Primary Differential Diagnosis Research Articles

Striated Duct Adenoma: A Case Report and a Scoping Review.

Striated duct adenoma (SDA) is a rare benign salivary gland tumor with a recently described genetic signature. Recurrent oncogenic mutations affecting the IDH2 gene differentiate SDA from its primary differential diagnosis of canalicular adenoma. Here, we report a case of SDA affecting the parotid gland with IDH1/2 mutation-specific immunohistochemical positivity. Additionally, we provide a scoping review developed according to the Cochrane Methodology and reported following the Joana Briggs Institute (JBI) checklist to synthesize all previously published cases of SDA. The review protocol was registered on the Open Science Framework (OSF) platform ( https://osf.io/7mztg ). The searches were performed using Medline, Embase, Web of Science, and LILACS, with no date or language limit. Studies were evaluated for eligibility, extracted, and compiled in a narrative form. Seven studies with 20 patients with SDA, including ours, were analyzed. The tumors mainly affected the parotid gland (13/20) in patients with a mean age of 62 years and did not display sex predilection. Swelling was the leading clinical symptom. The mean follow-up duration was 26 months with no recurrence or metastasis after resection. Awareness of the clinicopathological features and the use of IDH1/2 mutation-specific immunohistochemistry are pivotal for the consistent identification of SDA, and assessment for true biological potential will require increased follow-up and scrutiny.

Diagnosing retinal disorders with artificial intelligence: the role of large language models in interpreting pattern electroretinography data

Aims: To evaluate the diagnostic accuracy of Claude-3, a large language model, in detecting pathological features and diagnosing retinitis pigmentosa and cone-rod dystrophy using pattern electroretinography data. Methods: A subset of pattern electroretinography measurements from healthy individuals, patients with retinitis pigmentosa and cone-rod dystrophy was randomly selected from the PERG-IOBA dataset. The pattern electroretinography and clinical data, including age, gender, visual acuities, were provided to Claude-3 for analysis and diagnostic predictions. The model’s accuracy was assessed in two scenarios: “first choice,” evaluating the accuracy of the primary differential diagnosis and “top 3,” evaluating whether the correct diagnosis was included within the top three differential diagnoses. Results: A total of 46 subjects were included in the study: 20 healthy individuals, 13 patients with retinitis pigmentosa, 13 patients with cone-rod dystrophy. Claude-3 achieved 100% accuracy in detecting the presence or absence of pathology. In the “first choice” scenario, the model demonstrated moderate accuracy in diagnosing retinitis pigmentosa (61.5%) and cone-rod dystrophy (53.8%). However, in the “top 3” scenario, the model’s performance significantly improved, with accuracies of 92.3% for retinitis pigmentosa and 76.9% for cone-rod dystrophy. Conclusion: This is the first study to demonstrate the potential of large language models, specifically Claude-3, in analyzing pattern electroretinography data to diagnose retinal disorders. Despite some limitations, the model’s high accuracy in detecting pathologies and distinguishing between specific diseases highlights the potential of large language models in ocular electrophysiology. Future research should focus on integrating multimodal data, and conducting comparative analyses with human experts.

Computed tomographic angiography of a presumed acquired transhepatic portosystemic shunt in a miniature horse filly.

A 1-year-old Miniature Horse filly was presented for chronic lethargy and hyporexia. Elevated liver enzymes, bile acids, and ammonia were noted on bloodwork. The primary differential diagnosis was a portosystemic shunt (PSS). Three-phase computed tomographic angiography findings were consistent with a transhepatic portosystemic shunt. Percutaneous liver biopsy confirmed severe diffuse hepatic changes, most likely due to chronic pyrrolizidine alkaloid toxicosis, and medical management was elected. Based on an extensive literature review, this is the first report of a transhepatic portosystemic collateral vessel in a horse. Computed tomographic angiography is feasible and useful for the diagnosis of PSS in miniature horses.

Enhancing Diagnosis and Treatment Adjustments for Travelers Infected with Burkholderia pseudomallei: A Case Report - Beijing Municipality, China, June 2023.

Burkholderia pseudomallei (BP) infection leads to melioidosis, a tropical disease endemic to coastal provinces of southern China. Physicians in non-endemic areas, do not commonly consider this disease as a primary differential diagnosis for febrile patients. This article discusses a case of melioidosis in Northern China. The patient, who had recently visited a Southeast Asian region with high melioidosis prevalence, fell ill after exposure to contaminated water. The disease progressed quickly and with severity. Healthcare workers need to remain vigilant regarding travel-related diseases for accurate differential diagnosis and to provide timely and effective treatment, especially for patients with recent travel history or symptoms during travel.

Extramedullary Intracranial Plasmacytomas: A Systematic Review of Literature.

Extramedullary plasmacytoma (EMP) is an uncommon disorder characterized by the development of abnormal plasma cell tumors outside the bone marrow. These tumors are typically observed in various locations, including the upper respiratory tract, gastrointestinal tract, and other soft tissues. Among the less explored manifestations of EMP is intracranial EMP, which remains poorly understood due to the limited literature available on the subject. The objective was to comprehend the population characteristics, localization, type, treatment, and outcomes of intracranial EMP. A systematic review of the literature for EMPs was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The strategy "extramedullary plasmacytoma AND multiple myeloma" was used for the search. The search terms were queried using PubMed, Embase, Scopus, Cochrane, and Web of Science databases. We included only those studies that presented clinical studies with patients diagnosed with intracranial plasmacytomas. In this study, a total of 84 patients from 25 studies were analyzed. The average age of diagnosis was 57.25 years, with a slightly higher proportion of females (57%) compared to male patients (43%). The most common locations of intracranial plasmacytomas were the clivus (29.7%), frontal lobe (18.9%), parietal lobe (8.1%), occipital lobe (6.7%), temporal lobe (6.7%), and sphenoid (4%). Chordoma and meningioma were the most common differential diagnoses encountered during clinical investigations. Treatment modalities included radiotherapy (RT), chemotherapy (QT), surgical resection (SR), and conservative approaches. The most frequent treatment combinations were SR + RT (19%) and RT only (17.8%). Mortality was reported in 48% of the cases, with complete resolution observed in 10 cases and partial resolution in 3 cases. The average follow-up duration was 37.5 months. The clivus is the most frequently reported site of extramedullary intracranial plasmacytoma (EMIP) occurrence, representing 29.7% of cases. Chordomas were commonly observed alongside EMIPs and emerged as the primary differential diagnosis. RT was the predominant treatment modality, with SR considered when feasible. RT alone demonstrated the highest effectiveness in managing EMIPs (30%), while QT as a sole intervention showed lower efficacy. However, a combination of dexamethasone, lenalidomide, and targeted RT displayed promising results, offering improved tumor response and increased safety.

Management of Pediatric Bilateral Vocal Fold Paralysis: A State-of-the-Art Review of Etiologies, Diagnosis, and Treatments.

This paper reviews the current literature about epidemiology, etiologies, diagnosis, and management of pediatric bilateral vocal fold paralysis (PBVFP). According to PRISMA statements, a narrative review of the current literature was conducted through the PubMed, Scopus, and Cochrane Library databases about the epidemiology, etiologies, diagnosis, and management of PBVFP. PBVCP is the second most common congenital laryngeal anomaly in the pediatric population, accounting for 10% to 20% of pediatric laryngeal conditions. PBVCP is related to idiopathic (42.2%), congenital (19.7%), and neurological (16.9%) conditions. A tracheotomy is required in 60% of cases regarding stridor and dyspnea, which are the most prevalent symptoms. The diagnosis is based on the etiological features, clinical presentation, laryngoscopic findings, and objective examinations. Laryngeal electromyography may be used to support the diagnosis in difficult cases, but its reliability depends on the practitioner's experience. The primary differential diagnosis is posterior glottis stenosis, which needs to be excluded regarding therapeutic and management differences with PBVCP. Transient surgical procedures consist of tracheotomy or laterofixation of the vocal fold. Current permanent procedures include uni- or bilateral partial arytenoidectomy, posterior transverse cordotomy, cricoid splits, and laryngeal selective reinnervation. There is no evidence of the superiority of some procedures over others. PBVCP is the second most common laryngeal disorder in the pediatric population. Diagnosis is based on etiological and clinical findings and may require the use of laryngeal electromyography. Therapeutic management may involve several transient or permanent surgical procedures that are associated with overall subjective improvements in symptoms, laryngeal findings, and low complication rates.

Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study

BackgroundThe consultation process, where a clinician seeks an opinion from another clinician, is foundational in medicine. However, the effectiveness of group diagnosis has not been studied.ObjectiveTo compare individual diagnosis to...

Intrathecal IgM synthesis as a diagnostic marker in patients with suspected CNS lymphoma.

For CNS lymphomas (CNSL), there is a high need for minimally invasive and easily obtainable diagnostic markers. Intrathecal IgM synthesis can easily be determined in routine CSF diagnostics. The aim of this study was to systematically investigate the diagnostic potential of intrathecal IgM synthesis in primary and secondary CNSL (PCNSL and SCNSL). In this retrospective study, patients with a biopsy-proven diagnosis of PCNSL or SCNSL were compared with patients with other neurological diseases in whom CNSL was initially the primary radiological differential diagnosis based on MRI. Sensitivity and specificity of intrathecal IgM synthesis were calculated using receiver operating characteristic curves. Seventy patients with CNSL were included (49 PCNSL and 21 SCNSL) and compared to 70 control patients. The sensitivity and specificity for the diagnosis of CNSL were 49% and 87%, respectively, for the entire patient population and 66% and 91% after selection for cases with tumor access to the CSF system and isolated intrathecal IgM synthesis. In cases with MRI-based radiological suspicion of CNSL, intrathecal IgM synthesis has good specificity but limited sensitivity. Because of its low-threshold availability, analysis of intrathecal IgM synthesis has the potential to lead to higher diagnostic accuracy, especially in resource-limited settings, and deserves further study.

Dual-phenotype hepatocellular carcinoma: correlation of MRI features with other primary hepatocellular carcinoma and differential diagnosis.

Dual-phenotype hepatocellular carcinoma (DPHCC) is a rare subtype of hepatocellular carcinoma characterized by high invasiveness and a poor prognosis. The study aimed to compare clinical and magnetic resonance imaging (MRI) features of DPHCC with that of non-DPHCC and intrahepatic cholangiocarcinoma (ICC), exploring the most valuable features for diagnosing DPHCC. A total of 208 cases of primary liver cancer, comprising 27 DPHCC, 113 non-DPHCC, and 68 ICC, who undergone gadoxetic acid-enhanced MRI, were enrolled in this study. The clinicopathologic and MRI features of all cases were summarized and analyzed. Univariate and multivariate logistic regression analyses were conducted to identify the predictors. Kaplan-Meier survival analysis was used to evaluate the 1-year and 2-year disease-free survival (DFS) and overall survival (OS) rates in the cohorts. In the multivariate analysis, the absence of tumor capsule (P = 0.046; OR = 9.777), persistent enhancement (P = 0.006; OR = 46.941), arterial rim enhancement (P = 0.011; OR = 38.211), and target sign on DWI image (P = 0.021; OR = 30.566) were identified as independently significant factors for distinguishing DPHCC from non-DPHCC. Serum alpha-fetoprotein (AFP) >20 μg/L (P = 0.036; OR = 67.097) and hepatitis B virus (HBV) positive (P = 0.020; OR = 153.633) were independent significant factors for predicting DPHCC compared to ICC. The 1-year and 2-year DFS rates for patients in the DPHCC group were 65% and 50%, respectively, whereas those for the non-DPHCC group were 80% and 60% and for the ICC group were 50% and 29%, respectively. The 1-year and 2-year OS rates for patients in the DPHCC group were 74% and 60%, respectively, whereas those for the non-DPHCC group were 87% and 70% and for the ICC group were 55% and 37%, respectively. Kaplan-Meier survival analysis revealed significant differences in the 1-year and 2-year OS rates between the DPHCC and non-DPHCC groups (P = 0.030 and 0.027) as well as between the DPHCC and ICC groups (P = 0.029 and 0.016). In multi-parameter MRI, combining the assessment of the absence of tumor capsule, persistent enhancement, arterial rim enhancement, and target sign on DWI image with clinical data such as AFP >20 μg/L and HBV status may support in the diagnosis of DPHCC and differentiation from non-DPHCC and ICC. Accurate preoperative diagnosis facilitates the selection of personalized treatment options.

Retraction: Dual-phenotype hepatocellular carcinoma: correlation of MRI features with other primary hepatocellular carcinoma and differential diagnosis.

[This retracts the article DOI: 10.3389/fonc.2023.1253873.].

Une ectasie cornéenne sévère unilatérale de l’enfant

We report a case of unilateral Terrien's marginal degeneration in a 14-year-old girl. Slit-lamp examination of the affected eye revealed 360° circumferential lipid deposits with 6mm of superior limbal distension, superficial neovascularization, a zone of corneal thinning from 3:00 to 9:00 with a zone of corneomalacia at 11:00. The remainder of the cornea was clear, without fluorescein staining or anterior chamber reaction. Terrien's marginal degeneration (TMD) is typically known to occur bilaterally in men over the age of 40. Terrien's degeneration must be differentiated from other causes of peripheral corneal thinning; the primary differential diagnosis is Fuchs' marginal keratitis. Other causes of corneal thinning must be ruled out, including Mooren's ulcer. In Terrien's degeneration, there is no central mined edge in the thinning sulcus, the epithelium remains intact, and affected patients do not present with pain. Other differential diagnoses include pellucid marginal degeneration and sulcus degeneration, which are characterized by the absence of lipid infiltrates associated with the central region of the thinning zone, thus distinguishing them from TMD. It is important to keep in mind that Terrien's marginal degeneration can occur in children.

До питання про рідкісні захворювання, які маніфестують у дітей лихоманкою і соматичним болем. Клінічний випадок

Neuroblastoma is one of the most common tumor in the pediatric population, with the frequent localization in the retroperitoneal space. In the early stages disease can be asymptomatic and complicates diagnostic. The initial manifestations are not specific and can be considered as symptoms of different diseases. Purpose - to analyze and note some "red flags" of certain rare diseases that allow to suspect these diseases in children with fever and somatic pain. The article presents the data and clinical observation of a child with neuroblastoma with rapid progressive development and rapid metastasis. The features of the course and complications of the primary differential diagnosis of a malignant tumor process are described in a 3-year-old boy. The child was taken to the SI «Institute of Pediatrics, Obstetrics and Gynecology named of academician O.M. Lukyanova NAMS of Ukraine» with complaints of back pain, refusal to walk, weight loss and fever. The child was transferred to the intensive care unit for hemotransfusion due to progressive negative dynamics of the condition (pronounced pain syndrome, intoxication syndrome, oliguria). After demonstration an improvement the boy with the diagnosis of «Retroperitoneal neoplasm (neuroblastoma?), neoplasm of the left hand, neoplasm of the sternum; severe anemia of complex genesis; pathological compression fractures of vertebral bodies Th3, Th10, Th12 and L2; secondary hypoparathyroidism; functional bowel disorder; moderate degree of hypermetropia, strabismus, partial atrophy of the optic nerve» was transferred to the National Cancer Institute in the department of pediatric oncology for further examination and determination of the tactics of further therapy, where MRI of the brain and spinal cord with contrast, SCT of the head, chest, abdomen, pelvis, and bone biopsy were performed. This case will help pediatricians to suspect the presence of a tumor in the early stages and refer them to specialized specialists for the further examination as early as possible. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Who's your data? Primary immune deficiency differential diagnosis prediction via machine learning and data mining of the USIDNET registry

PurposeThere are currently more than 480 primary immune deficiency (PID) diseases and about 7000 rare diseases that together afflict around 1 in every 17 humans. Computational aids based on data mining and machine learning might facilitate the diagnostic task by extracting rules from large datasets and making predictions when faced with new problem cases. In a proof-of-concept data mining study, we aimed to predict PID diagnoses using a supervised machine learning algorithm based on classification tree boosting. MethodsThrough a data query at the USIDNET registry we obtained a database of 2396 patients with common diagnoses of PID, including their clinical and laboratory features. We kept 286 features and all 12 diagnoses to include in the model. We used the XGBoost package with parallel tree boosting for the supervised classification model, and SHAP for variable importance interpretation, on Python v3.7. The patient database was split into training and testing subsets, and after boosting through gradient descent, the predictive model provides measures of diagnostic prediction accuracy and individual feature importance. After a baseline performance test, we used the Class Weighting Hyperparameter, or scale_pos_weight to correct for imbalanced classification. ResultsThe twelve PID diagnoses were CVID (1098 patients), DiGeorge syndrome, Chronic granulomatous disease, Congenital agammaglobulinemia, PID not otherwise classified, Specific antibody deficiency, Complement deficiency, Hyper-IgM, Leukocyte adhesion deficiency, ectodermal dysplasia with immune deficiency, Severe combined immune deficiency, and Wiskott-Aldrich syndrome. For CVID, the model found an accuracy on the train sample of 0.80, with an area under the ROC curve (AUC) of 0.80, and a Gini coefficient of 0.60. In the test subset, accuracy was 0.76, AUC 0.75, and Gini 0.51. The positive feature value to predict CVID was highest for upper respiratory infections, asthma, autoimmunity and hypogammaglobulinemia. Features with the highest negative predictive value were high IgE, growth delay, abscess, lymphopenia, and congenital heart disease. For the rest of the diagnoses, accuracy stayed between 0.75 and 0.99, AUC 0.46–0.87, Gini 0.07–0.75, and LogLoss 0.09–8.55. DiscussionClinicians should remember to consider the negative predictive features together with the positives. We are calling this a proof-of-concept study to continue with our explorations. A good performance is encouraging, and feature importance might aid feature selection for future endeavors. In the meantime, we can learn from the rules derived by the model and build a user-friendly decision tree to generate differential diagnoses.

634 Analgesia Use in Acute Renal Colic Patients- Complete Audit Cycle

Abstract Aim Prevalence of renal colic is up to 20% worldwide, with recurrence rates approaching 50% within 10 years- making it a common acute presentation. NICE guidance (NG118) states NSAIDs are first-line analgesia for renal colic, followed by intravenous paracetamol and opiates. Our aim was to assess compliance with NG118 within one acute NHS teaching Trust. Method All patients with renal colic as the primary differential diagnosis during March and April 2022 (1st cycle) and September and October 2022 (2nd cycle) were included. Data was extracted retrospectively from electronic patient records into a pre-designed proforma. Findings from the 1st cycle were presented within local departmental meetings. Posters were also installed reminding clinicians of the analgesic pathway within the relevant clinical areas. Subsequently, a re-audit was performed. Results 90 patients were included (60- 1st cycle, 30- 2nd cycle). There was a significant improvement in compliance between the 1st and 2nd audit cycles (60% versus 83%, p = 0.0193). However in cases of non-compliance, documentation was poor (>70% did not state a reason) during both cycles. Imaging confirmed renal colic in 82% of patients in the 1st cycle and 93% of patients in the 2nd cycle. PR Diclofenac was the most common NSAID prescribed. Conclusions Low-cost, easily reproducible interventions resulted in significant prescribing practice changes. Findings from the latest national renal colic audit (2012-13) showed analgesia compliance in only 69% of cases nationally- similar to our 1st audit cycle results. Disseminating our findings to other hospitals regionally and nationally will hopefully result in better outcomes for renal colic patients.

Abstract #1402832: Doege-Potter Syndrome Due to Solitary Fibrous Tumor of the Kidney

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor which can be benign or malignant. A small subset (<5%) of patients with SFT present with refractory hypoglycemia, known as Doege-Potter syndrome. This is due to increased production of insulin-like growth factor (IGF-2), its precursor pro-IGF-2, and is associated with large tumor size or aggressive clinical behavior. A 77-year-old female was brought to the ER after was found down at home with hypoglycemia down to 20 mg/dL during a wellness check. She had slurred speech and right-sided weakness. MRI of the brain and MRA of head and neck were unremarkable. She was found to have a urinary tract infection which was treated with antibiotics. Due to concern for stroke, aspirin was started. Subsequently she developed hematuria. A CT abdomen and pelvis was performed that revealed a large 17 x 12 x 11 cm heterogenous exophytic mass from the anterior margin of the right kidney. Patient's encephalopathy and focal weakness resolved with glucose administration, but she continued to have recurrent hypoglycemic episodes. A repeat MRI of the brain showed no evidence of metastatic disease and no evidence of CVA. Thyroid, adrenal and liver function tests were within normal range, and insulin and C-peptide levels were grossly suppressed during hypoglycemic episodes. IGF-1 and IGF-2 levels were normal. In the absence of any underlying endocrine pathology or the administration of any hypoglycemic agent, clinically Whipple’s triad was positive (symptoms attributable to hypoglycemia, plasma hypoglycemia at time of symptoms and resolution of symptoms with treatment of hypoglycemia). Tumor induced hypoglycemia was suspected and she underwent right radical nephrectomy. Pathology demonstrated a fully resected large (21 x 11.5 x 11 cm) spindle cell neoplasm, positive for CD34 and STAT6, consistent with solitary fibrous tumor. Post-surgically her hypoglycemia resolved. Our case highlights the importance of early diagnosis and intervention in Doege-Potter syndrome. Hypoglycemia with low levels of serum insulin, C-peptide, and beta-hydroxybutyrate in a healthy-appearing person should prompt evaluation for a tumor with cross-sectional imaging of the chest, abdomen, and pelvis. Although our patient had normal IGF-2 levels, pro-IGF-2 levels were not checked. In SFT the hypoglycemia may be due to elevated IGF-2 or pro-IGF-2 levels which leads to inappropriate activation of systemic insulin receptors and inhibition of glucose release from the liver leading to fatal hypoglycemia. Tumor induced hypoglycemia should be considered as the primary differential diagnosis when hypoglycemia is without an alternative cause.

Imaging features of benign synovial inflammation affecting the long digital extensor tendon sheath in a dog.

A dog was evaluated for right pelvic limb lameness. Computed tomography and magnetic resonance imaging revealed an irregular, contrast-enhancing mass extending along the proximolateral right tibia, involving the long digital extensor tendon (LDET) ± cranial tibialis muscle. Pulmonary nodules, nonspecific hepatomegaly, and splenic nodules were also present. The primary differential diagnosis was soft tissue neoplasia. Surgical biopsy with histopathology revealed benign, chronic inflammation, and fibrosis. Idiopathic synovial inflammation should be included as a differential diagnosis for dogs with this combination of clinical and imaging characteristics.

A Rare Case of Synchronous Cervical Squamous Cell Carcinoma and Ovarian Brenner Tumour in a Postmenopausal Female: A Histological Surprise

Synchronous Tumours (ST) are defined as two or more neoplasms originating within six months of diagnosing the first neoplasm. Due to the rarity of synchronous cervical Squamous Cell Carcinoma (SCC) and ovarian Brenner tumours, their pathology has been poorly understood. These patients usually present with symptoms related to cervical cancer and are often diagnosed early. Since many synchronous tumours are incidentally discovered postoperatively, it is important to conduct thorough grossing and histopathological examinations. The primary differential diagnosis for synchronous tumours is multiple metastases from a single primary tumour. The management of multiple tumours is not well-defined and depends on various factors. In the present case, authors present a rare occurrence of synchronous neoplasms: cervical SCC and preoperatively undiagnosed benign Brenner tumour of the left ovary in a 52-year-old postmenopausal female. Immunohistochemistry helped rule out metastasis from a single primary and metastasis from cervical cancer to the ovary. The ovarian tumour showed immunoreactivity for GATA Binding Protein 3 (GATA) but was negative for Carcinoembryonic Antigen (CEA). The cervical SCC was immunopositive for CEA and p40, while no immunoreactivity was observed with GATA 3.

Submandibular Secretory Carcinoma in a 10-year-old Filipino

Secretory carcinoma is a recently described salivary gland neoplasm reported in the fourth edition of World Health Organization classification of head and neck tumors.1 We report a case of a primary secretory carcinoma arising from the submandibular gland that was completely excised in a 10-year-old. The histomorphologic features and the immunophenotype studies are compatible with secretory carcinoma. Unless proven otherwise by immunohistochemical stains and cytogenetics, secretory carcinoma should be included as a differential in cases of lesion of the major and minor salivary glands that has the primary differential diagnosis of acinic cell carcinoma. This case report aims to contribute to the limited literature about this disease entity and would be one of the few reported cases of the disease in a school-age child.

Optic Chiasmal Fungal Granuloma - Rare Cause of Blindness

Intracranial fungal infections are rare. Their presentation is mostly subtle, clinically atypical in presentation, and they are usually mistaken for tuberculosis or brain tumour. Aspergillosis is the most common cause of intracranial fungal infections. Fungal infection enters the brain directly from the paranasal sinuses, ear, skull bone, or haematogenous spread from the lungs and gastrointestinal tract, or direct inoculation during surgery or trauma. The pathology depends on the route of spread, host immunity, and type of fungus. Intracranially, fungal infection invades brain matter or blood vessels. [1]&#x0D; The rarity of brain fungal infection, with nonspecific clinical picture, and progression to a fatal outcome provides considerable challenges for both diagnosis and management. Invasive sino-orbital fungal infections are rarely reported in immunocompetent patients in literature. We could not find anything related to primary fungal granuloma of the optic tract reported in literature. We report a case of primary fungal granuloma of optic chiasm in an immunocompetent patient.[2]&#x0D; 13-year-old female patient presented to us with sudden onset of loss of vision in both eyes. There were no other complaints. On neurological examination, there was no vision in both eyes (no perception of light). On fundoscopy, there was bilateral optic atrophy. Rest of the neurological examination was normal. Patient was investigated for magnetic resonance imaging (MRI) of brain with contrast study. MRI of brain was suggestive of a 2.2 x 1.8 x 1.6 cm mass in suprasellar region with its epicentre in the optic chiasma and extending to both optic nerves and optic tract. The lesion was separate from the underlying pituitary gland. The lesion was iso-intense on T1 weighted images and hyper-intense on T2 weighted images. It showed homogenous post-contrast enhancement. Our primary differential diagnosis was optic nerve glioma.&#x0D; Patient underwent immediate surgery, right peritoneal craniotomy, for excision of lesion. Intra-operatively, a firm yellowish white colored lesion arising from the optic chiasm was seen. Safe subtotal excision was done. Post-operative, there was no improvement in vision.

PH Grand Rounds: COVID-19 Infection Causing Delayed Pulmonary Arterial Hypertension

PH Grand Rounds: COVID-19 Infection Causing Delayed Pulmonary Arterial Hypertension