Nonspecific Radiological Findings Research Articles

Predictive factors for tuberculous peripheral pulmonary lesions during radial endobronchial ultrasound

BackgroundTuberculosis frequently poses diagnostic challenge when it presents as a peripheral pulmonary lesion (TB-PPL). The growing use of radial endobronchial ultrasound (rEBUS) for PPL biopsy highlights the need to identify predictive factors for TB-PPL, which is crucial for procedure safety. MethodsA six-year retrospective review at our institution on adult patients with TB and malignant-PPL diagnosed from rEBUS procedure from October 1, 2016, to December 31, 2022. Clinical, radiological, procedural, histological and microbiological data were extracted and analysed. Results387 PPLs were included in our cohort, 32 % were TB-PPL and 68 % were malignant-PPL. The median age was 63 (IQR 55–70) years, with the TB-PPL group significantly younger. The median size of the target lesion was 2.90 (IQR 2.26–4.00) cm. The overall rEBUS diagnostic yield was 85.3 %, with a 1.3 % pneumothorax risk. Multivariate analysis identified independent predictors for TB-PPL, including age <60 years (adj OR 2.635), target lesion size <2 cm (adj OR 2.385), upper lobe location (adj OR 2.020), presence of a cavity on pre-procedural CT (adj OR 4.186), and presence of rEBUS bronchogram (adj OR 2.722). These variables achieved an area under the curve of 0.729 (95 % CI 0.673–0.795) with a diagnostic accuracy of 75.49 % (95 % CI 70.68–79.88). ConclusionsDespite non-specific radiological findings in TB-PPL, our study identifies younger age, target lesion size less than 2 cm, upper lobe location, the presence of cavitation, and rEBUS bronchogram were independent clinical predictors for TB-PPL. This prediction model potentially helps mitigate the risk of accidental TB exposure during bronchoscopic procedures. A future prospective cohort study to validate these findings is essential to allow proper triaging of patient planning for rEBUS procedure.

Radiological findings in blunt abdominal trauma: bowel and mesenteric injuries

Mesenteric and intestinal injuries resulting from blunt abdominal trauma are relatively uncommon, but can be life-threatening. In this case, we present the story of a 46-year-old man who experienced blunt abdominal trauma due to a traffic accident. We will examine the specific and non-specific radiological findings that should alert us to the possibility of mesenteric or intestinal injury in such cases.

A review of histopathologic and radiologic features of non-atherosclerotic pathologies of the extracranial carotid arteries.

Diseases of the carotid arteries can be classified into different categories based on their origin. Atherosclerotic carotid disease remains the most encountered arterial wall pathology. However, other less-common non-atherosclerotic diseases can have detrimental clinical consequences if not appropriately recognized. The underlying histological features of each disease process may result in imaging findings that possess features that are obvious of the disease. However, some carotid disease processes may have histological characteristics that manifest as non-specific radiologic findings. The purpose of this manuscript is to review various non-atherosclerotic causes of carotid artery disease as well as their histologic-radiologic characteristics to aid in the appropriate recognition of these less-commonly encountered pathologies.

A rare cause of neonatal feeding intolerance: congenital segmental intestinal dilatation—a case report

BackgroundCongenital segmental intestinal dilatation (CSID) is a rare cause of neonatal bowel obstruction. Patients can present in the early newborn period with feeding intolerance and abdominal distension. Diagnosis is challenging due to its rarity and non-specific clinical and radiological findings in a well neonate. Surgical excision remains the mainstay treatment for this disease.Case presentationWe report a case of a newborn male with congenital segmental ileal dilatation, who presented with abdominal distension and feeding intolerance. He was born preterm at 32 weeks and was treated for presumed sepsis due to a premature rupture of the membrane. The patient developed persistent abdominal distension upon initiation of feedings with large amount of gastric aspirates. Otherwise, there was no delay in the passage of meconium. Serial abdominal radiographs showed persistent focal bowel dilatation on the right side. He was initially diagnosed with small bowel atresia. Ultrasound abdomen and lower gastrointestinal contrasted study showed focal ileal dilatation with no evidence of pneumoperitoneum. Intraoperative findings revealed a segmental ileal dilatation with no evidence of mechanical obstruction. The abnormal dilated bowel was excised and sent for histopathological examination. He recovered well after surgery.ConclusionDiagnosis of CSID can be challenging due to its clinical polymorphism and non-specific radiological findings. CSID should be suspected in neonates with feeding intolerance and focal intestinal dilatation without clinical features of sepsis, peritonitis, or mechanical obstruction. Surgical excision is curative with a good outcome.

Radiological Imaging Results in HIV-Infected Patients in Mogadishu-Somalia: A Four-Year Retrospective Review

Somalia, which is one of the countries that has been trying to integrate with the rest of the world in terms of many socio-economic parameters, including the field of health in recent years, still faces some important health problems. One of these problems is the difficulties encountered in the early diagnosis and treatment of patients with human immunodeficiency virus (HIV) infection, primarily due to social discrimination and limited treatment access. In this study, it was aimed to examine the findings detected in the radiological imaging examinations requested during the first examination in patients who were diagnosed with HIV for the first time by detecting HIV seropositivity in tests performed for different clinical reasons, and to determine the pathologies caused by advanced disease in patients who did not receive treatment. The study includes 235 patients who were diagnosed for the first time out of 269 patients with HIV confirmed by two different serological diagnostic tests during a previous comprehensive seroepidemiological study, and 14 patients with a suspicious test result for HIV infection but the presence of infection cannot be definitively proven in the absence of molecular diagnostic methods. In retrospective examinations, it was determined that 117 (49.8%) and 13 (92.9%) patients in both groups had radiological imaging (magnetic resonance imaging-MRI, computed tomography-CT, ultrasonography, and chest X-ray), respectively. While 16 of 117 HIV-infected patients had non-specific radiological findings and 53 had normal radiological findings, at least one radiological imaging of 48 patients revealed abnormal radiological imaging findings that may be associated with HIV infection. In these 48 patients, pneumonia findings in thorax CT and chest X-ray examinations, and encephalitis-related findings in patients with central nervous system involvement were the most common anomalies. In addition of these, other abnormal radiological findings included mass lesions compatible with neoplasia, lesions compatible with metastasis, lymphadenopathies, hepatosplenomegaly, and lesions indicating spleen involvement. The presence of similar findings (lesions compatible with pneumonia, encephalitis, and neoplasia) in 9 of 13 patients whose HIV infection could not be confirmed indicates that radiological tests can make significant contributions to clinical evaluations in the management of patients with suspicious laboratory results. The data we present from a region where significant obstacles are encountered in the diagnosis and follow-up of HIV infections due to the fear of discrimination (stigma) of the patients and the lack of molecular tests draw attention to the fact that many patients have advanced lesions when they are diagnosed, and this situation will have negative effects in the patient management and treatment process.

Rapid Respiratory Panel Testing for SARS-CoV-2: Experience in a Private Tertiary Hospital

SARS-CoV-2 has infected more than 643 million individuals worldwide and accounts for close to 64,950 deaths in the Philippines. Due to COVID-19’s clinical overlap with other diseases and non-specific radiologic findings, its diagnosis rests primarily on laboratory methods, including reverse transcription polymerase chain reaction (RT-PCR) and multiplexed molecular platforms for rapid syndromic testing. Compared to RT-PCR which has a turnaround time of 24 to 72 hours, multiplexed molecular platforms can provide alternative diagnoses to COVID-19 in an average of one hour, providing meaningful data that can impact clinical and resource management when handling acute surge of patients with respiratory symptoms.

Child Thoracic Osteoid Osteoma; Case Presentation, Review of Radiology and Management

OO accounts for 10% of all benign bone tumors but only 1% of all spinal tumors. Only 4–13 percent of spinal injuries are caused by benign tumors [1]. osteoid osteoma accounts for just 0.3 percent of all primary bone tumors [2]. Osteoid osteomas are bone cell growth lesions that commonly affect lengthy bones. Only 20% of osteoid osteomas are seen in the spine. 9 Osteoid osteomas are composed of osteoblasts, which create juvenile bone tissue. They are typically tiny, benign, and self-limiting, with local prostaglandin PGE2 synthesis in the nidus (to which its main symptom, local pain, is attributed) [3]. An axial pain or nocturnal pain, as well as warning signs and nonspecific radiological findings, are some of the common symptoms of benign lesions in the spine. Osteoid osteoma is one of them. Osteoid osteoma is a benign bone-forming tumor affecting adolescents and young adults [4]. The typical presentation is painful nocturnal pain which alleviates by NSAIDs. Common locations are cortical diaphysis and spine; they are usually located in posterior elements and may cause painful scoliosis when affecting the spine. Imaging appearance on CT are oval lytic lesions known as nidus located within the dense cortical bone; on MR, reactive soft tissue and bone marrow edema is evident [5, 6].

447 Full-Endoscopic Resection of Osteoid Osteoma in the Thoracic Spine

INTRODUCTION: Common symptoms such as axial pain or nocturnal pain, associated with warning signs that are often worrisome, in addition to non-specific radiological findings can characterize benign lesions in the spine, and Osteoid Osteoma is among them. METHODS: This case report is the first in the literature whereby this modality, which until now has been reserved for degenerative diseases, was used successfully for diagnosis and treatment of osteoid osteoma. RESULTS: The patient reported immediate pain improvement without neurological changes in the postoperative period. She was discharged less than 24 hours after surgery and routine activities were resumed within 7 days. The anatomopathological examination identified osteoid osteoma. At the 1-year outpatient follow-up, the patient showed complete remission of clinical symptoms and no radiological signs of recurrence The technique allows good preservation of adjacent structures (muscle tissue and nerve roots), does not compromise spinal stability, allows good resection of the nidus, and, with the use of radiofrequency probes, allows cauterization of neovascularization, limiting tumor's recurrence. CONCLUSION: Endoscopy is becoming the preferred method in terms of therapeutic effectiveness and medical costs, it is important to remember, that in general (whatever the technique), the results of surgical treatment for osteoid osteoma reported in the literature are satisfactory: complete pain relief was achieved in more than 90% of the cases, and the majority (70%–90%) of patients with preoperative scoliosis evolved satisfactorily. Moreover, for good results with endoscopic techniques, experience and skill are required, which are achieved only with a considerable learning curve.

REACTIVATION OF PULMONARY COCCIDIOIDES IN THE SETTING OF COVID-19 INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Clinical course and management of severe acute respiratory syndrome COVID-2 (Covid-19) infection has been full of uncertainties. As a viral respiratory illness, its presentation can be very similar to other respiratory diseases. Therefore, it is essential to have a high degree of suspicion for superimposed bacterial and fungal infections. CASE PRESENTATION: A 65-year-old male with insulin-dependent diabetes mellitus presented to the emergency department with fever, sudden shortness of breath, cough, and diffuse chest discomfort. Upon arrival his blood pressure was 155/76 mmhg, heart rate 91 bpm, respiratory rate of 22, with temperature of 101.9 F. The patient's Covid-19 PCR nasopharyngeal swab resulted positive. Imaging showed moderate to severe bilateral lung ground-glass infiltrates and consolidation pattern and a 1.9 cm, left upper lobe cavitary lesion. No prior imaging was available for review. Patient was treated with supplemental oxygen, antibiotic therapy for community acquired pneumonia, Remdicivir, and convalescent plasma therapy. Given low suspicion for active TB, steroid therapy was continued. Patient's QuantiFERON gold resulted positive, and he was found to have positive coccidioides IgG, but the complement fixation titer was negative on the day of admission. Three AFB samples, serum (1-3)-beta-D-Glucan assay and Aspergillus assay resulted negative. Bronchoalveolar lavage was performed. Serum coccidioides antibody complement fixation and immunodiffusion results were made available after the patient's passing, which showed positive for IgG and IgM with titers 1:256. Bronchoalveolar lavage cultures revealed Coccidioides Posadasii and Immitis. DISCUSSION: Coccidioidomycosis, commonly known as valley fever, is caused by dimorphic fungi of the Coccidioides family, which is endemic to California, south-central Washington, and northern Mexico. Pulmonary Coccidioides has a similar clinical presentation to Covid-19 infection and seldom, associated with cavitary lesions. Fever, cough, and shortness of breath are the most common presenting symptoms. Radiographic findings vary with COVID -19 showing bilateral peripheral ground glass opacifications with or without consolidations. Among the bacterial co-infections, streptococcus pneumoniae is the most common followed by Klebsiella pneumoniae and Haemophilus influenzae. Due to lengthy wait periods for many laboratory studies to be resulted, it is challenging to distinguish co-infection cases. Reactivation of coccidiodes has been seen in patients with HIV, and patients on chemo and immunotherapy despite antifungal prophylaxes. CONCLUSIONS: Given nonspecific radiological findings of Covid-19 infection that are seen with other causes of pneumonia and its uncertain and similar clinical course to other respiratory infections, it is crucial to have a high degree of suspicion for superimposed bacterial and fungal infections. REFERENCE #1: Freedman M, Jackson BR, McCotter O, Benedict K. Coccidioidomycosis Outbreaks, United States and Worldwide, 1940-2015. Emerg Infect Dis. 2018;24(3):417-423. doi:10.3201/eid2403.170623 REFERENCE #2: Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis. 2016;63(6):e112-e146. doi:10.1093/cid/ciw360 REFERENCE #3: Zhu X, Ge Y, Wu T, et al. Co-infection with respiratory pathogens among COVID-2019 cases. Virus Res. 2020;285:198005. doi:10.1016/j.virusres.2020.198005 DISCLOSURES: No relevant relationships by Nami Moradi, source=Web Response No relevant relationships by Paloma Rivero-Moragrega, source=Web Response

Case Report: Diagnostic challenge of COVID-19 associated pulmonary aspergillosis (CAPA)

Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020 by the World Health Organization (WHO). Severe COVID-19 is represented with acute respiratory distress syndrome (ARDS) that requires mechanical ventilation. Moreover, recent studies are reporting invasive fungal infection associated with severe COVID-19. It is unclear whether the prescription of immunotherapies such as corticosteroids, or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection itself is risk factor for COVID-19-associated invasive pulmonary aspergillosis (CAPA). Hence, fungal infections present an additional uncertainty in managing COVID-19 patients and further compromise the outcome. Case study: Here we report a case of SARS-CoV-2 complicated by invasive pulmonary aspergillosis (IPA) in a patient with no traditional risk factors for IPA. Admitted to ICU due to ARDS on mechanical ventilation, the patient deteriorated clinically with unexplained increased of fraction of inspired oxygen (FiO2) requirement from 50% to 80%. Investigations showed borderline serum galactomannan, nonspecific radiological findings reported to be atypical for COVID-19, and the respiratory sample grew Aspergillus spp. Main diagnosis: COVID-19 related fungal infection. The patient was treated with antifungal therapy for four weeks. He improved clinically after one week of starting antimicrobial treatment. After a prolonged ICU stay (87 days) due to infection control precaution, he was discharged from the ICU and moved to a long-term facility for further management and support. Conclusions: This case highlights the diagnostic challenge in such cases. and the importance of early recognition of CAPA which can optimize therapy by administration of appropriate antifungal agents that may impact mortality.

Chasing the culprit in shadow - Sinonasal mucormycosis in an immunocompetent host.

Rhino-orbital mucormycosis is an uncommon, rapidly progressive, fulminant, angio-invasive deep mycosis usually affecting individuals with underlying immunosuppression, the most common being diabetes mellitus. In such, the course may be fatal with dissemination. Early detection with control of underlying predisposing conditions is critical with respect to the prognosis. Rarely, mucormycosis may develop in an immunocompetent host, when its non-specific symptomatology and inconspicuous radiological findings may obscure its diagnosis. Any delay in treatment predisposes to multi-organ morbidity and potential mortality. We present an immunocompetent adult with no underlying predisposing illness who was harbouring invasive sinonasal mucormycosis causing orbital cellulitis. A high index of suspicion is mandatory.

Case Report: Diagnostic challenge of COVID-19 associated pulmonary aspergillosis (CAPA)

Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020 by the World Health Organization (WHO). Severe COVID-19 is represented with acute respiratory distress syndrome (ARDS) that requires mechanical ventilation. Moreover, recent studies are reporting invasive fungal infection associated with severe COVID-19. It is unclear whether the prescription of immunotherapies such as corticosteroids, or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection itself is risk factor for COVID-19-associated invasive pulmonary aspergillosis (CAPA). Hence, fungal infections present an additional uncertainty in managing COVID-19 patients and further compromise the outcome. Case study: Here we report a case of SARS-CoV-2 complicated by invasive pulmonary aspergillosis (IPA) in a patient with no traditional risk factors for IPA. Admitted to ICU due to ARDS on mechanical ventilation, the patient deteriorated clinically with unexplained increased of fraction of inspired oxygen (FiO2) requirement from 50% to 80%. Investigations showed borderline serum galactomannan, nonspecific radiological findings reported to be atypical for COVID-19, and the respiratory sample grew Aspergillus spp. Main diagnosis: COVID-19 related fungal infection. The patient was treated with antifungal therapy for four weeks. He improved clinically after one week of starting antimicrobial treatment. After a prolonged ICU stay (87 days) due to infection control precaution, he was discharged from the ICU and moved to a long-term facility for further management and support. Conclusions: This case highlights the diagnostic challenge in such cases. and the importance of early recognition of CAPA which can optimize therapy by administration of appropriate antifungal agents that may impact mortality.

Full-Endoscopic Resection of Osteoid Osteoma in the Thoracic Spine: A Case Report.

Common symptoms such as axial pain or nocturnal pain, associated with warning signs that are often worrisome in addition to nonspecific radiological findings, can characterize benign lesions in the spine, and osteoid osteoma is among them. We describe here a clinical case of a pediatric patient with an expansive bone lesion in the thoracic spine discovered after investigation for thoracic pain, mainly at night, which, despite a good response to simple analgesics, evolved in the short term with global spinal deformity. After a multidisciplinary evaluation, she underwent surgical resection using a pioneering endoscopic technique that allowed the definitive anatomopathological diagnosis of osteoid osteoma and guaranteeing very satisfactory treatment and evolution. Although there are already several therapeutic techniques described and with good results in specific cases of osteoid osteomas and other benign neoplastic lesions of the spine, full-endoscopic resection appears as an innovative and potentially promising option for diagnosis and treatment, especially since it is a safe, effective, and not too morbid intervention.

Extensive malignant melanoma of the oral cavity: a rare occurrence

ABSTRACTPrimary malignant melanoma of the oral cavity is a rare tumor in clinical practice. Extensive malignant melanomas are still very rare in the literature. Patients with malignant melanoma of oral cavity are often diagnosed at the advanced stage of the disease due to their painless and nonspecific radiological findings. Histopathology is the gold standard for the final diagnosis and staging of the tumor. Surgery followed by radiotherapy is the standard treatment offered to patients with malignant melanoma. Here we present a rare case of extensive malignant melanoma of oral cavity which was successfully managed by surgical excision followed by adjuvant radiotherapy.

A Case of Chronic Pulmonary Aspergillosis with Non-specific Radiological Findings

A Case of Chronic Pulmonary Aspergillosis with Non-specific Radiological Findings

Chondroblastoma of bone: case presentation, immunohistochemistry findings and literature review

Chondroblastoma is a rare benign cartilage-producing tu­mor, with an incidence of approximatively 1% of all pri­ma­ry bone tumors. It arises mostly in the second decade of life, affecting mainly the ends of the long tubular bones. We present two cases of chondroblastoma diagnosed and trea­ted in the “Foişor” Orthopedics, Traumatology and Oes­teo­articular TB Clinical Hospital, Bucharest, Romania. The purpose of this study is to contrast two different forms of presentation of the same histologic entity: one case of a 19-year-old male patient with a chondroblastoma lo­ca­ted in the proximal humerus, and the case of a 37-year-old male patient with a chondroblastoma of the cal­ca­neus. The mor­phological fea­tures, radiologic aspects and im­mu­no­his­tochemical stu­dies have been assessed. None of the cases presented with spe­ci­fic radiologic signs for chondroblastoma, both lesions being osteolytic and well-delineated, in favor of a benign en­ti­ty. The classic mor­pho­lo­gical aspects of chondroblastoma re­pre­sen­ted by tumor cells with round poly­gonal shape and nuclei with longitudinal grooves were as­so­cia­ted with variable amounts of chondroid matrix, pe­ri­cellular calcification and few randomly distributed osteo­clast-like giant cells. The im­mu­no­his­to­chemical studies showed the osteoblastic and chon­dro­blastic phenotype of the neoplastic cells, sustained by positivity for CD56 and S100. DOG1, cytokeratin 8/18 and smooth muscle actin (SMA) were also found focally po­si­tive. All cases were treated by curettage with bone graf­ting, without recurrence in the short-term follow-up. Given the nonspecific radiologic findings and the histologic he­te­ro­ge­nei­ty, chondroblastoma is sometimes misinterpreted as a ma­lig­nant tumor, while this neoplastic lesion has a benign be­havior and benefits from conservative surgical treatment only.

Pediatric Demyelinating Disease: Emerging Patterns from Multiple Sclerosis to Anti-Myelin Oligodendrocyte Glycoprotein‐Associated Encephalomyelitis

Ongoing progress is being made in the understanding of pediatric demyelinating diseases, including the recent discovery of anti-myelin oligodendrocyte glycoprotein (anti-MOG) encephalitis. Radiologists play a key role in the diagnostic work-up of these patients. Demyelinating diseases can be challenging to differentiate from each other and can mimic anti-MOG encephalitis, especially because the various disorders can present with nonspecific radiologic cord findings and overlapping CNS features. There are some key imaging features that can be explained by the more recent development in the pathophysiological basis of these different entities. Attention to pertinent clinical history allows for improved diagnostic accuracy. Identifying MR imaging predictors of a particular demyelinating diagnosis in the pediatric population can have broad implications on treatment.

Evaluation of Commercially Available Real-Time Polymerase Chain Reaction Assays for the Diagnosis of Invasive Aspergillosis in Patients with Haematological Malignancies.

Early diagnosis of invasive aspergillosis (IA) is a challenge. Non-specific clinical and radiologic findings, as well as difficulties in conventional diagnostic method application, may delay correct diagnosis. Nowadays, nucleic acid-based assays have reduced the need for conventional antigen detection and culture-based methods and provided new opportunities for patient care. Aspergillus PCR is now included in the latest European Cancer Research and Treatment Organization/Mycosis Study Group definition updates. We evaluated the performance of commercial real-time polymerase chain reaction (PCR) MycAssay Aspergillus PCR and Artus Aspergillus RG PCR assays and compared the results with galactomannan enzyme immunoassay. During 41 febrile neutropenic episodes, 168 serum samples were collected from 32 patients with haematological malignancies. IA diagnosis was established according to the revised guidelines of the European Organization for Research and Treatment of Cancer/Mycoses Study Group. Twenty-one probable episodes were identified. There were no proven IA cases in the study. In 20 episodes, patients did not fulfil the established criteria for the IA diagnosis. Artus Aspergillus RG PCR assay had a sensitivity of 47.6% and specificity of 100%, while those of MycAssay Aspergillus PCR were 61.9% and 100%, respectively. Two different PCR assays were used in this study. Although there are many studies that evaluated MycAssay Aspergillus PCR, data regarding Artus Aspergillus RG PCR assay are scarce. We found moderate sensitivity and high specificity in the diagnosis of IA in patients with haematological malignancy in both PCR methods. Our results demonstrated that commercial PCR assays can be applied for the early diagnosis and pre-emptive treatment of IA.

A RARE PRESENTATION OF PRIMARY PULMONARY EXTRANODAL DIFFUSE LARGE B CELL LYMPHOMA

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: Diffuse large B cell lymphoma (DLBL) is a common subtype of non-Hodgkin’s lymphoma (NHL) that usually presents with rapidly expanding lymphadenopathy. Here we present an unusual case of DLBL with a primary extra-nodal pulmonary presentation. CASE PRESENTATION: A 91-year-old female presented to her PMD for evaluation of a non-productive cough of several weeks’ duration. She had no prior history of pulmonary disease, was a never smoker, and was independent. She denied recent travel, pets, or known sick contacts and was up-to-date with pneumonia vaccinations. Complete blood counts and routine serum chemistries were unremarkable. She returned three months later with continued non-productive cough as well as generalized fatigue and intermittent chills. She was prescribed benzonatate and doxycycline for management of bronchitis. A CXR was ordered which showed a 4.5 cm right hilar opacity. CXR performed one year prior was unremarkable. She was referred for pulmonary consultation. CT chest showed a right upper lobe 4.8 x 5.9 cm mass, a left lower lobe 2.1 x 2.3 cm mass, right pleural thickening, and right cardiophrenic adenopathy measuring 2.0 x 1.2 cm. A navigational bronchoscopy with biopsy demonstrated a mass partially occluding right upper lobe bronchus and biopsy was consistent with DLBL. PET-CT revealed multiple areas of hypermetabolic activity in the abdomen, pelvis, and chest with multiple pulmonary masses, the most superior of which occluded the right upper lobe bronchus, as well as extensive pleural disease. She was started on a non-anthracycline chemotherapy regimen within two weeks of diagnosis. DISCUSSION: Primary NHL of the lung is rare, accounting for 0.4% of all malignant lymphomas. DLBL is an uncommon subtype within that group. Symptoms are non-specific, as are associated radiologic findings, making initial diagnosis difficult. Fine needle aspiration of DLBL usually obtains insufficient material to evaluate the architecture of the lymphoma for diagnosis. The majority of patients require invasive diagnostic biopsies to provide adequate tissue for evaluation. Several studies have shown that cell marker studies using bronchoalveolar lavage may be useful. Prompt initiation of treatment is necessary as DLBL of the lung has a worse prognosis than the more common MALT lymphoma of the lung. However, some studies report survival rates as high as 86% at three years for primary NHL of the lung. CONCLUSIONS: DLBL is a common NHL subtype that rarely manifests with primary pulmonary presentation masquerading as a primary lung malignancy. Given the non-specific clinical presentation, non-specific radiologic findings, and overall rarity, initial diagnosis is difficult, making prompt treatment a challenge. Further research is warranted to better diagnose and prognosticate primary DLBL of the lung. Reference #1: Teras, L. R., DeSantis, C. E., Cerhan, J. R., Morton, L. M., Jemal, A. and Flowers, C. R. (2016), 2016 US lymphoid malignancy statistics by World Health Organization subtypes. CA: A Cancer Journal for Clinicians, 66: 443-459. https://doi.org/10.3322/caac.21357 Reference #2: Kandori S, Kojima T, Nishiyama H. The updated points of TNM classification of urological cancers in the 8th edition of AJCC and UICC. Jpn J Clin Oncol. 2019; Reference #3: Kurtin PJ, Myers JL, Adlakha H, et al. Pathologic and clinical features of primary pulmonary extranodal marginal zone B-cell lymphoma of MALT type. Am J Surg Pathol. 2001;25(8):997-1008. DISCLOSURES: No relevant relationships by Joseph Berman, source=Web Response No relevant relationships by Miguel Conde, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Killol Patel, source=Web Response

Intestinal endometriosis: Diagnostic ambiguities and surgical outcomes.

BACKGROUNDEndometriosis is a common disease for women of reproductive age. However, when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose.AIMTo analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases.METHODSWe retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January 2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes.RESULTSTwenty-three (76.6%) patients showed symptoms associated with endometriosis, with dysmenorrhea being the most common (n = 9, 30.0%). Thirteen patients (43.3%) had a history of pelvic surgeries. Ten patients (33.3%) had a history of treatment for endometriosis. Only 4 patients (13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients (43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients (56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine (n = 8, 26.7%), followed by malignancies of the colon/rectum (n = 3, 10.0%) and ovary (n = 3, 10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9 (0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis.CONCLUSIONIntestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings, intestinal endometriosis should be included in the differential diagnosis.