Pathognomonic Pattern Research Articles

Functional magnetic resonance imaging and functional dyspepsia: Predictive value questioned

Functional dyspepsia is a challenging condition in gastroenterology, characterized by digestive symptoms without evidence of organic pathology. Conventional diagnostic methods have significant limitations in terms of sensitivity and specificity. This study aims to explore the potential of functional magnetic resonance imaging (fMRI) as an innovative diagnostic approach for functional dyspepsia, with a view to improving diagnostic accuracy and benefiting patients. This integrative literature review, following the PRISMA guidelines, investigated the use of fMRI in the diagnosis of functional dyspepsia. Sixteen articles were selected after rigorous screening, employing detailed descriptive analysis and narrative synthesis. As a result, it was noted that patients with functional dyspepsia exhibit alterations in brain activity, especially in areas associated with sensory processing and emotional control, indicating dysfunction in these regions. It is concluded that fMRI has promising potential in the diagnosis of functional dyspepsia, complementing conventional methods. Although specific pathognomonic patterns have not been identified, the affected brain areas offer a basis for applying fMRI, improving understanding of the condition and enabling more targeted therapies.

Pathomorphosis of eyelid tumor pathology in demodectic infection

Background. Pathological changes in the tissues of the oculo-conjunctival region caused by the activity of the Demodex mite is represented by the development of inflammatory process. On detection of the parasite on eyelashes, the presence of the Demodex mite is diagnosed in half of adult patients seeking ophthalmic care. Pathomorphological descriptions of specific patterns associated with the presence of Demodex infection are practically absent. During pathological examination, in the vast majority of cases it is almost impossible to see the parasite in the test material. There are pathomorphological patterns associated with the presence of the mite as a commensal, not only on the eyelid surface or in the conjunctiva, but also in morphological structures formed against the background of pathological processes in this area. Aim. To find out the morphological patterns reflecting the pathomorphosis of some tumor processes in the eyelid thickness caused by demodectic invasion, which have not been identified so far in ophthalmopathological studies. Materials and Methods. We analyzed the archival material from the oculo-conjunctival region submitted to the ocular pathology laboratory within the period of 2020–2023. Surgical and biopsy specimens were processed by standard histologic methods. Results. One of the pathognomonic patterns of demodecosis are calcifications with fragments of the dead mite and cysts. When a mite rapidly destroys tissue, it leaves the site until it dies without retaining its fragments. Post-demodecosis pathomorphosis in basal cell carcinoma of the eyelids complicates the pathomorphologic diagnosis of the biopsy. Conclusions. Our results prove the presence of mites in tumor tissues and illustrate their influence on the development of the pathomorphological picture, which should be taken into account in the practical activity of a pathologist. Keywords: demodex mite, pathomorphology, ophthalmopathological examination, oculo-conjunctival region.

Characterising polymyalgia rheumatica on whole-body 18F-FDG PET/CT: an atlas.

The impact of modern imaging in uncovering the underlying pathology of PMR cannot be understated. Long dismissed as an inflammatory syndrome with links to the large vessel vasculitis giant cell arteritis (GCA), a pathognomonic pattern of musculotendinous inflammation is now attributed to PMR and may be used to confirm its diagnosis. Among the available modalities, 18F-fluorodeoxyglucose (18F-FDG) PET/CT is increasingly recognized for its high sensitivity and specificity, as well as added ability to detect concomitant large vessel GCA and exclude other relevant differentials like infection and malignancy. This atlas provides a contemporary depiction of PMR's pathology and outlines how this knowledge translates into a pattern of findings on whole body 18F-FDG PET/CT that can reliably confirm its diagnosis.

Failing to palpate femoral pulses in adult hypertensive patients may lead to diagnostic wandering and major cerebrovascular events in cases of undetected aortic coarctation

In developed countries, aortic coarctation (AC) is generally diagnosed by fetal echocardiography during the third trimester of pregnancy, or during the neonatal period based on the absence of femoral pulses or the presence of a left supraclavicular systolic murmur. However, AC may be diagnosed late, such as in adult migrants arriving from developing countries without documented medical history although they may require healthcare support during their stay. We report three cases of the incidental diagnosis of thoracic aortic malformations in adults (27, 38 and 43 years) referred for the management of uncontrolled high blood pressure, with major cerebrovascular events for the two oldest. Doppler ultrasound imaging indicated for suspected renal artery stenosis and atheroma lesions revealed abnormal lower-body and normal upper-body arterial blood flow velocity waveforms constitutive of a pathognomonic hemodynamic pattern of AC, a diagnostic which was in all three cases confirmed by multidetector computed tomography-angiography. None of these patients had undergone complete cardiovascular examination, particularly with effective peripheral pulse palpation, during the period preceding the occurrence of major cardiovascular events or at any other time after birth. Our observation suggests that a simple medical examination could have prevented diagnostic wandering and, possibly, the occurrence of severe cerebrovascular complications in two of these three patients.

The role of the anatomical structure of the lymphatic system of lower limbs in the development of chronic venous edema in varicose veins disease

Introduction. Varicose veins disease of the lower extremities is often accompanied by edema, which persists even after the elimination of the causes of venous insufficiency. Clinically, the etiopathogenesis of edema in such patients is not always possible to differentiate. Objective. To determine the role of the lower limb lymphatic vasculature stucture variants in the development of chronic venous edema in patients with varicose veins disease. Materials and methods. A retrospective analysis of the results of X-ray contrast lymphography and radionuclide lymphoscintigraphy of 257 patients with different stages of chronic venous insufficiency (CVI). Results. Pathognomonic patterns of the lymphatic vasculature structure at various stages of lymphedema in patients with C3-C5 CVI were discovered. We found that the increasing number of cases of persistent oedema could be associated with the lower limb lymphatic vasculature hypoplasia and higher classes of CVI: 43.95 % among the patients with C4 CVI and 88 % with C5 CVI. The majority (94,1 %) of patients with C3 CVI with a normal-like lymphatic system presented with transitory oedema. With CVI C5, the capacity of the groin lymph nodes was impaired in 64 %. In C4 CVI, weak contrasting was observed in 45.1 %. With C3 – in 35.1 % of cases. Conclusions. The progressing degree of chronic venous oedema could be associated with the lymphatic vasculature hypoplasia and the malfunction of the groin lymph nodes.

Role of Ultrasonography, Doppler, and Elastography in the Evaluation of Non-Hodgkin Lymphoma of the Neck with Pathological Correlation

Non-Hodgkins lymphoma involves lymph nodes which show a characteristic micronodular (reticulated) pathognomonic pattern on sonography. We are presenting sonography, Doppler, and strain elastography findings with pathological correlation in a 65-year-old patient with posterior neck lymphadenopathy.

Pediatric Otoscopy Video Screening With Shift Contrastive Anomaly Detection.

Ear related concerns and symptoms represent the leading indication for seeking pediatric healthcare attention. Despite the high incidence of such encounters, the diagnostic process of commonly encountered diseases of the middle and external presents a significant challenge. Much of this challenge stems from the lack of cost effective diagnostic testing, which necessitates the presence or absence of ear pathology to be determined clinically. Research has, however, demonstrated considerable variation among clinicians in their ability to accurately diagnose and consequently manage ear pathology. With recent advances in computer vision and machine learning, there is an increasing interest in helping clinicians to accurately diagnose middle and external ear pathology with computer-aided systems. It has been shown that AI has the capacity to analyze a single clinical image captured during the examination of the ear canal and eardrum from which it can determine the likelihood of a pathognomonic pattern for a specific diagnosis being present. The capture of such an image can, however, be challenging especially to inexperienced clinicians. To help mitigate this technical challenge, we have developed and tested a method using video sequences. The videos were collected using a commercially available otoscope smartphone attachment in an urban, tertiary-care pediatric emergency department. We present a two stage method that first, identifies valid frames by detecting and extracting ear drum patches from the video sequence, and second, performs the proposed shift contrastive anomaly detection (SCAD) to flag the otoscopy video sequences as normal or abnormal. Our method achieves an AUROC of 88.0% on the patient level and also outperforms the average of a group of 25 clinicians in a comparative study, which is the largest of such published to date. We conclude that the presented method achieves a promising first step toward the automated analysis of otoscopy video.

Novel application of optical coherence tomography and capillaroscopy in psoriatic arthritis in relationship to psoriasis and hand osteoarthritis.

ObjectivesNailfold video capillaroscopy (NVC) and angiographic optical coherence tomography (OCTA) have potential in diagnosing PsA and differentiating it from psoriasis vulgaris (PsO) and hand OA. We aimed to assess the diagnostic properties of NVC and OCTA in patients with PsA compared with patients with PsO and hand OA based on nailfold capillary patterns.MethodsPatients with DIP joint PsA and nail involvement (n = 50), PsO with nail involvement (n = 12) and OA (n = 13) were included in this cross-sectional study. Capillaries were evaluated semi-quantitatively and qualitatively. Differences in capillary findings between groups were assessed using mixed linear models. Binary logistic regression analyses were performed to determine the probability for PsA diagnosis based on capillaroscopy findings.ResultsBelow mean capillary density and reduced nailfold blood flow in OCTA images distinguished PsA from both PsO (P = 0.004 and P = 0.052, respectively) and OA (P = 0.024 and P < 0.001, respectively). Qualitative analysis revealed that glomerular capillaries were found in only 3% of PsA patients but in 13% of PsO patients (P = 0.003). Furthermore, crossed vessels were seen in only 55% of PsA patients and 71% of PsO patients (P = 0.043). NVC microhaemorrhage was dominant in PsA patients (13%) and significantly different from OA patients (P <0.05). No capillary pattern was associated with an increased probability of the PsA diagnosis.ConclusionA pathognomonic pattern for PsA diagnosis was not identified; however, we demonstrated some characteristic capillaroscopy findings for PsA, such as decreased capillary density, reduced blood flow and fewer crossed vessels in OCTA and presence of NVC microhaemorrhages.

Abusive head trauma: neuroimaging mimics and diagnostic complexities.

Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.

Possibilities of nailfold capillaroscopy in the differential diagnosis of immuno-inflammatory and rheumatological diseases

This article considers capillaroscopic changes in the patients with systemic sclerosis compared to the patients with a group of rheumatological diseases (rheumatoid arthritis, polymyositis, osteoarthritis) and the patients with idiopathic pulmonary hypertension. All the patients diagnosed with systemic sclerosis according to nailfold capillaroscopy had a characteristic combination of capillary disorders (Raynauds syndrome): the expansion of all three segments of the capillary loop, the loss of capillaries, and the destruction of the nail fold. In the comparison groups, the capillaroscopic picture was represented by single pathological changes that did not add up to the pathognomonic scleroderma patterns, with the exception of the groups with dermato/polymyositis, where 2 patients had significant Raynauds syndrome. There were also significant differences in the density of the capillaries in the patients with systemic sclerosis in comparison with the other groups.

Myositis ossificans mimicking sarcoma: a not so rare bioptic diagnostic pitfall

BackgroundMyositis ossificans (MO) is a heterotopic bone formation in soft tissues, usually caused by traumas or neuropathies. Although the aetiology remains unclear, MO is supposed to be an osteoblast metaplasia with a benign and self-limiting course. Remarkably, at onset MO can be clinically, radiologically and histologically indistinguishable to soft tissue malignancies, especially in cases lacking a history of trauma, leading to misdiagnoses and improper treatments.Case presentationA 13-year-old male was referred to the Oncology Department because of a previous diagnosis of osteogenic sarcoma of his left thigh. The diagnosis was made upon a history of isolated thigh pain in the absence of traumas, the evidence of a contrast-enhanced soft tissue mass on magnetic resonance imaging and the histological findings of atypical nuclei and mitotic figures. The lesion was eventually radiologically unchanged after five cycles of chemotherapy; thus, the child was referred for radical surgery. At admission, endorsing the child well-appearance, together with the evidence of a reduced calcified lesion on a further magnetic resonance, a clinical suspicion of myositis ossificans was raised. Hence, the excisional biopsy confirmed the pathognomonic zonal pattern of myositis ossificans.ConclusionsThis case highlights some frequent diagnostic pitfalls facing myositis ossificans. A lacking history of traumas, along with a too early radiological and histological evaluation can lead to a misdiagnosis of soft tissue malignancies. Even in the absence of a clear history of trauma, a painful soft tissue swelling with a benign clinical course should raise the suspicion of myositis ossificans.

MORPHOLOGICAL AND FUNCTIONAL CHARACTERISTICS AT THE ONSET OF EXUDATIVE CONVERSION IN AGE-RELATED MACULAR DEGENERATION.

To characterize retinal morphology differences among different types of choroidal neovascularization and visual function changes at the onset of exudative age-related macular degeneration. In a post hoc analysis of a prospective clinical study, 1,097 fellow eyes from subjects with choroidal neovascularization in the study eye enrolled in the HARBOR trial were evaluated. The onset of exudation was diagnosed on monthly optical coherence tomography by two masked graders. At conversion as well as 1 month earlier, pigment epithelial detachment, intraretinal cystoid fluid, subretinal fluid, subretinal hyperreflective material, as well as ellipsoid zone and external limiting membrane loss were quantitatively analyzed. Hyperreflective foci, retinal pigment epithelial defects, haze and vitreoretinal interface status were evaluated qualitatively. Main outcome measures included visual acuity and rates of morphologic features at conversion and 1 month earlier. New-onset exudation was detected in 92 eyes. One month before conversion, hyperreflective foci, pigment epithelial detachment, retinal pigment epithelial defects, and haze were present in the majority of eyes. At the onset of exudation, the volumes of intraretinal cystoid fluid, subretinal fluid, subretinal hyperreflective material and pigment epithelial detachment, and the areas of external limiting membrane and ellipsoid zone loss significantly increased. The mean vision loss was -2.2 letters. Pathognomonic patterns of the different choroidal neovascularization types were already apparent 1 month before conversion. Characteristic choroidal neovascularization-associated morphological changes are preceding disease conversion, while vision loss at the onset of exudation is minimal. Individual lesion types are related to specific changes in optical coherence tomography morphology already before the time of conversion. Our findings may help to elucidate the pathophysiology of neovascular age-related macular degeneration and support the diagnosis of imminent disease conversion.

Role of ocular cytology in vernal keratoconjunctivitis.

BackgroundChildren with vernal keratoconjunctivitis (VKC) present symptoms that are similar to other ocular allergies, but more pronounced, and are controlled using topical steroids. To avoid excessive and prolonged use of topical steroid eye drops, over the past 20 years galenic eye drops of cyclosporine with a concentration of 1% to 2% and tacrolimus with a concentration of 0.1% have been introduced as a treatment for the severe and unresponsive forms. The main symptoms of VKC occur most frequently during the spring and tend to get worse during the summer, meaning that affected children tend to avoid exposure to sunlight. The aim of this study was to assess the most common cell types present in the conjunctiva of children with VKC, how ocular treatment can influence them, and whether affected children express a typical conjunctival pattern, which could be useful as a pathognomonic pattern of VKC, allowing us to study this rare eye disease.MethodThis was a cohort study of 56 children, of whom 17 were not receiving any treatment at the time of testing, 14 were using steroid eye drops or had taken them in the previous 10 days, and 25 were treated with cyclosporine eye drops or tacrolimus eye drops 0.1%.ResultChildren in group 1 (no topical therapy) express more epithelial cells, neutrophils, mast cells, eosinophils, and lymphocytes than the other two groups.ConclusionGiven the ease of performance, when conducting further longitudinal studies, the conjunctival cytology examination could be used, on the one hand, to diagnose VKC, especially when the clinical diagnosis is uncertain, and, on the other, to follow disease evolution and monitor the response to topical treatment.

Síndrome de Brugada. Aspectos fisiopatológicos, clínicos y su asociación con enfermedades infecciosas

El síndrome de Brugada (SBr) es una enfermedad cardiaca no estructural que afecta los canales iónicos cardiacos, caracterizado por manifestaciones clínicas como arritmias, taquicardia, síncope y muerte súbita, entre otras. Su diagnóstico es netamente electrocardiográfico, con un patrón altamente sugestivo pero no patognomónico, por lo que existen diagnósticos diferenciales desde el punto de vista electrocardiográfico.Existen tres patrones electrocardiográficos en los pacientes con SBr, de los cuales el tipo I es el patrón más característico. Actualmente, múltiples genes se han relacionado con la presentación de este síndrome, entre los cuales se destaca el gen SCN5A, el más descrito en la literatura. Se conoce que este síndrome es más frecuente en el género masculino; sin embargo, no existen estudios epidemiológicos en Latinoamérica que lo confirmen. Pese a que la investigación alrededor de los mecanismos causales del síndrome ha avanzado, existen varias cuestiones sin resolver, como su desenmascaramiento por los signos que producen algunas enfermedades infecciosas causadas principalmente por virus. Por lo tanto, dada la relevancia clínica del tema para el médico general y para el especialista, el objetivo de esta revisión es describir no solo aspectos fisiopatológicos y clínicos de la enfermedad, sino también resaltar casos de pacientes con enfermedades infecciosas quienes posteriormente han sido diagnosticados con el síndrome de Brugada.

The Evolving Role of Cardiovascular Magnetic Resonance Imaging in the Evaluation of Systemic Amyloidosis.

Systemic amyloidosis is a serious multiorgan disease with reduced life expectancy, irrespective of type. The impact of magnetic resonance imaging (MRI) in managing this condition has been immense. The last decade in particular has seen a surge of interest in the assessment and evaluation of the heart in patients with systemic amyloidosis by cardiovascular magnetic resonance imaging (CMR), with approximately 85% of all publications on this subject arising in the last 10 years. This has been largely driven by the creation of new sequences and their subsequent modernisation and technical development, thereby rendering previously prohibitive methods clinically more relevant and applicable. In turn, this has led to an increased awareness and recognition of the disease. This review demonstrates how MRI has become a pivotal diagnostic tool in the assessment of cardiac amyloidosis over the last 2 decades, with the ability to track disease and predict mortality. Several different pathognomonic patterns of late gadolinium enhancement (LGE) are now recognised and are able to prognosticate. T1 mapping and extracellular volume (ECV) techniques have resulted in even earlier disease detection before LGE is even visible and along with T2 mapping, provide new insights into biology. As newer therapies also evolve and become available, the need for accurate tracking of cardiac disease response to treatment carries increasing importance. All these are examined in this review, mainly focussing on light-chain (AL) and transthyretin (ATTR) amyloidosis.

Diagnostic yield of fiber optic bronchoscopy in alveolar and/or ground glass opacification in chest computed tomographic scan

Background and objectiveTransbronchial lung biopsy (TBLB) can be obtained using forceps and usually represents the centrilobular regions. Therefore, disorders that are centered around terminal and respiratory bronchioles or distributed along the lymphatic routes can be diagnosed. This study investigated the diagnostic yield of flexible bronchoscopy in patients with ground-glass opacity (GGO) or alveolar filling for histopathological diagnosis and found out its complications.Patients and methodsTwenty-six patients with predominant GGO or alveolar opacity in the chest computed tomographic (CT) scan were submitted for TBLB for histopathological confirmation. Patients with respiratory failure, heart failure, coagulopathy, or pathognomonic CT patterns were excluded. All patients were subjected to full history taking, chest CT scan, and TBLB with histopathological examination of the specimens.ResultsThe diagnostic yield of TBLB was 73.1%. Histopathological diagnoses included hypersensitivity pneumonitis (23.1%), sarcoidosis (19.2%), adenocarcinoma (11.5%), small cell lung cancer (7.7%), alveolar proteinosis (3.8%), alveolar hemorrhage (3.8%), organizing pneumonia (3.8%), and chronic nonspecific inflammation (26.9%). There was no significant correlation between age, sex, smoking, and histopathological diagnoses. Regarding the predominant CT finding, 15 (57.7%) patients had GGO, whereas 11 (42.3%) patients had alveolar filling with significant (P=0.008) positive correlation between the CT predominant pattern and histopathological diagnoses. There was a positive significant correlation between lymph node enlargement in CT and histopathological diagnosis (P=0.029). Complications from TBLB included the pneumothorax (15.4%) and bleeding (7.7%).ConclusionsTBLB seems to be a useful and safe procedure. It is of a high diagnostic value. Therefore, it could be considered a routine diagnostic procedure before thoracoscopic or open lung biopsy.

The Complexity and Fractal Geometry of Nuclear Medicine Images.

Irregularity in shape and behavior is the main feature of every anatomical system, including human organs, tissues, cells, and sub-cellular entities. It has been shown that this property cannot be quantified by means of the classical Euclidean geometry, which is only able to describe regular geometrical objects. In contrast, fractal geometry has been widely applied in several scientific fields. This rapid growth has also produced substantial insights in the biomedical imaging. Consequently, particular attention has been given to the identification of pathognomonic patterns of "shape" in anatomical entities and their changes from natural to pathological states. Despite the advantages of fractal mathematics and several studies demonstrating its applicability to oncological research, many researchers and clinicians remain unaware of its potential. Therefore, this review aims to summarize the complexity and fractal geometry of nuclear medicine images.

S61. Electroencephalography patterns in patients with thymoma and limbic autoimmune encephalitis: Report of three cases

Introduction Although Myasthenia gravis (MG) is the most common autoimmune disease associated with thymoma, a small proportion of thymomatous patients can suffer from limbic autoimmune encephalitis (LE). LE is usually characterized by rapid progressive short-term memory deficits, psychiatric symptoms, and seizures. Patients can present antibodies against cell surface antigens, including contactin-associated protein-like 2 (CASPR2) and a-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR). Our aim was to analyze the EEG findings of these patients to find possible EEG homologies among their patterns. Methods Clinical information was obtained from a retrospective review of medical records and EEG recordings of three patients with thymoma and LE: two with seropositivity for AMPAR antibodies and one for CASPR2 antibodies. Results The first case was a 37 years-old man with a subacute onset of memory loss, confusion, anxiety and behavioral disorders in the setting of an invasive thymoma (type B2-B3). Brain MRI and dosage of acetylcholine receptor antibodies (AChR-Abs) were normal. EEG showed bilateral fronto-temporal spikes together with slow theta and delta activity. Clinical suspicion of a paraneoplastic neurological syndrome associated with thymoma was confirmed by the serological presence of AMPAR-Abs. The second case was a 47 years-old female patient with Myasthenia Gravis (MG) and seropositivity for AChR-Abs, treated for recurrent thymoma (type B2). She presented three episodes of generalized seizures, together with mental disorientation, impairment of recent memory and insomnia. Brain MRI was normal. EEG showed a peculiar pattern, comprising lateralized right fronto-temporal spikes and generalized sharp waves. Serological tests detected the presence of antibodies to CASPR2. The third case was a 52 years-old female patient with thymoma (type B2-B3) who developed confusion, short-term memory loss and psychomotor agitation after thymectomy. Cerebrospinal fluid (CSF) examination showed a mild blood-CSF barrier damage and brain MRI revealed increased T2 signal involving mesio-temporal cortical areas. EEG showed electrical abnormalities in the fronto-temporal regions. Antibodies to the glutamate receptor 1 (GluR1) and GluR3 subunits of AMPAR were detected both in serum and CSF. Conclusion Limbic autoimmune encephalitis should be suspected in patients with invasive thymoma and subacute onset of confusion, memory loss and seizures. In all these three cases EEG showed epileptiform activity, especially in the fronto-temporal regions, together with slow theta and delta activity, without a pathognomonic pattern. Our results strongly emphasize the importance of testing biological samples when a possible autoimmune CNS involvement is suspected. Even if antibody testing remains the cornerstone in the diagnostic pathway, EEG is paramount in the differential diagnosis with similar disorders, in orienting toward limbic encephalopathy, especially when MRI is inconclusive.

Reversed Halo Sign in a Middle-Aged Female With Neutropenic Sepsis Following Chemotherapy for Acute Lymphoblastic Leukaemia

SESSION TITLE: Other Infections SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: The reversed halo sign (RHS) has been described with increasing incidence in pulmonary mucormycosis in immunocompromised hosts, which has a high risk of morbidity and mortality.1 CASE PRESENTATION: A 58-year-old woman with acute lymphoblastic leukaemia who had completed her first cycle of hyper-CVAD chemotherapy presented with persistent fever for 3 days and neutropenia. She was empirically started on piperacillin-tazobactam for neutropenic sepsis. Chest CT scan showed a left upper lobe lesion with central ground-glass density surrounded by denser consolidation, corresponding to the RHS (Fig.1). It involved the mediastinum and abutted the pericardium and main pulmonary trunk. She underwent a bronchoscopy with BAL and transbronchial lung biopsy for which microbiology and histology were unremarkable. Post-bronchoscopy, she was started on ambisome and had a brain MRI which was normal. However, she continued to be febrile. She underwent a left VATS which was converted to a posterolateral thoracotomy with upper lobectomy and abscess resection. Intraoperatively, there was abscess invasion into the anterior chest wall, pericardium and right ventricular outlet tract. Histology showed a cavitatory nodule surrounded by geographic necrosis with mucormycosis and fungal angioinvasion (Fig 2). She completed 2 months of ambisome before conversion to posaconazole. Post-operative recovery was uneventful and she underwent her second cycle of chemotherapy on post-operative day 24 with further plans for haematopoetic stem cell transplant following completion of chemotherapy. DISCUSSION: The RHS may be seen on chest CT in a range of conditions. It was originally described in cryptogenic organising pneumonia;2 but can be seen in invasive pulmonary infections, Pneumocystis jirovecii pneumonia, sarcoidosis, lipoid pneumonia, lymphomatoid granulomatosis, granulomatosis with polyangiitis and lepidic predominant lung adenocarcinoma.2,3 It has been described with an increasing incidence in pulmonary mucormycosis, particularly in immunocompromised patients with haematologic disease. Pulmonary mucormycosis has high morbidity and mortality. Early diagnosis and prompt treatment with amphotericin B and surgical resection can improve outcomes.1 CONCLUSIONS: The RHS in an immunocompromised host should prompt consideration of invasive fungal infections, including pulmonary mucormycosis. Reference #1: Legouge C, Caillot D, Chrétien ML, et al. The reversed halo sign: Pathognomonic pattern of pulmonary mucormycosis in leukemic patients with neutropenia? Clin Infect Dis. 2014;58(5):672-8. Reference #2: Raju S, Ghosh S, Mehta AC. Chest Computed Tomography Signs in Pulmonary Disease - A Pictorial Review. CHEST Pulm Dis - A Pict Rev CHEST [Internet]. 2016;12. http://dx.doi.org/10.1016/j.chest.2016.12.033 Reference #3: Marchiori E, Zanetti G, Meirelles GS, et al. The reversed halo sign on high-resolution CT in infectious and noninfectious pulmonary diseases. Am J Roentgenol. 2011 Jul;197(1):W69-75 DISCLOSURE: The following authors have nothing to disclose: Michelle Kam, Lionel Cheng, Norman Chan, Denise Tan, Heng Joo Ng, Keng Leong Tan No Product/Research Disclosure Information

Venous ectasia of gastric antrum

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal bleeding. GAVE may be asymptomatic or accompanied by clinical anemia or overt gastrointestinal bleeding. The diagnosis is mainly based on pathognomonic endoscopic pattern, defined as «watermelon stomach», located in antrum. Autoimmune disorders aye co-existing in about 60% of patients with GAVE, chirrosis in about 30%, and cardiac or renal failure in 10%.The "golden standarden" treatment of GAVE is endoscopic argon plasma coagulation (APC). There is poor information about diagnostics and treatment of GAVE in the domestic literature. The analysis of the presented materials shows that correct diagnostics takes much time and the choice of the optimum optimal treatment strategy encounters difficulty. Our experience with diagnostics and therapy of GAVE is based on the treatment of 4 patients. The diagnosis of GAVE was established within the period from 5 months to 1.5 years after onset of the disease. In two cases, GAVE was asymptomatic. Two patients with severe anemia completed endoscopic treatment; in one case, APC was supplemented by laser coagulation and bipolar coagulation. The implementation of laser coagulation caused some technical difficulties. Treatment of both patients was successful. Endoscopy pivotal for diagnosis of GAVE is the main method of its treatment. Due to the large number of diagnostic errors and the importance of correct diagnosis of GAVE, it is necessary to pay attention to this issue in training programs for endoscopists.