Onion Skin Appearance Research Articles

Predicting outcomes of unruptured intracranial artery dissection with clear symptoms onset using clinical and radiological features

We investigated the clinical and radiologic predictors of unruptured symptomatic intracranial artery dissection (IAD) outcomes. Unruptured symptomatic IAD patients who underwent vessel wall magnetic resonance imaging (VW-MRI) and time-of-flight magnetic resonance angiography (TOF-MRA) within 1 month after symptom onset, followed for over 12 months were included. Baseline features predicting the clinical outcome of recurrent symptoms and radiologic outcomes of aneurysmal dilatation and occlusion were analyzed using logistic regression analysis. The Kaplan–Meier method calculated the median time to morphological stability. Patients with aneurysmal dilatation were categorized into progressive and non-progressive enlargement subgroups. Seventy-three IADs from 65 patients were included. All patients showed benign clinical course (mRS 0–1). No baseline features were predictive of recurrent symptoms. Aneurysmal dilatation was associated with increased outer diameter in baseline VW-MRI (OR, 23.15; 95% CI, 3.78–141.75, P < 0.001) and TOF-MRA (OR, 10.81; 95% CI, 2.16–53.99, P = 0.004). Occlusion was inversely associated with preserved patency in baseline VW-MRI (OR, 0.1; 95% CI, 0.01–0.74, P = 0.024) and TOF-MRA (OR, 0.14; 95% CI, 0.02–0.98; P = 0.048). The median time to morphological stability was 3.9 months (95% CI, 3.16–5.5). While baseline features did not significantly differ between aneurysmal dilatation subgroups, follow-up imaging revealed significant differences in remodeling index, normalized wall index, relative signal intensity of intramural hematoma, and presence of onion-skin appearance and intramural hematoma (all P < 0.05). Our findings suggest that while unruptured IAD presents a benign clinical outcome, follow-up imaging may be necessary to monitor the progressive enlargement of aneurysmal dilatation.

INFLUENCE OF PIGEON PARAMYXOVIRUS TYPE-1 ON CLINCOPATHOLOGICAL PROFILES IN RACING PIGEONS ASSOCIATED WITH RECENT OUTBREAKS IN IRAQ

The number of racing pigeons recently increased in Iraq accompanied by significant increases in the number of events similar to the neurotrophic velogenic group of ND viruses in different regions. Thus, this research was designed to study the influence of natural infection with PPMV-1 on clincopathological profiles in four PPMV-1-associated mortality events in racing pigeons in the southern part of Iraq. The result revealed that HI antibody titers above the positivity threshold of four events were seen in (9 out of 24) of tested pigeons in all events, and the predominant signs included polyuria followed by neural symptoms which appear in most of the affected pigeons in the flock. All events showed a high mortality rate (60% - 70%) and absence of gross abnormalities in necropsied pigeons. kidney showed widespread interstitial hemorrhage and intensive epithelial sloughing of renal tubular epithelium, marked white pulp hyperplasia and marked peri-arteriolar fibrosis with onion skin appearance in the spleen, and marked destruction of the superficial intestinal mucosa and intensive inflammation in the site of tissue destruction. This study demonstrates the role of PPMV-1 on clincopathological profiles in racing pigeons associated with recent outbreaks in Iraq, polyuria followed by neural symptoms represent the predominant symptoms in the affected pigeons.

PERIOSTITIS OSSIFICANS: REPORT OF TWO CASES

Periostitis ossificans, more popularly known asGarres osteomyelitis is a distinctive type of chronic osteomyelitis occurring in children and youngadultsandiscommonly associated with odontogenic infection. This paper describes two cases of Periostitis ossificans, one a nine-year-old girl and the other aneleven-year-old boy who presented with a bony hard swelling of the lower jaw. Both of them had an associated decayed permanent mandibular molar tooth. Occlusal radiograph revealed the pathognomonic onion skin appearance. Extraction of the molar teeth was performed as the patients did not consent for endodontic managementdue to financial constraints. There was complete remission of the swelling when reviewed after 6 months and later after7 yrs, showed complete bone remodelling.

Non- Invasive Cone Beam Tomography (CBCT) to diagnose jaw bone Osteomyelitis in Sickle cell anaemia patients.

Patients suffering from haemoglobinopathies most commonly show bone infection as a complication, of which Sickle cell anaemia (SCA) patients are the most susceptible to osteomyelitis. There are very few documented cases of jaw bone osteomyelitis in SCA patients. Keeping in mind the number of children diagnosed with SCA in India, this article reports how a commonly available and non-invasive radiographic method, dental CBCT, can be used to timely diagnose jaw bone osteomyelitis. Key Words : Sickle Cell Anemia ,Chronic Osteomyelitis , Jaw , Mandible , Case Report India , Sickle Cell Anemia complications , Radiograph , CBCT , Third molar pain , Onion skin appearance , Punched out lesions

Eosinophilic Angiocentric Fibrosis in Bilateral Upper Eyelid Conjunctivas: A First Case Report

Patient: Female, 55-year-oldFinal Diagnosis: Eosinophilic angiocentric fibrosisSymptoms: Lid swellingMedication: Topical eye dropsClinical Procedure: Resection of conjunctivasSpecialty: OphthalmologyObjective:Rare diseaseBackground:Eosinophilic angiocentric fibrosis (EAF) is an extremely rare disease with characteristic histopathological findings of fibrotic onion-skin appearance and eosinophils. The lesion primarily affects the nasal cavity, paranasal sinus, and orbit. Although there have been approximately 78 cases of EAF reported in the literature to date, no cases of EAF in the eyelid conjunctiva have ever been reported.Case Report:Herein, we describe the case of a 55-year-old Japanese woman with a history of eosinophilic sinusitis and EAF in bilateral upper eyelid conjunctivas who underwent surgical resection of the affected tissue. Histopathological examination revealed collagen bundles winding around the vessels in an onion-skin pattern, and the presence of eosinophils, lymphocytes, and plasma cells.Conclusions:We describe the first reported case of EAF in bilateral upper eyelid conjunctivas. It can be successfully treated by surgical resection, and with no recurrence within 6 months postoperatively.

Imaging of Fulminant Demyelinating Disorders of the Central Nervous System.

We aim to review the imaging appearance of fulminant demyelinating disorders of central nervous system that have different pathological features, clinical course, clinical features, and imaging findings different from classic multiple sclerosis. Routine magnetic resonance imaging (MRI) can help in accurate localization of the lesions, detection of associated lesions, and monitoring of these patients. Advanced MRI combined with routine MRI can aid in differentiation fulminant demyelinating lesions from simulating malignancy. Tumefactive demyelination lesions are located in supratentorial white matter mainly frontal and parietal regions with incomplete rim enhancement. Baló concentric sclerosis shows characteristic concentric onion skin appearance. Schilder disease is subacute or acute demyelinating disorders with one or more lesions commonly involving the centrum semiovale. Marburg disease is the most severe demyelinating disorder with diffuse infiltrative lesions and massive edema involving both the cerebral hemisphere and brain stem.

Nasal Framework Reconstruction in Patient with Eosinophilic Angiocentric Fibrosis

Eosinophilic angiocentric Fibrosis (EAF) is a rare condition involving the sinonasal tract and nasal septum which is mostly considered as a benign condition. EAF could present with progressive nasal obstruction as its most common symptom. In this case report, we try to report a case of middle aged man with nasal septum tumor-link lesion which was diagnosed with EAF. A 45years old man presented with complete nasal obstruction who described a growing nasal cavity mass for over 6months. Anterior rhinoscopy revealed bilateral mass with a smooth surface on the nasal septum and mass protruded into both nasal cavities. CT scan showed a 28 × 18mm soft tissue mass in nasal cavity mostly in right side with erosion of right maxillary alveolar ridge. Microscopic examination of a biopsy taken from the mass showed dense infiltration of inflammatory cells rich in eosinophils as well as perivascular condensation of fibrotic bundles creating onion-skin appearance was noted. The patient went under surgical ablation of the tumor and has been followed up every 2-3month for about 1year and there was no evidence of recurrent disease. The complete surgical excision may eradicate the allergic manifestations in the EAF patients and cartilage graft such as rib graft seems to be safe if the reconstruction is needed. It is important to prevent tumor from recurrence by totally resecting the involved tissues.

Bloodless Glomeruli: A Case Report on Scleroderma Renal Crisis

Scleroderma renal crisis (SRC) is a main complication of systemic sclerosis affecting approximately one-fifth of the patient population with the disease. We present a case of a 38-year-old African American female who initially presented with findings suggestive of thrombotic thrombocytopenic purpura; however, the clinical manifestations, laboratory findings and renal biopsy confirmed the diagnosis of SRC. The case is worth reporting in medical literature because of its unique presentation and to note the findings of the kidney biopsy. SRC can present initially as thrombotic thrombocytopenic purpura; therefore, clinicians need to be more aware of this entity and it should be considered in the differential diagnosis of microangiopathic hemolytic anemia. This case also illustrates that the classic “onion skin appearance” on kidney biopsy in SRC is not always present and that patients can have “bloodless” glomeruli. J Med Cases. 2018;9(7):229-232 doi: https://doi.org/10.14740/jmc3018w

Imaging in testicular epidermoid cysts

ObjectiveTo evaluate the utility of findings on ultrasound and magnetic resonance imaging (MRI) for the preoperative diagnosis of testicular epidermoid cysts (TEC). MethodsThe medical records of five patients treated for TEC at our institution between July 2010 and May 2017 were retrospectively reviewed. ResultsImaging revealed a target or onion skin appearance on ultrasonography and MRI. Pathological examinations showed “bread slag-like” materials within the TEC. Lesions failed to demonstrate enhancement after Gd-DTPA injection. ConclusionIn the cases of TEC in the current study, accurate diagnosis ensured enucleation of the testicular cyst was performed rather than testicular resection.

Neuroendoscopic and histopathological correlation in 13 cases of cystic fluid filled brain tumours

Neuroendoscopical images of fluid-filled cavity walls within encephalic tumours in thirteen adult patients were correlated with histopathology results of samples harvested during surgery. Extensive vascular proliferation, with mesh-like formations in a 3D pattern, as well as onionskin appearance, were observed in malignant tumours, as opposed to normal or slightly increased vascular pattern, observed in benign neoplasms. Medical facilities lacking sufficient technical resources where limited pathologist experience is expected, and can be associated with intraoperative histological misdiagnosis. Detailed high quality endoscopical observations of tumour cavity walls may be helpful to differentiate between benign and malignant lesions, and therefore, immediate surgical decisions can be made.

Cytodiagnosis of a testicular epidermoid cyst in a young male: A rare entity.

Intratesticular epidermoid cyst is a rare benign lesion of testis. It is important to distinguish this benign lesion from malignant testicular tumor . This is a case report of a 18yr old patient who presented with a mass in the left testis. His ultrasound showed typical onion skin appearance and tumour markers were within normal limits. Subsequently FNAC was performed which showed anucleated clumps of squamous epithelial cells admixed with the native testicular cells, thus diagnosis of testicular epidermoid cyst was made. Cytology along with sonographic findings provide rapid diagnosis and patient can be relieved of unnecessary anxiety. DOI: 10.21276/APALM.1152

Mucocele of Appendix

A 55 years old patient presented with pain in the right lumber region/Right iliac fossa for last two months. He also complains of fever off and on for last 2-3 months. He got intermittent treatment from one of the rural health centre in Manga Mendi Lahore. On examination in surgical emergency there was a mobile mass felt in the right iliac fossa. On abdominal ultrasound there was a long 11 X 5 cm well defined tubular mass with blind end is seen in the right iliac fossa. The mass is mobile while pressing with the ultrasound probe. This tubular structure shows typical Onion skin appearance. There was no evidence of any free fluid in the vicinity &amp; in pelvis. No evidence of enlarged mesenteric lymph nodes noted in Right Iliac fossa. This tubular mass was clearly separated from the iliac vessels &amp; ileal loops. Other findings on ultrasound was bilateral multiple renal cysts and two calculi impacted in the right utero-vesical junction with mild to moderate retrospective obstructive uropathy. The diagnosis on ultrasound was Mucocele of Appendix. On surgery there was large 11-12 cm tubular mass seen in the right iliac fossa which is freely mobile. The mass was surgically removed. On dissection there was whitish thick secretion seen coming out of the tubular mass. On histopathology Mucocele of appendix is confirmed

PROLİFERATİF PERİOSTİTİS (GARRE OSTEOMYELİTİ): OLGU SUNUMU

Proliferative Periostitis (Garre’s osteomyelitis) is a specific type of chronic osteomyelitis that mostly affects children and adolescents. This chronic disease is characterized by reactive subperiosteal bone formation and nonsuppurative ossifying periostitis as a response to a mild local infection or irritation. Periosteal reaction in Garre's osteomyelitis usually represents an onion skin appearance. This disease is rare in occurrence due to the presence of a set of integrated conditions such as chronic infection in a young patient, increased osteoblastic activity and a balance between the virulence of the infectious agents and the resistance of the host. The purpose of this presentation is to report a rare case of Garre's osteomyelitis and to give information about the imaging findings with 2 years follow-up. Key words: Periostitis; osteomyelitis; mandible

Clinical study of benign and malignant fibrous-osseous lesions of the jaws

Introduction: Fibrous-osseous lesions of the jaws are difficult to diagnose precisely until excised biopsy results are found, so they might be confused with malignant lesions. This clinical study focused on the diagnostic aids of lesions that demonstrate different clinical, radiologic, and histological findings. Materials and Methods: A total of 16 patients with benign fibrous-osseous lesions on the jaws (6 fibrous dysplasias, 6 ossifying fibromas, 3 cemental dysplasias, and one osteoblastoma) were reviewed. Nine patients with malignant fibrous-osseous lesions (8 osteosarcomas and one Ewings sarcoma) were also retrospectively reviewed. Results: Osteosarcoma patients complained of facial swelling and tooth mobility. The radiographic findings showed the irregular resorption of cortical bone and periosteal reactions. Histological features included cellular pleomorphism and atypical mitosis. An Ewings sarcoma patient complained of tooth mobility and facial swelling. Onion-skin appearance and irregular expansile marginal bony radiolucency were seen in the radiography. Fibrous dysplasia patients complained of facial swelling and asymmetry. The radiographic features were mostly ground-glass radiopacity. Histological findings showed a bony trabeculae pattern surrounded by fibrous ground substances. Ossifying fibroma patients complained of buccal swelling and jaw pains, showing expanded cortical radiolucent lesions with a radiopaque margin. Histological findings were revealed as cellular fibrous stroma with immature woven bones. In cemental dysplasia, most of their lesions were found in a routine dental exam. Well-circumscribed radiopaque lesions were observed in the radiography, and cementum-like ossicles with fibrous stroma were seen in the microscopy. An osteoblastoma patient complained of jaw pain and facial swelling. Radiographic findings were mottled, dense radiopacity with osteolytic margin. Trabeculae of the osteoid with a vascular network and numerous osteoblasts with woven bone were predominantly found in the microscopy. Conclusion: Our study showed similar results as other studies. We suggest the clinical parameters of diagnosis and treatment for malignant and benign fibrous-osseous lesions of the jaws.

Testicular epidermoid cyst - Ultrasound and MR typical findings with macroscopy correlation

Figure 1 a. Longitudinal US image of the right testis show a bilobulated mass in the upper medial aspect of the testis. The mass had sharp margins, composed of a central echogenic area and of alternating hyperechogenic and hypoechogenic rings in the periphery (onionskin sign), measuring 2.4 x 1.7 x 1.7 cm. b. Longitudinal Doppler-US image of the right testis demonstrates the absence of vascularization of the mass. Ultrasound (US) revealed a solid mass in the upper pole of the right testis that was well circumscribed, avascular, and displayed the onionskin appearance suggestive of testicular epidermoid cyst (1,2) (Figure-1). Magnetic resonance (MR) confirmed the well-circumscribed intra-testicular mass with a

Fate of Flavonoids in the Outer Skins of Onion (Allium cepa L.) Throughout Curing

Reducing the current U.K. curing temperature from 28 to 20 °C would help to reduce energy costs; however, onion skin appearance and consumer acceptability may be detrimentally affected. The aim of this study was to elucidate the compounds responsible for the difference in color between brown and red onions cured at 20 and 28 °C by monitoring dynamic biochemical changes in the skin at set intervals during curing and after storage from two years' data. Sugar concentrations appeared to play no role in the difference in onion skin appearance when cured at different temperatures. Using regression, principal component, and partial least-squares discriminant analyses, the decrease in skin H° after the curing of brown onion cultivars at 28 °C was linked to a decrease in individual flavonol concentrations, possibly due to their oxidation at higher temperatures into brown pigmented compounds. Red onion cultivars cured at lower temperatures and for a shorter curing period had higher concentrations of individual anthocyanins as well as a darker skin color. Skin water content was reduced significantly in only the first 6 days of curing. Taken together, this suggests that current U.K. curing practice could be carried out at a lower temperature (20 °C) and/or for a shorter duration, resulting in reduced curing costs and possibly improved skin appearance.

Castleman's Disease of the Neck: Report of 4 Cases With Unusual Presentations

In 1956, Castleman and colleagues first described the clinicopathologic entity of mediastinal lymphnoid hyperplasia with hyalinization of follicles and interfollicular vascular formation.1 Subsequent reports described additional sites of disease and different names were used for this entity, including Castleman’s disease (CD), angiofollicular or giant lymph node hyperplasia.2 CD represents a morphologically distinct form of lymph node hyperplasia rather than a neoplasm or hamartoma. The etiology and pathogenesis of CD are not completely understood. Microscopically, two major categories have been described.3 The first, designated as hyaline vascular type shows large follicles scattered in a mass of lymphoid tissue. The follicles show marked vascular proliferation and hyalinization of their abnormal germinal centers. Many of large cells with vesicular nuclei present in the hyaline center are follicular dendritic cells. There is a tight concentric layering of lymphocytes at the periphery of the follicles (corresponding to the mantle zone), resulting in an onion-skin appearance. The second major morphologic category of CD is known as the plasma cell type. It is characterized by a diffuse plasma cell proliferation in the interfollicular tissue. The hyaline vascular changes in the follicles are inconspicuous or absent. CD is clinically heterogeneous with either solitary CD (SCD) or multicentric CD (MCD). Over 90% of the cases are of the hyaline vascular type, and the remainder are of the plasma cell type.3 The former usually presents with asymptomatic solitary mass and can mostly be treated effectively with surgery,4–6 whereas the plasma cell type often has a more aggressive course and tends to be MCD with systemic sympotoms (including fever, night sweats, weight loss, and recurring infections) and multiple peripheral lymphadenopathies.7, 8 CD with severe systemic manifestations and poor prognosis is frequently associated with POEMS syndrome (Polyneuropathy, Organomegally, Endocrinopathy, M protein, and Skin changes), renal or pulmonary complications and malignancies, such as Kaposi’s sarcoma, non-Hodgkin’s lymphoma, Hodgkin’s lymphoma, and follicular dendritic cell sarcoma.8–13 CD may occur anywhere along the lymphatic chain, but the mediastinum is the most common location. Neck involvement with CD is relatively uncommon. To our knowledge, most descriptions of CD in the neck were isolated cases or small series and most of the previously reported cases of CD of the neck were of the hyaline vascular type. 4–6 In this article, we describe four cases of CD in the neck with unusual presentations, different histopathologic subtypes and discuss the problems arising in their clinical findings.

Haematuria and hydronephrosis caused by Castleman's disease.

A 16-year old man was referred with intermittent gross haematuria and left flank pain. On physical examination, there was a large mass in the left flank. Enhanced computed tomography demonstrated a 10 cm solid mass on the left retroperitoneal space compressing the renal pelvis and causing hydronephrosis on the left kidney. A few small lymph nodes were noted on the left para-aortic region (Figure ​(Figure1A1A and B). F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed a mildly hypermetabolic tumour in retroperitoneum with para-aortic lymph nodes. The mass was resected surgically. Operative findings showed a huge retroperitoneal mass and upward displacement of the left kidney and ureter by the mass. The histopathological diagnosis of the resected tissue revealed hyaline vascular type of Castleman's disease (CD) (Figure ​(Figure2).2). Histologically, lymphoid follicles showed marked vascular proliferation and hyalinization of their germinal centre. There was a tight concentric layering of lymphocytes at the periphery of the follicles, resulting in an onion skin appearance. CD is a rare lymphoproliferative disorder characterized by hyperplasia of lymphoid follicles and proliferation of lymphocytes. CD consists of unicentric Castleman's disease (UCD) and multicentric Castleman's disease (MCD). UCD is often a benign disorder not associated with human herpesvirus 8 (HHV-8) infection, while MCD is associated with HHV-8 infection and immunosuppression [1,2]. The patients with CD may have complications including infection, nephrotic syndrome and malignancy such as Kaposi's sarcoma, Hodgkin lymphoma and non-Hodgkin lymphoma [3,4]. Although Castleman's disease is a rare retroperitoneal tumour, we should always consider this tumour in the differential diagnosis of retroperitoneal mass associated with hydronephrosis and haematuria. Fig. 1 Contrast-enhanced computed tomography demonstrated a 10 cm solid mass on the left retroperitoneal space (arrow) (A) and severe hydronephrosis on the left kidney (arrow) (B). Fig. 2 Microscopic features are a typical pattern of hyaline-vascular Castleman's disease. The lymph node contains atrophic follicles with hyalinized vessels and concentric rings of lymphocytes. (H&E stain, × 200). Conflict of interest statement. None declared.

Osteosarcoma of jaw bone

Osteosarcoma is the most common primary malignant bone tumor in children. Its radiolographic appearances vary considerably. It may show a number of presentations from onion skin or sunburst appearance. Osteosarcoma of maxilla and mandible are distinct from long bone osteosarcoma and shows a distinct clinical, histologic and prognostic characteristic that when diagnosed and treated properly have a better prognosis from the later. The present article reports a case of osteogenic sarcoma of maxillary alveolar ridge and compares it with long bones osteosarcomas.

Growth and rupture mechanism of partially thrombosed aneurysms.

Within the group of giant and large aneurysms the subgroup of the so-called "partially thrombosed" aneurysms can be differentiated according to clinical and neuroimaging findings. The present study was carried out to determine the site of bleeding of these aneurysms and what implications concerning their pathomechanism can be drawn from these findings. Twenty patients aged two to 77 (mean 44) years who exhibited a partially thrombosed aneurysm that had recently bled were included. Images (MRI including T1 pre- and postcontrast and T2 weighted images in multiple planes, CT and digital subtraction angiography) and patients' charts were reviewed. MRI showed an onion-skin appearance of the thrombus in 19 patients, rim enhancement of the aneurysm wall (either partial or complete) in 17, and a perifocal edema in 16 patients. The acute hemorrhage was typically crescent-shaped and located at the periphery of the aneurysm, distant from the perfused lumen of the aneurysm within the thrombosed part of the aneurysm. The current denomination "partially thrombosed" intracranial arterial aneurysms leads to the presumption that thrombus is present endoluminal whereas in fact the site of hemorrhage is within the vessel wall. A more accurate nomination would, therefore, be "aneurysms with intramural hemorrhage". The enhancing wall and the edematous reaction of the adjacent brain parenchyma might be a sign for an inflammatory pathomechanism which is reinforced by histological and pathophysiological studies. This disease should be regarded as a clinical entity separate from saccular or non-thrombosed giant or large aneurysms.