Heterogeneous Parenchyma Research Articles

Pulmonary hypertension in patients carrying FLNA loss-of-function variants.

Pulmonary hypertension (PH) is an unusual complication of X-linked disease caused by loss-of-function (LOF) variants in the filamin A (FLNA) gene. Patients with FLNA LOF may also present dysmorphic facial features, aortic dilation, thrombopenia, and periventricular nodular heterotopia (PVNH). We reported clinical, functional, radiologic, and hemodynamic characteristics of patients with FLNA LOF variants and PH from the French PH Network. Nine patients were identified with a female to male ratio of 8:1. PH was diagnosed at a median age of 36 [0-69] years. Associated conditions included epilepsy (n=5), PVNH (n=7), valvular heart disease (n=8), congenital heart diseases (n=4), thrombocytopenia (n=4), and hyperlaxity (n=4). Right heart catheterisation confirmed moderate-to-severe precapillary PH with a median mPAP of 33 [22-49] mmHg and PVR of 4.7 [2.4-8.0] WU. The DLCO was markedly decreased (48 [22-64] %pred) and five patients had obstructive ventilatory disorder. High-resolution CT showed heterogeneous parenchyma (n=8), emphysema (n=3), presence of a peripheral hyperclear band (n=3) and aortic ectasia (n=4). Pathologic assessment available in one patient revealed significant remodelling of small pulmonary arteries, interstitial edema, and irregular alveoli shapes. During follow-up, three patients died, including two from right heart failure. No patient died from aortic rupture. Precapillary PH, likely due to multiple mechanisms, may complicate the course of patients with LOF FLNA variants and may be the presenting symptom leading to diagnosis. The combination of PH with parenchymal involvement and extrapulmonary symptoms (epilepsy, congenital heart diseases, valvular and aortic involvement, thrombocytopenia) should prompt genetic screening for FLNA.

8467 From Highly Suspected Hemochromatosis to Liver Metastasis Neuroendocrine Tumor

Abstract Disclosure: M.E. Chacon Cruz: None. M. Sanchez Cordero: None. G. Guerra Velazquez: None. K.C. Velez Rivera: None. A neuroendocrine cancer, often referred to as a neuroendocrine tumor (NET) or neuroendocrine neoplasm begins in the specialized cells of the body's neuroendocrine system. These cells have traits of both hormone-producing endocrine cells and nerve cells. The carcinoid is the most common neuroendocrine tumor causing liver metastases, especially when of midgut origin. However, although appendix is the most common location for midgut carcinoids it most unusually gives rise to hepatic spread. NETs are described as functional or non-functional, depending on the release of hormones. About 60% of NETs are non-functional. Case of a 66 year old male patient with medical history of ESRD on HD, PPM placement, hypertension, type 2 diabetes mellitus, and auditory impairment presents to ED of this institution after presenting with RUQ abdominal pain of one day of evolution. Patient's pain is associated with food intake or changes in diet. Laboratory work on admission patient found with leukocytosis in 16.69, anemia 10.5 and transaminitis ALT 180, AST 176 and ALP 589. Abdominal ultrasound shows Hepatomegaly with a slightly irregular surface contour. Correlate for chronic liver disease. Abdomino pelvic CT showed Hepatomegaly with a diffusely heterogeneous parenchyma and ill-defined nodular foci of hypoattenuation. During admission liver enzyme and alkaline phosphatase continue in increasing trend up to 1,172 IU/L. Ferritin in 12,203, Transferrin saturation in 23.71%. Hemochromathosis DNA not detected, Angiotensin convert enzyme in 73 U/L, tumor marker alpha-fetoprotein in 1.8 ng/ml, carcinoembryoninc antigen in 25.63 ng/ml, CA19-9 in 903 U/ml, Serotonin 23 ng/ml. MRCP was ordered and show Hepatomegaly with innumerable T2 hyperintense nodules replacing the hepatic parenchyma, may be related to cirrhosis including regenerative nodules. Interventional radiologist was consulted for liver biopsy and came back positive for Malignant Neuroendocrine Tumor, Favor Metastatic Tumor This case illustrates the challenges physicians face in quickly identifying and diagnosing pathologies as unusual as neuroendocrine tumor. Furthermore, it points out that primary care physicians should consider this disease in the differential diagnosis (DDx) in case of non-specific signs and symptoms such as abdominal pain and how the DDx can change depending on the patient's clinical symptoms and evolution. The case shows us how, with the physical examination that the patient presented, his skin was like that described in hemochromatosis, skin hyperpigmentation (Bronze Skin), weakness, diabetes mellitus, along with elevated levels of ferritin, transaminitis, alkaline phosphatase and the finding of iron deposit in the kidney using CT, our differential diagnosis was our first diagnosis, until the genetics for hemochromatosis came back negative and the liver biopsy was positive for neuroendocrine tumor. Presentation: 6/2/2024

5039 Chronic Painful Hashimoto's Thyroiditis

Abstract Disclosure: S. Ahmed: None. M. Vahidi Rad: None. S.A. Westphal: None. M.D. Whitaker: None. Introduction: Painful Hashimoto thyroiditis is a rare variant of Hashimoto thyroiditis that mostly affects women. Most cases are empirically treated as subacute thyroiditis with corticosteroids, levothyroxine, or nonsteroidal anti-inflammatory drugs. However, no medical treatment may provide sustained pain resolution, so optimal treatment remains unclear. We describe the case of a 40-year-old female with longstanding throbbing anterior neck discomfort that failed medical therapy and her symptoms completely resolved with total thyroidectomy. Case Report: A 40-year-old lady with anterior neck pain centered over the thyroid for more than 16 years, shortly after she delivered her last child. The pain is described as intense, it tends to wax and wane but there is a constant throbbing with occasional radiation to the angle of the jaw. Over the years the pain has gradually worsened and during its flares, the thyroid itself is very tender to the point where she experiences difficulty in swallowing and hoarseness of voice. Complicating the issue is her underlying diagnosis of fibromyalgia, as she tends to experience discomfort in many other areas of her body. However, the neck pain appears to be of a different character. No symptoms of hyper or hypothyroidism. The anterior neck pain has been difficult to alleviate, she has used chronic opioids for it which seems to have helped to some extent, in the past she was on prednisone for 1 month however this made no difference to it. On examination, the thyroid is tender and somewhat firm without lymphadenopathy. Thyroid levels have been consistently normal and the most recent of which was a TSH: 1.48, FT4: 1.4, FT3: 3.5 with negative TPO and thyroid stimulating antibodies. ESR and CRP were unremarkable. Thyroid ultrasound showed mildly heterogeneous parenchyma with no solid nodules or lymphadenopathy. Interestingly she had an elevated thyroid uptake in her scan dated April 1st 2022, 4 hour and 24-hour uptakes were abnormal at 23% and 49% respectively which can be seen with Hashimoto's. She underwent total thyroidectomy and her surgical pathology showed benign thyroid tissue with multiple foci of chronic lymphocytic thyroiditis and hyperplastic nodules. Her pain completely resolved after total thyroidectomy. Discussion: Painful Hashimoto thyroiditis is a rare diagnosis and optimal treatment remains unclear. The painful variant of Hashimoto's thyroiditis should be considered in the differential diagnosis of pain and tenderness of the thyroid which can be managed successfully by surgical treatment. Thyroidectomy not only can lead to alleviation of symptoms but also provides the definitive diagnosis. The risks of surgical intervention must be taken into consideration, especially because painful Hashimoto thyroiditis can be associated with a small fibrous gland; hence, the importance of access to highly skilled, experienced surgeons cannot be overemphasized. Presentation: 6/1/2024

Selenium levels and their association with thyroid autoimmunity and severe preeclampsia in pregnancy: Insights from a prospective ideal breast milk cohort study.

This study aimed to assess selenium status in South Korean pregnant women and its impact on maternal thyroid function and pregnancy outcomes. 'Ideal Breast Milk (IBM) Cohort Study' included 367 pregnant women out of 442 participants and categorized into three groups based on plasma selenium levels: deficient (< 70 μg/L), suboptimal (70-99 μg/L), and optimal (≥ 100 μg/L). During the second or third trimester, various blood parameters, including selenium, thyroid-stimulating hormone, free T4, free T3, and anti-thyroid peroxidase antibody levels, were measured. Thyroid parenchymal echogenicity was assessed as another surrogate marker for thyroid autoimmunity using ultrasonography. The median plasma selenium was 98.8 (range: 46.7-206.4) μg/L, and 30 individuals (8%) were categorized as deficient, while 164 (45%) were classified in the suboptimal group. Selenium deficiency was associated with markers of autoimmune thyroiditis, including positive anti-thyroid peroxidase antibody results (13.3 (deficient) vs 4.6 (optimal) %, P = 0.031) and thyroid parenchymal heterogeneity on ultrasound (33.3 (deficient) vs 14.6 (suboptimal) vs 17.3 (optimal) %, P = 0.042), independently of gestational age. The incidence of severe preeclampsia was higher in the group not taking selenium supplements, particularly among those with twin pregnancies, compared to the group taking selenium supplements (0 (selenium supplement) vs 9.0 (no supplement) %, P = 0.015). Pregnant women experience mild selenium deficiency, which can lead to significant health issues including maternal thyroid autoimmunity and obstetrical complications during pregnancy. Guidelines for appropriate selenium intake according to the stage of pregnancy and the number of fetuses are needed.

Disease severity prognostication in primary sclerosing cholangitis: a validation of the Anali scores and comparison with the potential functional stricture

ObjectivesOur aim was twofold. First, to validate Anali scores with and without gadolinium (ANALIGd and ANALINoGd) in primary sclerosing cholangitis (PSC) patients. Second, to compare the ANALIs prognostic ability with the recently-proposed potential functional stricture (PFS).Materials and methodsThis retrospective study included 123 patients with a mean age of 41.5 years, who underwent gadoxetic acid-enahnced MRI (GA-MRI). Five readers independently evaluated all images for calculation of ANALIGd and ANALINoGd scores based upon following criteria: intrahepatic bile duct change severity, hepatic dysmorphia, liver parenchymal heterogeneity, and portal hypertension. In addition, hepatobiliary contrast excretion into first-order bile ducts was evaluated on 20-minute hepatobiliary-phase (HBP) images to assess PFS. Inter- and intrareader agreement were calculated (Fleiss´and Cohen kappas). Kaplan-Meier curves were generated for survival analysis. ANALINoGd, ANALIGd, and PFS were correlated with clinical scores, labs and outcomes (Cox regression analysis).ResultsInter-reader agreement was almost perfect (ϰ = 0.81) for PFS, but only moderate-(ϰ = 0.55) for binary ANALINoGd. For binary ANALIGd, the agreement was slightly better on HBP (ϰ = 0.64) than on arterial-phase (AP) (ϰ = 0.53). Univariate Cox regression showed that outcomes for decompensated cirrhosis, orthotopic liver transplantation or death significantly correlated with PFS (HR (hazard ratio) = 3.15, p < 0.001), ANALINoGd (HR = 6.42, p < 0.001), ANALIGdHBP (HR = 3.66, p < 0.001) and ANALIGdAP (HR = 3.79, p < 0.001). Multivariate analysis identified the PFS, all three ANALI scores, and Revised Mayo Risk Score as independent risk factors for outcomes (HR 3.12, p < 0.001; 6.12, p < 0.001; 3.56, p < 0.001;3.59, p < 0.001; and 4.13, p < 0.001, respectively).ConclusionANALINoGd and GA-MRI-derived ANALI scores and PFS could noninvasively predict outcomes in PSC patients.Clinical relevance statementThe combined use of Anali scores and the potential functional stricture (PFS), both derived from unenhanced-, and gadoxetic acid enhanced-MRI, could be applied as a diagnostic and prognostic imaging surrogate for counselling and monitoring primary sclerosing cholangitis patients.Key PointsPrimary sclerosing cholangitis patients require radiological monitoring to assess disease stability and for the presence and type of complications.A contrast-enhanced MRI algorithm based on potential functional stricture and ANALI scores risk-stratified these patients.Unenhanced ANALI score had a high negative predictive value, indicating some primary sclerosing cholangitis patients can undergo non-contrast MRI surveillance.Graphical

Are sonographic characteristics of Hashimoto's thyroiditis related with immunologic parameters? A cross-sectional study.

The clinical, laboratory, and imaging characteristics of Hashimoto's thyroiditis are widely recognized. However, there is a dearth of information concerning the relationship between these aspects. The primary objective of this study was to investigate the correlation between sonographic features and immunologic parameters in individuals with Hashimoto's thyroiditis. This cross-sectional study enrolled a cohort of 100 consecutive patients diagnosed with Hashimoto's thyroiditis. Ultrasonography was performed to classify thyroid gland characteristics, including parenchymal heterogeneity (mild/moderate-to-high), extent of fibrosis (none-to-mild/moderate-to-high), and volume (atrophic/non-atrophic). As for immunologic parameters, thyroid autoantibodies (TOA; anti-TPO and anti-Tg), along with IG (immunoglobulin) G4 levels and lymphocyte subsets, were assessed. Of the 100 patients evaluated, 88 were female (88%) and 12 were male (12%). IgG4/IgG ratio and weekly levothyroxine (LT4) dose were significantly higher in the group with moderate-to-high heterogeneity than the group with mild parenchymal heterogeneity (p = 0.043 and p < 0.001, respectively). Compared to the group with none-to-mild fibrosis, the anti-TPO, IgG4, IgG4/IgG ratio and LT4 dose were significantly higher in the moderate-to-high fibrosis group. Anti-TPO and IgG levels were significantly lower in the atrophic thyroid group compared to the non-atrophic thyroid group. Although not reaching statistical significance, the proportion of plasma cells in the moderate/high fibrosis group was higher than in the non-fibrosis/mild fibrosis group. There was a moderate positive correlation between fibrosis with Anti-TPO, and a low positive correlation between anti-Tg, IgG4 levels with IgG4/IgG ratio. TOA, Ig G4 levels and severity of hypothyroidism were associated with ultrasonographic features such as parenchymal heterogeneity and fibrosis in Hashimoto's thyroiditis.

P-66 Primary Thyroid Lymphoma mimicking Riedel Thyroiditis

Abstract Introduction Although Riedel's thyroiditis and primary thyroid lymphoma are rare diseases of the thyroid, they should be considered in the differential diagnosis of patients presenting with a neck mass. We report here the case who was followed up with the diagnosis of Riedel's thyroiditis and later diagnosed with lymphoma. Clinical Case A 67-year-old female presented with swelling in the neck, pain and shortness of breath. Thyroid ultrasound demonstrated enlarged thyroid gland, heterogeneous parenchyma, irregular contours, thin septations and pseudonodule formations. Laboratory tests revealed, TSH 4.17 mIU/L, fT4 1.37 ng/dl, anti TPO 147 IU/mL, sedimentation 13mm/h, and CRP of 5.5 mg/dl. In neck CT, an 8*4 cm hypodense mass infiltrating both thyroid lobes, extending anteriorly and superiorly, surrounding the trachea by 270 degrees, was detected. Follicle cells were seen in the fine needle aspiration biopsy, but no neoplasm was found. In PET-CT, increased FDG uptake was detected in the thyroid parenchyma (SUVmax: 22.89) and in one subcentimetric lymph node (SUVmax: 3.5) in the right cervical region. No neoplasm was found in the tru-cut biopsy and the biopsy was reported as granulomatous thyroiditis. When her current complaints and physical examination findings were evaluated together, methylprednisolone was started, considering Riedel's thyroiditis. In the follow-up examination, the thyroid size of the patient decreased significantly and the steroid dose was reduced. The patient, who could not be followed up for a while, developed swelling and pain in the neck again, and was followed up in the ICU with acute respiratory failure, a tracheal stent was applied to the patient. The patient was then followed in the ward, with dyspnea, dysphagia and hoarseness continued, was admitted to our polyclinic again and was hospitalized. The patient stated that her oral intake decreased due to dysphagia and there was a loss of 40 kg. She had no fever or night sweats. She was not smoking. Physical examination revealed a hard, fixed mass that completely filled the right neck and reached the midline. In the endoscopic examination, the vocal cords were paralytic, the air passage was inadequate, and the mass was invading the trachea. Tracheostomy was applied to the patient. Trucut biopsy was taken from the thyroid tissue. In addition, PET-CT was taken. On PET-CT, right thyroid dimensions showed significant morphological progression compared to the previous study, very dense at similar levels (previous SUVmax: 22.89,current SUVmax: 22.76);intense FDG uptake was detected in 8 mm lymph nodes in the left cervical and 19×20 mm lymph nodes in the right supraclavicular (SUVmax 22.17) region.Diffuse Large B-Cell Lymphoma was detected as a result of thyroid biopsy and R-CHOP treatment was started on the patient. She was discharged after 2 cycles of chemotherapy (Figure). The diagnosis of both Riedel's thyroiditis and primary thyroid lymphoma are histopathological. The importance of open surgical biopsy and cooperation with an endocrine-specific pathologist was emphasized through our case.Figure.Photos of the patient at her initial and last state

Calcium Carbide Poisoning in a Dog - Ultrasound Findings

Background: Calcium carbide has been used not only in industry, but it is also present in the domestic environment. Thissubstance goes through chemical reactions that lead to the release of acetylene gas and heat being capable of causing burns, damage to mucous membranes, eyes and skin, central nervous system depression and also described as an anesthetic agent. It is lethal in concentrations of 35 % for humans and 80 % for dogs. Although reports that involve this substance in animals as scarce, emergency calls related to intoxication are part of the small animal clinical routine. This report aims to describe laboratory and ultrasonography findings in a case of carbide poisoning in a dog.Case: A 8-year-old American Staffordshire Terrier with a history of emesis, bloody diarrhea, hiporexy, oligodipsy and ingestion of calcium carbide for 3 days was admitted for medical care at the University Veterinary Hospital of Universidade Federal de Santa Maria (UFSM). The patient had a previous diagnosis of hypoadrenocorticism which was treated with sodium liothyronine 800 mg prescribed by another professional and whose dose was reduced to 600 mg by the owner without veterinary indication. Physical examination showed a high body score, evident lameness of the hind limbs, hyperemic mucosa with elevated time of capillary perfusion and an increase of mandibular and popliteal lymph nodes. Dehydration, fever, elevated heart and respiratory rates and skin lesions of the front limbs were also noted. The main possible differentiate diagnosis based on these clinical signs and history presented by the patient were poisoning calcium carbide intoxication, diabetes mellitus and hypoadrenocorticism. The dog was hospitalized to receive initial treatment and undergo further examination The first treatment instituted was dipyrone [Dipyrone Ibasa 50%® - 15 mg/kg, i.v, TID, for 3 days], tramadol hydrochloride [3 mL/kg, i.v, TID, for 2 days], sucralfate [Sucrafilm® - 5 mg/mL, v.o, TID, for 2 days],maropitant citrate [Cerenia® - 0.1 mg/kg, sc, SID, for 3 days], omeprazole [1 mg/kg, i.v, SID, for 3 days], levothyroxine [300 mg, ½ (half) tablet, v.o, BID, for 2 days]. Blood results have shown leukocytosis (19,600; reference 5,700-14,200) e lymphopenia (196/μL; reference 900/μL-4,700/μL) and in the biochemical tests, there was an increase in triglycerides (175 mg/L; reference 23 mg/L-102 mg/L), without signs of renal or hepatic lesions. In the ultrasonography exam, hepatomegaly and splenomegaly with a heterogeneous parenchyma were noticed. Alteration of the gastrointestinal tract with a thickened wall was also noticed associated with gas in the digestive tract and hyperechoic area in mucous layer. These findings are compatible with reports of mucosal irritation associated with this substance. The pancreas parenchyma was slightly heterogeneous and hyperechoic with enlargement of the body and small disperse hyperechoic focuses. Left adrenal images were compatible with clinical suspicions of hyperadrenocorticism.Discussion: All the alterations found in the imaging exam were compatible with the clinical signs due to direct contact with the substance in question. Dystrophic mineralization focuses found in spleen and pancreas can be due to the alterations of phosphorus and calcium even if not described in literature associated with calcium carbide poisoning. In conclusion, the clinical signs presented, and the image findings of this patient confirmed the danger and potentially lethal effects of the contact and ingestion of calcium carbide. The literature about this subject is scarce and deeply in need of more attention associated with new measures for prevention, instruction to owners and development of diagnose and treatment emergency protocols of these animals. Keywords: ultrasonography, dog, intoxication, toxicity.

Tomographic evaluation of the glands and lymph nodes of the cervical region in the crab-eating fox (Cerdocyon thous).

The present study aimed to determine references of normality of computed tomographic (CT) images of mandibular and parotid salivary glands (PSGs), medial retropharyngeal and mandibular lymph nodes and thyroid gland of 10 clinically healthy crab-eating foxes, Cerdocyon thous. The location, shape, homogeneity of the parenchyma, and length, height, width and pre- and post-contrast attenuation values were evaluated. The anatomical structures in the crab-eating foxes studied here presented anatomical landmarks similar to those described for domestic dogs, and showed a regular shape and homogenous parenchyma, except for the PSGs, that showed predominantly heterogeneous parenchyma. The thyroid gland topography in the crab-eating fox, though very similar, is not identical to the domestic dog and the presence of isthmus between the lobes was not detected. The values obtained from crab-eating foxes are within the normal range, although in the upper limits of dogs. There was a significant difference in the attenuation values between the right and left lobes of the thyroid gland, being greater in the left thyroid lobe. CT attenuation values ranges for this neotropical canid can be incorporated into routine staging procedures in the veterinary care of the crab-eating foxes. Furthermore, the CT images obtained were similar to those of healthy dogs, and the information obtained can be considered as initial tomographic references of normality in the cervical structures of the crab-eating fox, in order to aid in the diagnosis of future diseases that can affect this neotropical canid.

Abstract 13481: A Rare Case of Pembrolizumab (Keytruda®) -Associated Thyrotoxicosis Causing Atrial Dysrhythmias

Introduction: Immune-Check-Point Inhibitors such as pembrolizumab (Keytruda®) are associated with the development of several immune-related adverse events. Case: 70-year-old malewith history of pleomorphic sarcoma of the right lower extremity with metastases to the lungs was started on Pembrolizumab 3 weeks before presenting to the ER with complaints of generalized weakness and palpitations. The patient was tachycardic and EKG showed atrial tachycardia at 144 beats/minute with right bundle branch block (RBBB) ( FIG 1B ). RBBB had been previously noted on EKG ( FIG 1A ). High-sensitivity-troponins were in the range of 29 to 37 ng/l. The TSH on admission was 0.01 mcu/ml with free T4 of 4.7 ng/dl (&gt; twice the upper limit of normal). Of note, TSH was normal prior to the initiation of Pembrolizumab (2.01 ng/dl). Anti-microsomal anti-thyroid peroxidase (TPO) antibodies were also elevated. US thyroid showed heterogeneous thyroid parenchyma concerning for thyroiditis. The patient received multiple doses of IV metoprolol and IV digoxin for rate control before converting spontaneously to normal sinus rhythm, and was then started on metoprolol succinate to maintain the heart rate. Decision Making: Based on the patient’s recent history of initiating Pembrolizumab therapy and normal thyroid function before, his thyroid dysfunction was attributed to the immunotherapeutic agent leading to atrial dysrhythmias. Endocrinology team was consulted, and prednisone 40 mg daily was started. Repeat free T4 after 5 days came down to 2.5 ng/dl. The patient was discharged home on oral Metoprolol and slow prednisone taper in the next few weeks and outpatient follow-up with endocrinology. Conclusion: Thyroid dysfunction is one of the most common immune-related adverse effects of Pembrolizumab that can cause multisystem dysfunction such as dysrhythmias. Therefore, clinicians should be familiar with their unique adverse effects to minimize morbidity and enable appropriate management.

An Elusive Diagnosis: Diffuse Large B-Cell Lymphoma Masquerading as Acute Liver Failure with Persistent Lactic Acidosis.

BACKGROUND Acute liver failure (ALF) associated with malignant lymphoma is a rare condition with non-specific clinical and radiological features. Here, we describe an unusual case of ALF due to DLBCL with an image negative on presentation posing diagnostic difficulty. CASE REPORT A 74-year-old man was admitted to our hospital with abdominal pain. Radiological and laboratory investigations revealed lymphadenopathy with mildly elevated transaminitis and alkaline phosphates levels. A right upper-quadrant ultrasound showed heterogeneous hepatic parenchyma. Eight days later, he had worsening abdominal pain. He was found to have altered mental status and asterixis. His liver function was worsened with ALT 101, AST 328, lactic acid 4.2, total bilirubin 2.5, INR 6.35, and ammonia level 117 µmol/L. He continued to deteriorate with worsening lactic acidosis, coagulopathy, severe anemia, elevated liver enzymes, and thrombocytopenia. Unfortunately, the patient died of multi-organ failure on the 14th day of hospitalization. The autopsy findings revealed DLBCL involving multiple organs, including the liver, lung, bone marrow, and multiple lymph nodes. Despite an extensive diagnostic workup, an underlying diagnosis was unable to be established antemortem. CONCLUSIONS We describe a case of ALF linked to DLBCL discovered at autopsy. The non-specific clinical and radiological features of this condition make diagnosis challenging, and the prognosis is often poor. Further research and awareness are needed to improve the early detection and management of ALF associated with malignant lymphoma. By expanding the literature on this topic, we aim to improve outcomes and optimize patient care in similar clinical scenarios.

151 Isolated tuberculosis liver abscess in an immuno-competent patient – A case report

Abstract Introduction Tuberculosis presenting as an isolated liver abscess is extremely rare. Case Summary A 55 year old woman presented with complaints of pain right hypochondrium associated with low grade fever and weight loss for last 1 year. Abdominal examination revealed mild tenderness in right hypochondrium. Rest of system examination was unremarkable. Laboratory investigations and chest radiograph were normal. Ultrasound abdomen showed coarse heterogeneous liver parenchyma with increased echogenicity. Single irregular hypoechoic area in segment IV A of the liver was noted. CECT scan of abdomen showed a single well defined focal lesion of 4.2*5.5*4.9 cm in segment V/VI, which was hypovascular on both arterial and venous phases. Delayed imaging revealed thick rim of contrast enhancement suggestive of fibrous capsule. Ultrasound guided biopsy of the lesion was done which showed chronic caseating granulomatous inflammation suggestive of tuberculosis. Patient was started on anti- tuberculous therapy. However, she showed worsening of symptoms. A repeat triphasic CT scan showed a complex multiseptated thick-walled necrotic lesion measuring 8.5*6.9*6.4 cm in segment V/VI of the liver. Her total leucocyte count was 14,500/mm3, CRP levels 19.4 mg/l and ESR 99mm3. Ultrasound guided drainage was done and a drain was placed in right hypochondrium. Patient was discharged on oral antibiotics. The follow- up CT scan showed a significant decrease in the size of abscess (3.8*4.2*5.8 cm) with marked improvement in the symptoms. Conclusion An isolated tuberculous liver abscess poses challenge to the clinical acumen of the treating physician and an early diagnosis can help reducing the morbidity and mortality associated with it.

Assessment of thyroid nodule malignancy risk in medical radiation workers using ACR TI-RADS

BackgroundLow-dose radiation exposure brings medical radiation professionals at risk for thyroid parenchymal disease and nodules. ObjectiveTo classify thyroid nodules in medical radiation workers according to their risk, and to look into parenchymal disease and thyroid dysfunction. Design, setting and participantsRetrospective observational study in a tertiary health facility with 148 healthcare workers working in radiation-containing areas. Main outcome and measuresParticipants were divided into groups based on their sociodemographic characteristics, the department they worked in, and the number of years they had been in the profession. The levels of TSH, parenchymal heterogeneity, and thyroid nodule presence were compared between the groups. American College of Radiology (ACR) Thyroid Imaging – Reporting and Data System (TI-RADS) classification was used to evaluate thyroid nodules. ResultsThe presence of nodules was significantly more prevalent in patients over the age of 33 (p = 0.02). The majority of individuals (98%) had nodules that below the American College of Radiology (ACR) Thyroid Imaging – Reporting and Data System (TI-RADS) category 4. Age and professional experience both elevated TSH results (p = 0.015, p = 0.033). With age, parenchymal heterogeneity became more prominent (p = 0.04). For the parameters, there were no appreciable differences between the occupation and department. The results applied to both genders equally. ConclusionWith increasing long-term low-dose exposure, medical radiation workers are at risk for nodules and parenchymal disease. However, the majority of the nodules in our study were sonographically in the low risk group, therefore routine follow-up is advised.

Challenges in Accurate Diagnosis of HCC in FALD: A Case Series.

Patients with single ventricle cardiac disease palliated with Fontan procedures inevitably develop Fontan-Associated Liver Disease (FALD), which poses a significant risk for hepatocellular carcinoma (HCC). Standard imaging criteria for the diagnosis of cirrhosis are not reliable due to parenchymal heterogeneity of FALD. We present 6 cases to demonstrate our center's experience and the challenges in diagnosing HCC within this patient population.

Effectiveness of US Surveillance of Hepatocellular Carcinoma in Chronic Hepatitis B: US LI-RADS Visualization Score.

Background US is a standard surveillance tool of hepatocellular carcinoma (HCC), but its effectiveness varies depending on the degree of fibrosis or steatosis and the etiologies of liver disease. Purpose To evaluate the detection power of US and the occurrence of HCC according to the US Liver Imaging Reporting and Data System (LI-RADS) visualization score in chronic hepatitis B (CHB). Materials and Methods Consecutive patients with CHB undergoing regular US surveillance of HCC at a tertiary referral hospital were retrospectively included in this study. During the follow-up, all patients underwent regular HCC surveillance mainly with US and, in some cases, alternative CT or MRI. Outcomes of interest included cumulative incidence of HCC and false-negative rate of US in the optimal (LI-RADS visualization A) versus suboptimal groups (visualization B or C). Cox regression analysis was conducted to calculate the hazard ratio (HR) of HCC occurrence. Results A total of 2002 patients (median age, 54 years [IQR, 46-60 years]; 1192 men) were included: 972 and 1030 in the optimal and suboptimal groups, respectively. Causes of suboptimal visualization included parenchymal heterogeneity from advanced cirrhosis (n = 489), limited penetration from fatty liver (n = 200), and limited window from overlying organ shadow (n = 341). During a median follow-up of 75 months (IQR, 69-77 months), 163 patients developed HCC. Compared with the optimal group, the suboptimal group had a higher risk of HCC (2.38% per year vs 0.48% per year: hazard ratio, 4.93; 95% CI: 3.28, 7.41; P < .001) and higher odds of a false-negative rate of US (43.9% vs 16.7%: odds ratio, 3.90; 95% CI: 1.02, 15.00; P = .04). Conclusion Among patients with CHB, those with suboptimal US LI-RADS visualization of B or C had a higher risk of HCC and higher odds of false-negative rates of US for detecting HCC than those with optimal visualization of A. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Barr and Scoutt in this issue.

Incorporation of Testicular Ultrasonography and Hair Steroid Concentrations in Bull Breeding Soundness Evaluation.

Testicular ultrasonography and steroid concentrations (cortisol, dehydroepiandrosterone sulfate (DHEA-S), cortisol/DHEA-S ratio, testosterone) in hair were examined for their utility in the bull breeding soundness evaluation (BBSE). Beef and dairy bulls (n = 16; 2.7 ± 0.4 years old; body condition score 3.2 ± 0.1) of five breeds were maintained under the same conditions at an accredited semen collection center. Bulls underwent routine semen collection twice weekly for 12 weeks and semen was processed and cryopreserved. Ultrasonography and hair sampling were undertaken at the last semen collection. Bulls with homogeneous testicular parenchyma (n = 8) had a higher (p < 0.05) percentage of motile sperm post-thawing compared with bulls with heterogeneous parenchyma (n = 8). There were no differences (p > 0.05) in the hair concentrations of cortisol, DHEA-S, and testosterone between bulls with homogeneous and heterogeneous parenchyma. In bulls with homogeneous parenchyma, hair DHEA-S concentration was positively correlated with percentage motile sperm (R2 = 0.76), progressively motile sperm (R2 = 0.70), and motility yield (R2 = 0.71). The findings indicate that the integration of testicular ultrasonography and hair DHEA-S status in the BBSE could provide a more comprehensive assessment of indicative fertility in bulls. Additionally, ultrasonography can be used in the BBSE when the evaluation of semen parameters is not available.

Is it tuberculosis mastitis or granulomatous mastitis? A thirteen-year experience at a university hospital.

Granulomatous mastitis (GM) is a rare inflammatory disease of the breast. Tuberculosis mastitis (TM), one of the causes of GM, is a rare form of extrapulmonary tuberculosis. The clinical, radiological, and histopathological findings of TM and GM are similar, and sometimes it is difficult to make a distinction between these disease states. In this study, we aimed to evaluate the clinical and radiological features, diagnostic techniques, treatment modalities and treatment outcomes of the patients with GM and TM. The data of the patients with confirmed GM by histopathologic examination of biopsy specimens between 2007 and 2020 were retrospectively analyzed. Demographic features, main complaints, physical findings, radiological and laboratory data, treatment modalities, and treatment outcomes were recorded. Sixty-eight GM patients with a mean age of 35.8 (18-63) years were evaluated. The patients had a mass lesion, pain, ulceration,and abscess in their breasts. All of the cases were female. Ultrasonographic examinations were performed on 62 cases. Abscess and/or sinus tract formation was detected in 34, heterogeneous hypoechoic mass in 15, heterogeneous parenchyma or parenchymal edema in 15, axillary lymphadenopathy in 18 and cysts in 13 patients. A total of 10 patients were lost to follow-up. Twenty-six patients underwent surgery for their breast lesions or had antibiotherapy (n = 13) or corticosteroid therapy (n = 7). Eleven (16.1%) patients were diagnosed with TM. These patients were evaluated by clinical examination, chest radiography, and tuberculin skin test. Acid-fast bacilli (AFB) staining and culture were negative in all cases. The diagnosis of TM was based on histopathological evaluation results. Eight of the 11 patients achieved complete remission with antituberculosis treatment. The etiological diagnosis of GM must be based on a multidisciplinary approach. Tuberculosis mastitis should become a part of differential diagnosis of breast diseases in populations with high incidence of tuberculosis.

Achados clínico-patológicos e imuno-histoquímicos em um caso de angiomatose cutânea bovina em uma novilha Holandesa

ABSTRACT: Bovine cutaneous angiomatosis (BCA) is a rare condition characterized by vasoproliferative skin lesions mainly affecting cattle in the northern hemisphere. An eight-month-old Holstein heifer showed two skin easy-bleeding nodules bulging from the epidermis in the forehead and close to the right prescapular region. Skin lesions were within the dermis and had an irregular surface and a soft heterogeneous reddish parenchyma composed of numerous variable-sized arterioles, veins, and capillaries surrounded by abundant collagenous fibrous tissue. Immunohistochemical assays evidenced endothelial cells lining proliferative vascular structure immunolabeled for CD31 and Von Willebrand factor, and vascular smooth muscle cells immunostained for smooth muscle actin. All clinical, pathological, and immunohistochemical features observed in the Holstein heifer were hallmarks of BCA. Considering its potential for hereditary spread, BCA must be included in the differential diagnosis of easily bleeding skin nodules that do not respond to routine topical wound treatments to prevent its spread in Brazilian herds.

Insight into clinical, laboratory, and GIT ultrasound diagnostic findings of cystic fibrosis in pediatrics

BackgroundCystic fibrosis (CF) is a multisystem disorder. Gastrointestinal tract (GIT) involvement presently requires medical attention, and this improves the survival rate of patients with CF. GIT imaging has an essential role in the early detection of GIT affection. This study aimed to quantify the abdominal symptoms and their relationship to clinical findings, abdominal ultrasound scoring system, and laboratory parameters, correlating GIT manifestation with ultrasound diagnostic findings.MethodsThis was a cross-sectional study that included 60 patients diagnosed with CF based on clinical manifestations and confirmed by a positive sweat chloride test ≥ 60 mmol/L and/or genetic analysis (CFTR gene mutation; a copy from each parent) in the CF clinic in the Children’s Hospital, in a period of 12 months.ResultsRecurrent abdominal pain (RAP) was the most common GIT manifestation, followed by abdominal distension and steatorrhea. Ultrasonography (US) showed that the most frequent findings were pancreatic lipomatosis in 16 patients (26.7%), the next common finding was heterogeneous coarse hepatic parenchyma in 14 patients (23.3%), while the least finding was the thickened bowel walls in 2 patients (3.3%). Abdominal US scoring revealed that the highest burden of GIT symptoms was clearly associated with pancreatic lipomatosis and liver steatosis with the highest score (6/7) (p = 0.048), while bowel wall thickness (BWT) had the lowest score (3/7) (Table 4).ConclusionThis study reveals that abdominal US is a non-invasive investigation that helps in the early detection of GIT involvement in CF. RAP is a common GIT manifestation and may reflect a major pathology. Moreover, a significant relationship was detected between RAP and pancreatic cystosis and lipomatosis. Therefore, the study also highlights the importance of US as a routine non-invasive follow-up tool for patients with CF and suggests close monitoring of patients with CF by abdominal US performed every 6 to 12 months.

S3254 A CCase of Seronegative Autoimmune Hepatitis During Pregnancy

Introduction: Autoimmune hepatitis (AIH) is a rare disease that usually affects women at reproductive age and is associated with an increased risk of adverse maternal and fetal outcomes. Diagnosis of AIH during pregnancy, particularly in absence of autoantibodies, poses a challenge for clinicians. We present the case of a patient with new-onset seronegative AIH during pregnancy. Case Description/Methods: A 29-year-old Hispanic female, G2P101 at 19 weeks presents complaining of yellowing of her skin and eyes for 1 week, associated with nocturnal pruritus. Physical exam showed generalized jaundice and scleral icterus. Laboratory investigations showed significantly elevated AST (452 U/L), ALT (165 U/L), alkaline phosphatase (182 U/L), hyperbilirubinemia, elevated bile acids, and elevated INR. Hepatitis panel and autoimmune work up, were negative. Abdominal ultrasound was normal. MRCP showed nonspecific hepatic parenchyma heterogeneity on T2 signal suggestive of infiltrative process. A diagnosis of intrahepatic cholestasis of pregnancy (IHCP) with atypical presentation was made, and patient was started on ursodeoxycholic acid, which improved her symptoms. At day 15, she developed lower abdominal and vaginal bleeding, caused by placental abruption. The fetus was deemed non-viable and an emergent C-section was performed. Patient was eventually discharged with outpatient GI follow up. At follow up, recurrent rise in liver function tests were noted, and repeat autoimmune work up showed elevated IgG (3600). Liver biopsy was performed, which showed active chronic inflammation with lymphoplasmacytic infiltrates, moderate interface hepatitis with ballooning degeneration and emperipolesis, and moderate portal fibrosis with bridging fibrosis, suggestive of autoimmune hepatitis. Patient was subsequently started on steroid therapy, with appropriate response as symptoms progressively resolved and liver function tests normalized. Discussion: AIH is a rare condition that can manifest with antepartum and postpartum flares, having negative consequences to fetal and maternal outcomes, hence the importance of controlling AIH activity throughout pregnancy and in the postpartum period. Liver biopsy should be considered in cases of antibody negative AIH, however there is paucity of data regarding its safety in pregnancy. We present the rare case of an initially seronegative AIH flare during pregnancy, possibly attributed to the potential physiologic effects of pregnancy in the regulation of immune system mechanisms.