspiration cytologic features of chondroid syringoma for diagnosis. We studied a 20-year-old male case from Taplejung district of Nepal came to Otorhinolaryngology out patient department with the complaints of painless, progressively enlarging swelling on the dorsum of nose. On examination, 2.0 x 2.0 cm, firm, non-tender swelling was seen on the right side of dorsum of nose. Overlying skin was normal, and the swelling was fixed to the skin but freely mobile over underlying structure. A clinical diagnosis of dermoid cyst was entertained, and the case was subjected to FNAC. FNA yielded mucoid material which on microscopy showed clusters of round cells with moderate to abundant cytoplasm embedded in chondromyxoid ground substance. The nuclei were monomorphic, centrally to eccentrically located and had fine chromatin. On the basis of these cytologic features, a diagnosis of chondroid syringoma was made. We concluded that Chondroid syringoma may be considered as a rare differential diagnosis in the swelling of head and neck region and the diagnosis can be easily confirmed or ruled out by means of fine needle aspiration cytology.

Body aches, tender bones and rapid loss of weight: a case report

IntroductionBone metastases presenting with pain and body-ache may be the first presentation of carcinoma in about a fourth of patients with cancer. Radiologically majority of the metastases are osteolytic and multiple. Sometimes these may be confused with infective or inflammatory conditions, particularly in young individuals, and degenerative conditions of the spine and hip in elderly, which may delay the diagnosis and treatment leading to poor outcomes.Case presentationA 30 year old non-smoking male teetotaller presented with intermittent, high-grade nocturnal fever with night sweats of one year. He also had low back ache over his right hip. We found him febrile, pale and his long bones, ribs and pelvis were tender. He had a 3 × 4 cm tender and hard swelling over the upper part of his sternum. Another firm, non-tender swelling about 4 × 5 cm was seen in the right iliac region. Radiographs of the skull, spine and pelvis revealed multiple variable sized lytic lesions. A metastatic malignancy or disseminated tuberculosis was considered. His anti-tubercular therapy was intensified Fine needle aspiration from sternal lesion showed inflammatory cells. A bone marrow biopsy showed infiltration by tumor cells suggestive of metastatic adenocarcinoma. Patient's condition continued to deteriorate and he died within a fortnight of his hospitalization.ConclusionAlthough masquerading as tuberculosis lytic lesions might be an evidence of malignant metastatic. Although, treatment is ineffective in this stage palliative efforts to improve quality of life should be made.