Left Shoulder Pain Research Articles

Poster Presentation

Poster Presentation

The Successful Treatment of Combined Local and Systemic Steroids in a Patient with Brachial Plexus Neuritis: A Case report

Brachial plexus neuritis (BPN), also known as Parsonage-Turner syndrome, is an uncommon neurological disorder that can manifest with acute extreme upper arm pain followed by patchy muscle paralysis. There is no evidence supporting any recommended treatments for BPN from randomized trials. Non-randomized studies have supported the effectiveness of early administration of high-dose oral corticosteroids during the painful phase. We present a case of a 41-year-old-female with a history of acute left lateral shoulder pain and shoulder girdle weakness who was diagnosed with acute BPN. To reduce the risk of complications arising from high-dose oral steroid administration, we used an ultrasound-guided brachial plexus blockade combined with low-dose oral steroids. The combined treatment approach successfully restored shoulder function and effectively alleviated pain while avoiding complications associated with systemic steroid administration. Keywords: Brachial plexus neuritis; Interventional ultrasonography; Steroid

Pituitary Apoplexy, an Endocrinological Emergency: Case Report

Pituitary apoplexy is a rare endocrine emergency that can occur due to bleeding or ischemia in the pituitary gland. Its incidence can vary between 0.6% and 16.8% in the general population (2-7% in pituitary adenomas). We herein report an unusual case of a 50-year-old female patient who presented to the emergency with complaints of left hemicranial headache, cervicalgia, shoulder pain and dizziness for 1 year worsened in the last three days. Her prolactin levels were high, and the first imaging exam suggested a silent apoplexy, since the clinical picture of the patient did not indicate such condition. In the second one, the patient presented a typical picture of apoplexy, including intense headache and nausea. Her temporal evolution suggested a macroprolactinoma with hemorrhagic degeneration or apoplexy. As she did not present signs of indication for transsphenoidal emergency surgery, conservative treatment was chosen. In this case, due to history of repeated apoplexy, nausea and intense headache, it is important to keep close monitoring for an eventual urgent surgical intervention in case of new bleeding, visual alterations and/or reduced level of consciousness, since these are indicative signs for transsphenoidal emergency surgery.

A tale of traumatic diaphragmatic hernia

A traumatic diaphragmatic hernia is uncommon which accounts for 0.8 to 1.6%. In Blunt or penetrating abdominal injury, the patient presents as early or delayed respiratory distress or intestinal obstruction. We present the 55-year old female with a road traffic accident (pedestrian versus two-wheeler) with left-sided chest pain and breathlessness, left shoulder and leg pain referred to our institute. On examination, left hemithorax decreased breath sound and bowel sound was present, chest compression test positive, normal bowel sound in the abdomen, restricted left shoulder movement and abnormal mobility of shaft of left tibia and fibula. A plain X-ray of the chest and abdomen showed bowel shadow in the left hemithorax up to the apex. Computed tomography (CT) of thorax and abdomen shows herniation of stomach, transverse colon, omentum in the left hemithorax with collapsed left lung. A plain X-ray of the left shoulder shows neck of scapula fracture, left leg both bone fracture. Suggesting traumatic diaphragmatic hernia took emergency surgery, laparotomy was made intact stomach, transverse colon, omentum reduced with no injuries, radially placed diaphragmatic rent of size 10 cm × 5.5 cm through which left lung inferior lobe visualized, medial edge of rent close to the pericardial pad of fat. Other solid organs normal, left thoracic drain was fashioned. Rent was closed with interrupted polypropylene with intraabdominal drain. Left leg both bone fracture was done with tibial nailing and left neck of scapula fracture managed conservatively. Abdominal approach is sufficient rather than a thoracoabdominal approach given associated intraabdominal injuries, nowadays minimal access approaches preferred.

NON-SMALL CELL CARCINOMA OF LUNG WITH METASTASIS TO DELTOID MUSCLE: A RARE AND UNUSUAL PRESENTATION

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung cancer is the leading cause of cancer-related death worldwide. Major risks factors include tobacco smoking and environmental pollution. Despite its high incidence, the lack of efficacious screening programs for early detection and presence of non-specific symptoms mimicking other respiratory diseases lead to late-stage diagnosis [1]. Lung cancer is known to metastasize to most organs, including brain, bone, liver, adrenal glands, and lymph nodes due to their abundant blood supply [2]. Metastatic spread of lung cancer to skeletal muscle, however, is an extremely rare finding seen in less than 1% of all cases [3]. Skeletal muscle metastases most commonly arise from primary tumors of the gastrointestinal and genitourinary tracts [4], with the muscles most frequently affected being the thigh, iliopsoas, and paraspinous muscles [5]. Multiple hypotheses have been formulated to explain the low prevalence of muscle metastases, which include muscle contractility, tissue pressure, variable blood flow, oxygen free-radical production, cellular and humoral immunity, and hypersensitivity reactions. CASE PRESENTATION: We are reporting a 61-year-old male presenting with left shoulder pain since motor vehicle accident, cough and weight loss. X-ray of shoulder was unremarkable. CT chest showed 10.0 x 7.4 cm mass noted in the left upper lobe concerning for neoplasm. MRI left shoulder showed significant edema involving the deltoid muscle with no drainable fluid. IR US guided deltoid biopsy showed poorly differentiated adenocarcinoma that favored the result of lung mass biopsy as well. DISCUSSION: Skeletal muscle is an extraordinarily rare site of metastasis of lung cancer and usually favors aggressive disease. Non-small cell lung cancer metastasis to skeletal muscle is seen in <1% of cases. Diagnosis is usually obtained by fine needle biopsy of muscle. Adenocarcinoma of the lung with metastatic spread to skeletal muscles described in the literature as more aggressive with median survival of approximately 6 months. The best effective treatment is currently unknown. CONCLUSIONS: Lung cancer is the most common cause of cancer related deaths worldwide, with non-small cell lung cancer (NSCLC) making up 8% of all cases. Skeletal metastatic disease is extremely rare, especially to upper extremities and if present usually affects injured muscle site.Alteration of muscle physiology increases susceptibility to cancer spread. The lactic acid producing activity of tumors has been described as a factor that contributes to the formation of new blood vessels by signaling low perfusion to an area of the body. This neovascularization produces a more hospitable environment for tumor growth. Muscle injury may decrease muscle ability to remove lactic acid. Increased vascular perfusion to injured areas has been associated with increased susceptibility for metastatic disease. Reference #1: Seely S. Possible reasons for the high resistance of muscle to cancer. Med Hypotheses. 1980;6(2):133–137. doi:10.1016/0306-9877(80)90079-1. https://pubmed.ncbi.nlm.nih.gov/7393016-possible-reasons-for-the-high-resistance-of-muscle-to-cancer/ Reference #2: Perisano C, Spinelli MS, Graci C, et al. Soft tissue metastases in lung cancer: a review of the literature. Eur Rev Med Pharmacol Sci. 2012;16(14):1908–1914. https://www.europeanreview.org/article/2667 Reference #3: Surov A, Kohler J, Wienke A, Gufler H, Bach AG, Schramm D, et al. Muscle metastasis: comparison of features of different primary tumors. Cancer imaging 2014;14:21 DISCLOSURES: No relevant relationships by Muhammad Faisal Aslam, source=Web Response No relevant relationships by Ritika Kompella, source=Web Response No relevant relationships by Luis Medina Mora, source=Web Response No relevant relationships by Anastasia Novikov, source=Web Response No relevant relationships by Theo Trandafirescu, source=Web Response No relevant relationships by Salim Yaghi, source=Web Response

CASE OF REFRACTORY INTERSTITIAL LUNG DISEASE IN ANTISYNTHETASE SYNDROME

SESSION TITLE: Medical Student/Resident Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Along with corticosteroids, patients with anti-synthetase syndrome associated interstitial lung disease (ILD) require a corticosteroid-sparing agent, such as azathioprine, rituximab, or cyclophosphamide. However, there is no study that demonstrates the superiority of one agent, making it difficult to choose one over the other given their high side effect profile. CASE PRESENTATION: A 67 years old female who had symptoms of left shoulder, arms, and eye pain that started 5 months ago, and dyspnea with exertion that started 7 months prior to presenting with worsening dyspnea. Initial work up was significant for elevated CK and aldolase, and positive ANA, anti Jo-1 and anti SS-A. CT was significant for NSIP pattern; and workup for infection was negative. Her initial oxygen requirement was 6 L. She was started on prednisone 60 mg daily, but her dyspnea progressed, getting into respiratory failure that required intubation. She was switched from prednisone to methylprednisolone 1 g/day for 3 days. She also received 2 doses of IV cyclophosphamide 1000 mg, followed by a total of 3 doses of IV Rituximab 700 mg that was initiated 8 days later. She was extubated 6 days later to facemask ventilation. She had frequent episodes of worsening dyspnea that occurred after a corticosteroid tapering attempt, therefore, requiring increased corticosteroids. She was eventually weaned to 2 liters of oxygen and discharged with home oxygen and a tapered dose of prednisone. DISCUSSION: Anti-synthetase syndrome is part of the idiopathic inflammatory myopathies (IIM) in which antibodies develop against aminoacyl tRNA. The diagnostic criteria for antisynthetase syndrome is the presence of tRNA synthetase autoantibody in addition to clinical features, such as ILD and/or myositis. The most commonly identified antibody is anti-Jo-1; other less common antibodies include: anti-PL12 and anti-PL7. ILD Anti-synthetase syndrome is more severe, rapidly progressing and leads to a high mortality when compared to ILD in the other IIMs. Corticosteroid-monotherapy in these patients is known to cause frequent lung disease reoccurrence. Therefore, an additional agent needs to be added in refractory cases. Azathioprine is a commonly used agent in conjunction with prednisone, but not well studied. Multiple other case studies showed improvement in lung function and/or pulmonary symptoms in patients who received Rituximab as the adjunctive medication. The treatment options that can be used in antisynthetase ILD lies at the discretion of the physician. In our case, the use of corticosteroids, Rituximab, and cyclophosphamide appeared to have significant clinical outcome. CONCLUSIONS: To better treat patients with this condition, high clinical suspicion is needed, and patients may benefit from early rituximab therapy. Future studies that compare the effect of corticosteroid-sparing agents would help on deciding the best treatment agents. Reference #1: Witt L., Curran J., Strek M. The Diagnosis and Treatment of Antisynthetase Syndrome. Clin Pulm Med. 2016 Sep; 23(5): 218-226. DISCLOSURES: no disclosure on file for Subramanyam Chittivelu; No relevant relationships by Ronald Espinosa, source=Web Response No relevant relationships by Abdirahman Hussein, source=Admin input

Parsonage-Turner syndrome presenting with left shoulder pain and weakness: a case report

Parsonage-Turner syndrome is a clinical syndrome that begins with a sudden, neuropathic pain on the shoulder girdle, followed by pain loss over time. It is a rare syndrome that can be overlooked during differential diagnosis of shoulder pain and weakness. In this paper, we aimed to present a 39-year-old male patient with sudden onset left shoulder pain and weakness who were diagnosed with Parsonage-Turner syndrome.

Shoulder Pain-Wheelchair Basketball

HISTORY: 39 year old male wheelchair basketball player was referred for shoulder pain and need for potential glenohumeral joint injection. He had experienced one year of left-sided shoulder pain that began after colliding with an opponent at high velocity during a game. At the time of the trauma, he had sudden onset burning left sided neck pain that radiated down his arm to his left thumb. He noticed that raising his left arm above his shoulder worsened the shoulder pain. Additionally, he noticed left-sided weakness with elbow flexion and shoulder abduction that made wheelchair transfers difficult. PHYSICAL EXAMINATION: 4/5 strength with left shoulder abduction and elbow flexion. Active left shoulder abduction and flexion was limited to 90 degrees, due to pain. Empty can, Hawkin’s, and Neer’s tests caused left anterior shoulder pain. Decreased sensation over the left lateral upper arm to pinprick and light touch. Hoffman’s elicited on the left. Reflexes: 3+ left biceps. Cervical forward and left lateral flexion limited due to pain. Left Spurling’s exacerbated shoulder pain. DIFFERENTIAL DIAGNOSIS 1. Cervical radiculopathy/myelopathy 2. Left supraspinatus tear 3. Left subacromial impingement 4. Left adhesive capsulitis 4. Left brachial plexopathy TESTS AND RESULTS Left Shoulder MRI -No supraspinatus tear -Subtle superior/posterior labral tear -Trace biceps tenosynovitis Cervical Spine MRI -Left paracentral disc herniation causing moderate spinal canal stenosis with compression of spinal cord and myelomacia at C5-6 level. -Moderate to severe foraminal stenosis, worse on the left at C5/6. Left Brachial Plexus MRI -No abnormality Upper Extremities EMG/NCS -Left primarily demyelinating median nerve mononeuropathy across the wrist. -Denervation and re-innervation at the level of the left triceps brachii muscle without abnormalities in other C6 or C7 innervated muscles or radial innervated muscles to assist with innervation suggestive of cervical radiculopathy FINAL WORKING DIAGNOSIS -Left cervical radiculopathy with myelopathic features TREATMENT AND OUTCOMES -Referral to Neurosurgery for potential surgical decompression in setting of cervical myelopathic findings. - Initiated physical therapy focusing on McKenzie based program with spine stabilization.

An Unusual Case Of Shoulder Pain In A High School Football Player

HISTORY: A 15 year-old right hand dominant male presented to sports medicine clinic due to left shoulder pain. The mechanism of injury was while playing football the day prior where he jumped to catch a pass, and landed directly on grass onto his left shoulder with arm by his side. Heard a “pop” when he landed, and was experiencing intermittent, generalized shoulder pain since the event. Denied prior injury of affected extremity as well as denied numbness or tingling. There was no swelling, discoloration, or bruising per the patient or the mother of the patient. There was no obvious reported deformity of the shoulder as well. The patient denied any neck or elbow pain. Symptoms were improved at rest and with arm at his side. PHYSICAL EXAM: Left Shoulder: Pain with passive abduction, flexion on range of motion (ROM) testing. Active ROM is full in all directions. Tender to palpation (TTP) at the AC joint and scapular angle; no TTP at scapular body. Strength: 2/5 supraspinatus, 3/5 external rotation, 4/5 internal rotation, abduction, and biceps. Positive empty can and drop arm. No erythema, normal sensation throughout left upper extremity, and radial and ulnar pulses 2+ and regular. DIFFERENTIAL DIAGNOSIS: 1. Acromioclavicular sprain 2. Rotator Cuff injury 3. Glenoid labrum injury 4. Distal clavicle contusion 5. Glenohumeral dislocation TEST AND RESULTS: 1. XR Left Shoulder: no acute fracture, dislocation, or soft tissue abnormality2. XR Left Scapula: No acute displaced fracture. 3. MRI (no IV contrast) Left Shoulder: Feathery edema in the rotator cuff musculature centered about the scapula. Low grade muscular strain vs underlying non-displaced scapular body fracture. 4. CT Shoulder Trauma w/ Joint (no IV contrast): Non-displaced hairline fracture in the mid scapular body perpendicular to the long axis. AC and GH joints are intact. FINAL WORKING DIAGNOSIS: Non-displaced extra-articular fracture in the mid scapular body TREATMENT AND OUTCOMES: 1. Immobilization with sling for initial 4 weeks with pendulum swings twice daily 2. At week 4, no pain at rest with asymptomatic full strength. Physical Therapy initiated. 3. Cleared for non-contact and non-collision activities at week 8. 4. Returned to all activities without restriction at week 12.

Shoulder Injury - Recreational Alpine Skiing

HISTORY: 54-year old female recreational alpine skier with history of left shoulder pain following a fall on hyperabducted outstretched arm after being hit from behind by another skier 3 days earlier. She noted immediate local pain of 8/10 on VAS and noticed a popping sound in the shoulder at injury. She was unable to lift her arm. PHYSICAL EXAMINATION: Edema was noted at the anterolateral shoulder, no gross deformity present. Palpation of soft tissues, tendon and bony structures revealed significant point tenderness at the greater tuberosity. Limited active ROM of 20 deg. in flexion, abduction and external rotation due to pain. Passive ROM was 80 degrees in flexion and abduction, 30 deg in ext. rotation. Resistive testing was weak and painful in flexion, abduction and ext. rotation. Due to significant pain complaints, further physical examination was suspended and clinician progressed to point-of-care ultrasound imaging of the shoulder complex. DIFFERENTIAL DIAGNOSIS: 1. Rotator Cuff Tear 2. Labral Tear/ Bankart Lesion 3. Proximal Humerus Fracture 4. Shoulder Sprain 5. Reduced Shoulder Dislocation TEST AND RESULTS: MSK Ultrasound Imaging of the shoulder complex revealed 10mm displacement of supraspinatus footprint of humerus in LAX. Patient was referred to orthopedic surgeon for further diagnostic imaging. XRI revealed displaced and comminuted greater tuberosity fracture. 3D CT also revealed acute greater tuberosity avulsion fracture with 9mm displacement. FINAL WORKING DIAGNOSIS: L shoulder displaced greater tuberosity fracture TREATMENT AND OUTCOMES: Patient underwent open ORIF of greater tuberosity fracture with two 6.5 PEEK anchors and parachute suturing. During procedure anterior/lateral rotator cuff tear was noted and repaired using high five sutures. Post surgical rehabilitation consisted of a modified RCR protocol: -Week 0-2: Brace immobilizer and PROM only in flexion to 90 deg. -Week 2-4: Brace continued. Progressed to PROM in all directions and pendulums in 4 weeks -Week 4-8: Progressive AAROM to AROM and gentle isometrics -Week 8-12: Progressed to RC strengthening and functional activities Patient outcomes were excellent with SPADI 4/100, full ROM in all directions, and only minor weakness in abduction/external rotation. Patient returned to full recreational athletic activities.

Extracapsular Hepatocellular Adenoma: A Diagnostic Dilemma

Hepatocellular adenoma (HCA) is a benign neoplasm of the hepatic parenchyma. The use of oral contraceptives (OCP) in women is the most well-established risk for the development of HCA. HCA commonly presents as an intracapsular mass of the liver but there are very few cases of extracapsular HCA. This is a case of a middle-aged female who presented to the emergency department with left shoulder pain and epigastric tenderness on physical exam. Subsequent imaging of the abdomen revealed a mass arising from the anterior wall of the stomach, with evidence of surrounding hemorrhage. The patient underwent exploratory laparotomy that revealed free blood in the peritoneum and a hemorrhagic mass arising from the stomach wall. The mass was successfully removed with no postoperative complications. Histopathological examination of the mass was consistent with an infarcted inflammatory HCA. This case illustrates this unusual presentation of a rare diagnosis.

TENSION BAND WIRING (TBW) OF DISTAL END CLAVICLE : A FORGOTTEN TECHNIQUE : SIMPLER, CHEAPER AND BETTER

Clavicle fracture is a common injury, and can be classified into middle third, medial third, and distal third fractures. Only 10-15% of clavicle fracture occur in the distal third segment. Neer classified the distal clavicle fracture into five types ; type II and V are unstable and requiring fixation . Various common methods of stabilizations are introduced such as K-wiring , tension band fixation , plate fixation, osteosynthesis with hook plate and coracoclavicular screw however all those operative methods have their own advantages and disadvantages.Materials and Methods:We presented a case of 21 years old male with left shoulder pain after motor vehicle accident. Examination revealed tenderness on his left shoulder, and radiograph showed fracture of distal end left clavicle Neer type II, requiring fixation. He was counselled for lateral extension clavicle locking plate but unable to pay due to financial constraint.Results:The patient underwent open reduction and internal fixation using Kirschner wire with tension band fixation . The fracture site was visualized and the hematoma was curetted and washed. The fracture was reduced and fixed with two 1.4 mm trans-acromial Krischner wires and the reduction was checked with an image intensifier. Then the TBW is applied using stainless steel wire size 1.0 . The K-wires are bent beneath the skin. Sling immobilization is used for 2 weeks after the operation. Unrestricted tolerable shoulder motion is permitted. Stretched and exertional exercise is allowed after radiography shows osseous union and the implants are removed.Discussions:TBW is widely employed to treat limb fractures, such as patella and olecranon fracture but seldom used for distal clavicle nowadays. The advantages of TBW are higher antirotation and antibending force compared with that in K-wire fixation and lower profile compared with the bone plate, which reduces tendon irritation and prominent implant. The use of K-wires and TBW also required only the exposure of the fracture site. The soft tissue around the clavicle incurred little damage, leading to a lower infection rate. In addition, the use of K-wires and TBWs can provide a more rigid fixation than K-wires only. Rigid fixation with little complication contributes to good results .Conclusion:Surgical management is recommended for unstable distal clavicle fracture. TBW can be preferred because of the simplicity of the procedure, low cost, simple hardware, high union rate and easy availability of the implant.

Necrotizing fasciitis of the upper back presenting with left shoulder pain.

Necrotizing fasciitis is a severe and progressive infection of deep soft tissues which results in destruction of the fascia and overlying subcutaneous fat. We report a case of a 45-year-old diabetic gentleman who initially presented with left shoulder pain, which was treated symptomatically. Upon representation, he had fever and the pain extended to his left upper back. There was a warm, firm and mildly tender purplish swelling on his mid to the left upper back. Blood tests revealed significantly elevated white cell counts and C-reactive protein. A CT thorax showed extensive soft tissue gas within the deep and superficial fascial layers of his left upper back. Necrotizing fasciitis was confirmed intraoperatively. The diagnosis of this condition is often difficult as early symptoms can be mild and nonspecific. A high Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC) score may be helpful to rule in this diagnosis and guide further management.

Streptobacillus moniliformis bacteraemia and septic arthritis in a child

Streptobacillus species are zoonotic pathogens colonising the oral cavity and upper respiratory tract of rats and other rodents.1 Transmission occurs via bites or scratches, referred to as rat-bite fever, or ingestion of contaminated food or water, referred to as Haverhill fever.1,2 Streptobacillus species are rarely isolated due to fastidious growth requirements, inhibition by sodium polyanethol sulfonate anticoagulant in blood culture bottles, and susceptibility to commonly-used antibiotics.1 A 12-year-old immunocompetent female with pet mice and rats presented with fever, left shoulder pain, and rash for five days. Examination demonstrated left axillary lymphadenopathy and left glenohumeral joint restricted range of motion, swelling, and warmth. Ultrasound confirmed a moderate glenohumeral joint effusion and subacromial bursitis. Arthroscopic washout of the joint revealed diffuse, non-purulent, synovitis. The synovial fluid cell count was 15,300×106/L with a mononuclear cell predominance. Streptobacillus moniliformis was isolated in culture of blood (paediatric blood culture bottle) and synovial fluid specimens after approximately 72 hours at the microbiology laboratory at Nepean Hospital. The patient admitted to kissing her pet rodents on their mouths and sustaining scratches to the skin of her hands whilst bathing them. She recovered completely with intravenous ceftriaxone for one week then oral amoxycillin for three weeks.

Expansile Lytic Lesions of Rib: Two Rare Case Reports

Of all primary bony tumors, chest wall is involved in only 5 – 8 % cases. Chondroblastoma and aneurysmal bone cyst (ABC) rarely occur in chest wall. Here, we would be presenting two such rare cases .One, a 26 year old male presenting with history of chest pain for 1 ½ year and other a 37 year old male with the chief complaint of pain in left shoulder for 3 years. X –ray, CT scan and MRI was done followed by guided FNAC and diagnosis of aneurysmal bone cyst in case1 and chondroblastoma in case 2 was made.

Bilateral Anterior Shoulder Dislocation Occurring Separately from the Same Injury: A Case Report

Bilateral anterior shoulder dislocation is a relatively rare condition. In a patient presenting with bilateral shoulder pain, a posteroanterior radiograph of the shoulders easily reveals the diagnosis. A 76-year-old woman presented to our emergency room with complaints of bilateral shoulder pain. She had fallen forward with both elbows hitting the ground and also hit her right shoulder. A posteroanterior radiograph revealed a right anterior shoulder dislocation with no remarkable changes noted on the left shoulder. The right shoulder dislocation was resolved, and she was sent home. Six hours later, she was brought back to our emergency room with left shoulder pain. A repeat posteroanterior radiograph of the left shoulder revealed left shoulder dislocation. Bilateral anterior shoulder dislocation occurring after 6 hours is an extremely rare condition. We report this case with a review of the literature.

Intramural submucosal hematoma of esophagus due to anticoagulant treatment

Esophageal intramural submucosal hematoma is a rare and uncommon condition which occurs due to anticoagulant or antiplatelet treatment in the elderly population, or secondary to trauma.A 63-year-old female was presented to emergency with sudden onset hematemesis, back and chest pain left shoulder pain and sweating. She has a history of non-regulated hypertension and new diagnosed atrial fibrillation with using warfarin for a week. Except for high blood pressure, her physical examination was normal with long International Normalized Ratio (INR). For confirming cardiac pathologies (abdominal aortic aneurysm or dissection) echocardiography and intravenous contrast computerized tomography of chest and abdomen was performed Computed Tomography (CT) findings were consistent with an intramural esophageal hematoma. She hospitalized intensive care unit and was controlled regularly with blood tests and vital signs. After decreasing INR, gastroscopy was performed, and findings were consistent with an intramural esophageal hematoma. By hemodynamic stabilization oral intake was starting with fluid. Control esophagogastroscopy was performed to exclude any malignancy underlying hematoma and also showed regression of hematoma. She was recovered with conservative treatment. On the day of the sixteenth, she was discharged. Spontaneously submucosal esophageal hematoma due to anticoagulant or antiplatelet treatment in the elderly patient, is a rarely seen condition. By conservative treatment, most of the cases can be recovered.

2469 Extracapsular Hepatocellular Adenoma: A Diagnostic Dilemma

INTRODUCTION: Hepatocellular adenoma (HCA) is a benign tumor of the liver and almost always located intracapsular. Bleeding (25%), and malignant transformation (5%) can complicate the disease course if left untreated. Herein, we present a case of extracapsular HCA of ectopic liver in the omentum complicated with intraperitoneal hemorrhage. CASE DESCRIPTION/METHODS: A 43-year-old lady with no past medical history presented to emergency department with two-day history of left shoulder pain and epigastric discomfort. Her only medication was an oral contraceptive pill (OCP). On physical exam, the patient had persistent sinus tachycardia, and epigastric tenderness. Initial labs were unremarkable except for mildly elevated AST at 58 IU/L (10-37). CT of the abdomen with IV contrast showed a heterogeneously enhancing mass likely arising from the anterior wall of the stomach. T2-weighted MRI abdomen demonstrated a hypoenhancing mass measuring 4 × 7 × 8 cm with adjacent hemorrhage (Figure 1). Exploratory laparotomy revealed an infarcted, hemorrhagic mass between the fundus of the stomach, spleen, and diaphragm with a large amount of clots and free blood occupying the greater curvature. The mass was separated from surrounding viscera however, slightly attached to the diaphragm. The mass was removed with the completely resolved tachycardia and epigastric pain postoperatively. Initially, the lesion was thought to be an accessory spleen based on location and gross examination. Microscopically, an infarcted, hemorrhagic mass composed of cords of degenerated epithelioid cells with vacuolated cytoplasm was surrounded by reactive fibro- and myofibroblastic tissue. Epithelioid cells were diffusely stained for HerPar-1 (hepatocyte origin), and CK AE1/AE3 (Figure 2). These findings were consistent with HCA. DISCUSSION: HCA is an overlooked diagnosis and can result in serious complications if unrecognized. Among the well-known risk factors of HCA are OCPs or anabolic steroids, pregnancy, and steatohepatitis. The prevalence of these lesions has been rising parallel to increasing use of OCP and abdominal imaging. In females, lesions &lt;5 cm with no associated symptoms or complications can be managed conservatively by terminating OCP use, and surveillance. Our patient presented with acute left shoulder pain which was likely due to phrenic nerve irritation by bleeding (Kehr's sign). To best of our knowledge, there are only three cases of extracapsular HCA reported in the English literature.

A CASE OF PANCOAST SYNDROME IN TB

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: Tuberculosis is one of the most common systemic infectious disease, and a major public health problem all over the world. It has several forms of presentation and clinical manifestations. Here we present an interesting clinical manifestation of Tuberculosis as Pancoast Syndrome. CASE PRESENTATION: A 55 year old male, smoker for past 30 years, presented with cough with expectoration, left shoulder pain and weakness of left upper limb of 6 months duration. He had irregular treatment for pulmonary tuberculosis two years ago. On examination he had partial ptosis of left eye, enophthalmos, miosis, ipsilateral anhydrosis, and tenderness in left supraclavicular region, wasting of left upper limb muscles. Sputum examination was positive for Acid fast bacilli. Cartridge based Nucleic Acid Amplification Test (CBNAAT) of sputum confirmed Rifampicin sensitive Mycobacterium Tuberculosis. Chest radiograph and CT Chest showed fibrocavitary changes, Cavitary consolidations predominantly involving right lung and mass like lesion in left apical lobe with erosion of left first rib. Histopathological examination with CT guided biopsy of the mass like lesion was negative for malignancy but showed caseous granulomatous inflammation. DISCUSSION: Pancoast syndrome1 refers to a constellation of symptoms of Brachial Neuralgia, Horner’s syndrome and atrophy of muscles of ipsilateral upper limb. Pancoast syndrome is commonly associated with Pancoast tumor of Squamous cell carcinoma , recently adenocarcinoma has emerged as commonest. Other conditions that may result in Pancoast syndrome are (1) Other tumors - primary chest wall and metastatic tumors, pleural mesothelioma, hematologic malignancies, (2) infectious and inflammatory lung diseases – tuberculosis, aspergillosis, echinococcosis, actinomyces and lung abscesses, inflammatory pseudotumor, amyloid nodules and (3) vascular lesions - carotid pseudoaneurysm, hemangioma.These conditions can invade and destruct the apical bony skeleton of the thorax, producing similar clinical and radiographic picture. CONCLUSIONS: We conclude that clinicians need to be aware of the variable manifestations of Tuberculosis. Reference #1: Pancoast HK. Superior pulmonary sulcus tumor: tumor characterized by pain Horner’s syndrome, destruction of bone and atrophy of hand muscles. JAMA 1932;19:1391-6. Reference #2: White HD, White BA, Boethel C, et al. Pancoast’s syndrome secondary to infectious etiologies: a not so uncommon occurrence. Am J Med Sci 2011;341:333-6 Reference #3: Beshay M, Roth T, Stein RM, et al. Tuberculosis presenting as Pancoast tumor. Ann Thorac Surg 2003;76:1733-5 DISCLOSURES: No relevant relationships by ALLWYN VIJAY GOWRI SHANKAR, source=Web Response No relevant relationships by Sagindar Samaraj, source=Web Response

Rhabdomyolysis and muscle infarcts associated with intra-operative compression

Rhabdomyolysis and muscle infarcts associated with intra-operative compression