Prominent Soft Tissue Research Articles

Role of steroidal anti-inflammatory agent prior to intracorporeal lithotripsy under local anesthesia for ureterovesical junction calculus: A prospective randomized controlled study.

Objective:The objective of the following study is to assess the effect of steroidal anti-inflammatory agent on the outcome of ureterorenoscopic lithotripsy (URSL) for ureterovesical junction (UVJ) calculus.Settings and Design:This was a prospective randomized controlled study conducted at the Department of Urology, Regional Institute of Medical Sciences, Imphal.Subjects and Methods:One hundred and twenty-six patients requiring ureteroscopic lithotripsy for UVJ calculus were randomly assigned into two groups. The study group received tablet deflazacort 30 mg once a day for 10 days prior to the procedure, whereas the control group did not receive such treatment. Parameters with respect to the outcome of the procedure were recorded for all patients in both groups.Statistical Analysis Used:Fisher's exact and independent t-test was used to compare the outcome between the groups where P < 0.05 was considered to be statistically significant.Results:There was significant statistical difference (P - 0.016) on the endoscopic appearance of the region of ureteric orifice in patients receiving steroidal anti-inflammatory agent compared with control. Severe procedure related pain and mean operative time was less in the study group compared to control (P - 0.020 and 0.031, respectively). Re-treatment rates in the study group were lower than the control group (4.76% vs. 17.46%) and found to be statistically significant (P - 0.044). It is found that computed tomography (CT) appearance (r - 0.399) and stone size (r - 0.410) strongly correlate with the endoscopic findings of the region of UVJ (P - 0.001).Conclusions:Inflamed and or obliterated ureteric orifice is the major constraints for stone clearance at ureterovesical junction. The present study showed the administration of tablet deflazacort (a steroidal anti-inflammatory agent) significantly improves the outcome of URSL under local anesthesia. We strongly recommend its use prior to URSL for UVJ calculus, especially for stone size ≥10.24 mm and on CT evidence of prominent soft tissue swelling at the UVJ.

Primary MALT Lymphoma of the Bile Duct

Introduction: Primary Non-Hodgkin's lymphoma (NHL) of the common bile duct (CBD) is a rare disease that usually presents with obstructive jaundice. We present the case of a patient who developed painless jaundice and a biliary stricture suspicious for cholangiocarcinoma. He underwent a pancreaticoduodenectomy (Whipple procedure). Post-surgical pathology of bile duct was diagnostic of extranodal mucosa-associated lymphoid tissue (MALT) lymphoma. Case presentation: A 63-year-old male with a history of arthritis, hypertension, COPD, and coronary artery disease was admitted with obstructive jaundice. The preoperative abdominal MRI showed soft tissue prominence around the mid and distal portions of the CBD. This area restricted on the diffusion weighted phase and was concerning for cholangiocarcinoma. The patient underwent a Whipple procedure. Post-surgical pathology from the stricture revealed a dense, nodular infiltrate of small lymphoid cells. These cells were strongly positive for CD45, CD20, PAX5, and BCL2. Many of them expressed kappa light chain with fewer lambda positive cells. The morphologic and immunophenotypic features were diagnostic of low-grade B-cell lymphoma. The lack of CD10 and BCL6 positivity did not favor follicular lymphoma. The low-grade cytologic features of the cells and presence of disrupted expanded follicular dendritic cells favored extranodal MALT lymphoma. In the absence of systemic disease, this represented a primary biliary MALT lymphoma. Discussion: Primary bile duct lymphomas are extremely rare. Most of them are diffuse large B-cell lymphomas. However, some are extranodal marginal zone B-cell lymphomas (as in our case) or follicular lymphomas. Only a few cases of primary MALT bile duct lymphomas have been described. Primary bile duct lymphomas account for less than 1% of all extranodal lymphomas. They typically present with obstructive jaundice. Clinical and radiological features are similar to extrahepatic cholangiocarcinomas. There are no standard treatments given the rarity of the disease. Multiple, deep biopsies from the suspected lesion are necessary for definitive diagnosis. Complications of curative surgery for biliary lymphomas, such as bile leak, hemorrhage, and cholangitis, are associated with a high morbidity rate of 13-42%. Primary NHL of the extrahepatic bile duct should be considered in the differential diagnosis when a patient with obstructive jaundice presents with discrepant imaging findings on CT or MRI and ERCP. An accurate histopathologic diagnosis and surgical resection, if feasible, combined with chemotherapy with or without radiotherapy may be the approach to offer a chance for cure.

Does Skeletal Surgery for Asymmetric Mandibular Prognathism Influence the Soft Tissue Contour and Thickness?

The purpose of the present study was to investigate whether asymmetric mandibular prognathism accompanies a fundamental difference in soft tissue thickness and whether asymmetric mandibular setback surgery would influence the contour and thickness of the soft tissue of the chin. The present retrospective study included skeletal class III patients with significant mandibular chin deviation greater than 6 mm at the pogonion, who had undergone cone-beam computed tomography before and 6 months after surgery during a 2-year period. The predictor variables were timing (pre- and postoperatively) and side (asymmetric vs contralateral). The outcome measures were the hard and soft tissue contours and soft tissue thickness of the chin at the infradentale, B-point, and pogonion level evaluated with reformatted computed tomography images. The study variables were statistically compared using regression model and correlation analysis. The present study consisted of 20 patients (10 males and 10 females; average age 20.2 years; range, 18 to 25). Preoperatively, the chin deviation side showed a more prominent hard and soft tissue outline but had a thinner soft tissue thickness, which camouflaged the hard tissue asymmetry. After surgery, the hard and soft tissue outline was greatly improved, and the soft tissue thickness had become nearly symmetric. Most of the soft tissue thickness changes correlated negatively with the hard tissue changes. Asymmetric mandibular prognathism accompanied the 3-dimensional soft tissue contour and thickness asymmetry. Because the soft tissue responds favorably after skeletal surgery, the correction of 3-dimensional asymmetry of bone should be emphasized in patients with asymmetric mandibular prognathism.

A Rare Case of Multicentric Extracavitary Solid Primary Effusion Lymphoma (ECPEL) Diagnosed by Upper Endoscopy and Colonoscopy

Purpose: A 52-year-old male with HIV/AIDS on HAART (non-compliant) was admitted for hypotension, anemia, weight loss and malaise. Laboratory findings: CD4 cells 3% (30% to 61%); CD8+cells 78% (12% to 42%); CD4:CD8 ratio 0.04 (0.86 to 5.0); white blood cell count 9.7 (4.8 to 10.8); hemoglobin 3.4 g (11.0 to 15.6 g). Total bilirubin 6.4 mg (0.2 to 1.2 mg/dl), direct bilirubin 4.9 (0.0 to 0.5 mg/dl), lactate dehydrogenase 960 (125 to 243 U/L). Imaging Studies: CT scan of chest, abdomen and pelvis showed several regions of soft tissue prominence in the pancreatic head, upper retro peritoneum and ascending colon. Bone marrow biopsy: Large granular lymphocytes that could be reactive or neoplastic. Immunohistochemistry showed MUM1 (multiple myeloma oncogene 1) positive and negative for CD20, CD3, CD30, CD15, CD79a, PAX-5, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9). EGD and colonoscopy were performed for anemia and abnormal findings on CT scan. EGD showed 3 friable nodules, the largest measuring 2x3 cm in the body of the stomach. The nodules bled on contact and were biopsied (Figure 1). Colonoscopy showed a large friable mass seen in the transverse colon and was biopsied. Histopathology of gastric nodules and colonic mass were consistent with solid Primary Effusion Lymphoma. The neoplastic cells were positive for Epstein Barr (EBV) and Kaposi's Sarcoma Virus (KSHV/HHV8). PEL is seen in body cavities such as the pleural space, pericardium and peritoneum. Extracavitary Solid Primary Effusion Lymphoma (ECPEL) is a rare occurrence and is often associated with Kaposi's sarcoma or multicentric Castleman's disease. It is seen in less than 1% of HIV/AIDS related lymphomas and is also reported rarely after solid organ transplantation. Detection of HHV8 in the neoplastic cells is the only confirmatory diagnostic test in PEL and ECPEL. This case represents an even rarer condition with ECPEL, involving multiple sites, and readily diagnosed by upper endoscopy and colonoscopy.Figure: [1338] Nodule in the body of stomach.

Monocular Vision Loss and Headache in a 60-Year-Old Liver Transplant Patient

Monocular Vision Loss and Headache in a 60-Year-Old Liver Transplant Patient

Metastatic Clear Cell Adenocarcinoma of the Urethra in a Male Patient: Report of a Case

A 39-year-old white male presented with urinary hesitancy 2.5 years ago. He was referred to a urologist who performed cystoscopic evaluation and discovered a urethral mass with no abnormalities in the bladder. A staging positron emission tomography (PET) scan revealed fluorine-18 (F) fluorodeoxyglucose (FDG) uptake in a soft tissue prominence in the urethra and bilateral inguinal and iliac FDG-avid lymphadenopathy. Computed tomography (CT) of the hest also demonstrated several bilateral lung nodules. Needle biopsy f a left pelvic lymph node showed adenocarcinoma with micropapllary architecture (Figure 1A). Immunohistochemical analysis howed the carcinoma was positive for CK7 and CAM 5.2 and negtive for CK20, -fetoprotein, CDX-2, and prostate-specific antigen the immunostains are not shown). Sections from the subsequent ransurethral resection specimen of the urethral tumor showed an denocarcinoma with a tubulocystic, micropapillary, and solid archiecture (Figure 1B-D). The tumor had hobnail cells, clear and amhophilic cytoplasm, and high-grade nuclear atypia (Figure 1E). An

Acromioclavicular Joint Synovial Chondromatosis

A 26-year-old man presented to physical therapy for evaluation of right shoulder pain. While history and physical examination findings were most consistent with right shoulder impingement, a firm mass over the acromioclavicular joint was observed. Radiographs of the right shoulder revealed a soft tissue prominence adjacent to the acromioclavicular joint, while contrast-enhanced magnetic resonance imaging revealed a 9 × 16-mm soft tissue mass arising from the right acromioclavicular joint. The patient underwent incisional biopsy, acromioclavicular joint capsulotomy, and distal clavicle excision. Histological evaluation revealed hyalinized fibrovascular connective tissue with focal calcification but no hemosiderin (insoluble iron deposits), consistent with synovial chondromatosis. The patient returned to full activity without limitations postoperatively. J Orthop Sports Phys Ther 2011;41(2):118. doi:10.2519/jospt.2011.0403

Early results of distal metatarsal osteotomy with K-wire fixation in the treatment of tailor’s bunion

Tailor's bunion deformity is a lateral side bone and soft tissue prominence of the fifth metatarsal bone. The aim of our study was to assess the clinical and radiographic results of distal metatarsal osteotomies in patients with tailor's bunion deformity. This study included 24 feet of 14 patients with tailor's bunion who were treated with distal metatarsal osteotomy of the 5th metatarsal between 2006 and 2009. The mean follow-up time was 24.45 (range: 12 to 47) months. Patients were evaluated clinically and radiographically, using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system with weight-bearing anteroposterior and lateral foot radiographs. Average AOFAS scores of the patients were 64.83 preoperatively and 91.62 at the final follow-up. Three patients had complications; avascular necrosis, delayed union, and superficial wound infection. Distal metatarsal osteotomy is a safe and easy treatment option for the painful tailor's bunion deformity and provides patient satisfaction rate of up to 96%.

Epidemiology and impact of hallux valgus: more than just bunions

Hallux valgus (HV) is a common deformity characterized by progressive lateral deviation of the great toe at the first metatarsophalangeal joint (1st MTPJ). It commonly associates with a painful overlying soft-tissue prominence, the “bunion”. A recent systematic review estimated the prevalence of HV to be 23% in adults aged 18 to 65 years. It becomes more frequent with increasing age and is more prevalent in women than men. Several potential risk factors for HV have been identified. Various mechanical factors are thought to associate with HV including metatarsal length and head-shape, first ray hypermobility and foot posture. HV is rare in unshod populations but associates with wearing high-heeled or narrow shoes. The relationship between HV and obesity is less clear. Some studies have found an association between HV and increasing body mass index (BMI) whereas others have found no association. Most recently, it has been suggested that the association between HV and BMI differs between the genders, with a lower prevalence with increasing BMI in women but no association in men. HV poses a significant health problem, and associates with foot pain, poor balance, gait impairment, immobility, and risk of falling. The likelihood of 1st MTPJ osteoarthritis (OA) increases with HV severity but nodal OA and pain at the low back, hip and knee are also associated with HV, suggesting that it is a component of generalised OA. Several recent studies have examined the relationship between HV and health-related quality of life (HRQOL). Symptomatic HV appears to associate with reduced HRQOL. However, both general and foot-specific HRQOL are progressively lower with increasing severity of HV deformity, regardless of foot pain. Importantly, the association of both the presence and severity of HV with impaired HRQOL is not limited to pain and physical function but extends to general health, vitality, social function, and mental health. In summary, the impact of HV extends beyond local influence on foot OA, balance, gait and falls, to impair HRQOL. Future prospective studies are required to identify risk factors for the development and progression of HV and hence possible targets for prevention and intervention.

Pathology Quiz Case 1

A 63-YEAR-OLD WOMAN PRESENTED WITH A 1-year history of left-sided epiphora. Her medical history included chronic sinusitis and hypertension. She also had a remote history of a peripheral leukocytosis, for which she saw an oncologist, who recommended no therapy. On ophthalmic examination, her vision was 20/25 OD and 20/40 OS. There was no afferent pupillary defect, and extraocular motility was full. The tear lake was increased on the left, with poor dye disappearance. Probing and irrigation on the left showed complete reflux with some mucous discharge. Nasal endoscopy revealed a left septal spur and bilateral ostiomeatal complex crowding. Computed tomography (CT) demonstrated scattered sinus disease, a minimal soft-tissue prominence in the left medial canthus (Figure 1), and multiple enlarged lymph nodes throughout the neck.The preoperative laboratory test results included a white blood cell count (WBC) of 21 900/μL (to convert to 10/L, multiply by 0.001), a hematocrit of 40.1%, and a platelet count of 168 10/μL (to convert to 10/L, multiply by 1.0). The patient underwent a septoplasty, left endoscopic anterior ethmoidectomy, and dacryocystorhinostomy (DCR). Microscopic examination of the specimen from the left sinus and lacrimal drainage system (LDS) showed extensive involvement by a dense infiltrate of small, round, mature lymphocytes (Figure 2). These cells contained scant cytoplasm and condensed chromatin. Histologic examination of the septal cartilage revealed a diffuse infiltration of the intratrabecular space by a histologically identical lymphoid infiltrate. Immunohistochemical analysis of the lymphoid cells demonstrated positivity for CD20, CD23 (Figure 3), and CD5 (Figure 4) and negativity for CD10 and BCL1. An additional immunostain for proliferation marker Ki-67 showed nuclear positivity in fewer than 5% of tumor cells. What is your diagnosis?

A Novel Treatment for Pseudoachalasia Secondary to Malignant Mesothelioma Using Botulinum Toxin

Purpose: Background: Secondary achalasia due to mesothelioma is a rare event that carries a poor prognosis. Most patients with mesothelioma will not respond to its primary treatment and may require palliative therapy. We present the first case, to our knowledge, of a patient with secondary achalasia due to mesothelioma treated successfully with botulinum toxin injections into the lower esophageal sphincter (LES). Case Description: A 66 year-old male recently diagnosed with malignant mesothelioma and being treated with chemotherapy, presented with progressive dysphagia to solids and liquids. His past history was remarkable for gastroesophageal reflux being treated with omeprazole twice daily. The patient had previously worked as a plumber. The physical exam was normal except for decreased breath sounds in the left lung. A CT scan of the chest revealed extensive soft tissue prominence from the level of the thoracic inlet with involvement of the mediastium, but sparing the distal esophagus. A double contrast esophagram showed a smoothly tapering stricture of the distal esophagus without associated mucosal abnormality. There were diffuse esophageal tertiary contractions, and decreased esophageal peristalsis. The patient refused esophageal manometry. Esophagogastroduodenoscopy (EGD) was performed, revealing a mildly dilated esophagus with uncoordinated contractions, no appreciable esophageal peristalsis, and a hypertonic LES, which was easily traversed with the endoscope. The mucosa was normal and the rest of the EGD was unremarkable. Botulinum toxin was injected directly into the four quadrants of the LES using 20 units of toxin per injection. The patient's dysphagia improved following this treatment and maintained symptomatic response during a 3-month follow-up. Discussion: Dysphagia is a rare preterminal event associated with mesothelioma. Postmortem examinations in cases of mesothelioma have shown the esophagus to be involved rarely or not at all. There have been several cases describing pseudoachalasia secondary to mesothelioma. The prognosis is poor, and the goal with these patients is to improve their quality of life. In previous cases that have addressed dysphagia secondary to mesothelioma, treatments included tumor resection, local myotomy, or pallative stents. To our knowledge this is the first reported case of a patient with pseudoachalasia secondary to mesothelioma treated successfully with botulinum toxin injections. In conclusion, just as in primary achalasia where botulinum toxin is an option primarily used for high-risk surgical candidates; we see that its use can be extended to include patients with pseudoachalasia secondary to mesothelioma.

Tuberculous dactylitis pseudotumor of an adult thumb: a case report

Tuberculous dactylitis is an uncommon condition which is particularly difficult to differentiate from other lesions, particularly tumors. We report the case of a 56-year-old, healthy, left-handed person who consulted for progressive painful swelling of 8-month duration in the right thumb, which had developed after direct trauma. The plain radiograph of the thumb revealed extensive destruction of the proximal phalanx associated with pathological fracture. Magnetic resonance imaging (MRI) showed replacement of the affected phalanx with prominent soft tissue mass with extension outside the bone margins. The diagnosis of tuberculous dactylitis was based on histological characteristics and positive acid fast bacilli using Ziehl-Neelsen stain. Surgical debridement and anti-tuberculous chemotherapy eradicated the infection. Seven years post treatment, the patient had good function of the thumb with no significant disability interfering with his daily activity.

A Rare Cause for Alarm

A Rare Cause for Alarm

Delayed sub-aponeurotic fluid collections in infancy: Three cases and a review of the literature

Background:Sub-aponeurotic fluid collections (SFCs) in the neonatal period are poorly described in the literature. We describe the occurrence, possible etiologies and treatment of sub-aponeurotic fluid collections following the neonatal period.Case Description:We present 3 cases of previously healthy children who developed soft, fluctuant, extracranial masses several weeks after birth. All 3 children were seen by a pediatric neurosurgeon after parents noticed scalp masses between 5 and 9 weeks of age. All 3 children were found to be otherwise healthy. Two of the children were born via C-section and 1 child was born vaginally. The vaginal delivery was described as difficult and utilized vacuum assist. Scalp electrodes were placed in all 3 children for intensive monitoring during labor. These children received plain skull x-rays to assess for abnormalities, and 2 of the children underwent a non-contrast brain CT scan to better characterize the fluid collection. Plain x-rays and CT scans showed no abnormalities of the skull or ventricles. In both patients who underwent a CT scan, a soft tissue prominence was noted with a Hounsfield unit similar to water. All cases resolved between 5 and 9 weeks after initial presentation, with no long-term sequelae.Conclusion:SFCs presenting after the neonatal period are usually associated with benign soft tissue swellings. Use of fetal scalp electrodes has been shown to cause cerebrospinal fluid (CSF) leakage in the neonatal period and may result in delayed SFC. This condition is benign, and the recommended course of treatment is conservative management.

Relationship Between Septal Body Size and Septal Deviation

The septal body is a distinct anatomic structure located on the nasal septum. It is located near the nasal valve and may play a role in regulating nasal airflow. The septal body is an area of mucosa and prominent soft tissue overlying the cartilage and bone.1 In the majority of cases, the septal body is present bilaterally and can be seen in CT imaging studies. This structure may be analogous to the nasal turbinates in its impact on nasal airflow. Despite its potential contribution to nasal obstruction, it has received little attention clinically. The relationship between septal deviation and contralateral inferior turbinate hypertrophy has been well described. The goal of this study was to compare the size of the septal body to the laterality of septal deviation. The aim was to determine whether there is a correlation between the laterality of the septal deviation and laterality of septal body prominence.

Budd-Chiari syndrome, mediastinal mass and recalcitrant leg ulcers, an unlikely trio

A 59 year old non-smoker male presented with a long history of recalcitrant lower extremity ulcers. Forty years ago, he underwent splenectomy for a nonmalignant reason. Shortly after his surgery, he developed multiple collateral veins over his abdomen with extensive lower extremities venous varicosities. He was ultimately diagnosed with Budd-Chiari syndrome (BCS), classified as Budd-Chiari type I whereby the thrombus was limited to the intrahepatic inferior vena cava, not directly compromising the hepatic veins [1, 2]. He was initially treated with warfarin but due to bleeding complications, this medication was discontinued. More recently, he has been plagued with chronic recurrent lower extremity ulcers. Although healing promptly with compression therapy, his clinical course was marked by frequent ulcer recurrence. He otherwise denied dyspnea or recent weight changes. Physical examination revealed a 10 cm ulcer involving the medial foreleg of the right lower extremity with hemosiderin staining and dermal sclerosis. Multiple large varices were evident on the inspection of his extremities. There was no evidence of lower extremity deep vein thrombosis on venous Doppler ultrasound. His ECHO revealed a normal left ventricular ejection fraction (68%) and normal right ventricular systolic pressure. Laboratory evaluation was negative for lupus anticoagulant, factor V Leiden and PT 20210 mutation. He had normal levels of protein C and S and there was no evidence of myelodysplasia. His initial evaluation however, also included a chest X-ray that revealed a soft-tissue prominence in the right tracheobronchial angle (Fig. 1) worrisome for malignancy.

Chondromyxoid Fibroma Involving the Metacarpophalangeal Joint

Chondromyxoid fibroma is a rare benign bony tumor classically occurring in the metaphyseal region of the long bones surrounding the knee, but also found with relative frequency in other long bones, the pelvis, ribs, and small foot bones. The small bones of the hand, however, are rarely involved. The tumor is considered a physeal plate remnant and may involve the epiphysis, diaphysis, or both along with its metaphyseal origin. It may cause cortical expansion and destruction, but consistently respects the periosteal boundary. We report a case of histopathologically confirmed chondromyxoid fibroma involving a metacarpal, proximal phalanx, and synovial tissues of the metacarpophalangeal joint. A 29-year-old woman presented with pain, weakness, and a mass of the right ring finger metacarpophalangeal joint that had persisted since prior surgery to remove an extraosseous chondroma. Prominent soft tissue swelling and limited range of motion were noted, corresponding to magnetic resonance imaging findings of lytic changes in the right ring finger metacarpal and proximal phalanx, surrounded by an irregularly enhancing mass with soft tissue extension. Open biopsy revealed calcified cartilaginous synovial deposits suspicious for synovial chondromatosis, with erosion into surrounding bones. Histologic examination revealed an unusual chondromyxoid fibroma with joint involvement. The patient is >15 months out from synovectomy, intralesional curettage, and placement of demineralized bone matrix and allograft cancellous chips, and is without signs of recurrence. This benign, curable lesion should be included in the differential diagnosis of a bony lesion, even when a joint and adjacent bones are involved.

Painful Swallowing After Herpes Stomatitis

A 3-year-old male was hospitalized for dehydration secondary to stomatitis. He had had poor oral intake for 2 days prior to admission, and his mother noted that the child appeared lethargic and was refusing to drink. He had vomited twice but had no hematemesis or bilious emesis. He was noted to have increased episodes of drooling at home. The child’s medical history was significant only for eczema and mild reactive airway disease that was treated with triamcinolone cream and nebulized albuterol, respectively. He had no previous symptoms of stomatitis and had no history of caustic ingestion. Family history was noncontributory. On physical exam, the patient was tachycardic with a pulse of 150 beats per minute, and his blood pressure was 121/86 mm Hg. Although he was alert, he had multiple erythematous ulcers in the oral-pharyngeal region. Serum electrolytes, blood urea nitrogen, and creatinine were normal. His blood count demonstrated a white blood cell count of 26 900 cells/mL (78% granulated neutrophils), hemoglobin 14.4 g/dL, hematocrit 41%, and platelet count of 545 000. A throat culture was negative for Group A Streptococcus, and a neck radiograph did not demonstrate abscess formation. He was given intravenous fluids to prevent dehydration, intravenous ketorolac for pain, and intravenous acyclovir for a presumed diagnosis of herpes simplex virus (HSV) stomatitis based on his clinical findings. The patient was discharged after 3 days, and at the time of discharge, his oral lesions were in various stages of healing. He returned to his primary care physician 2 weeks after hospital discharge with dysphagia, odynophagia, and a significant decrease in oral intake. He had no fever, weight loss, or diarrhea. His oral ulcers had completely resolved, and the remainder of his physical exam was within normal limits. A repeat neck radiograph demonstrated a prevertebral soft tissue prominence and distinct epiglottis and aryepiglottic folds, possibly consistent with edema. The patient was placed on a trial of lansoprazole and demonstrated no clinical improvement, so esophago gastroduodenoscopy (EGD) was performed, which revealed a narrow esophageal stricture less than 5 mm in diameter located just below the upper esophageal sphincter (Figure 1A). The endoscope could not be advanced beyond the stricture. Esophageal biopsies revealed a zone of parakeratosis, but no inflammation or giant cell formation (Figure 1B), and a culture and polymerase chain reaction testing of esophageal tissue were negative for HSV, consistent with a resolved infection. A barium esophagram demonstrated a narrowing of the upper esophagus consistent with a stricture, as well as a long segment of narrowing throughout the esophagus (Figure 2). These findings prompted serial dilation using a Savary dilator system (Cook Medical, Bloomington, IN) under fluoroscopic examination. After serial dilations, the patient had marked improvement in swallowing, and a repeat barium esophagram demonstrated a dilated esophagus. A subsequent immune workup for this child was found to be normal, and the patient recovered with good oral intake.

CT findings of “reduction en masse” of an inguinal hernia

“Reduction en masse” is the migration of a hernial sac into the extraperitoneal space. We report the CT findings of two cases of reduction en masse. In both cases, CT scans showed a ball-like closed-loop obstruction in a lateral lower quadrant and prominent inguinal soft tissue ipsilaterally. In one case, the peritoneal ring was also seen as a circular structure, and fluid in a sac extended between the closed loop and inguinal soft tissue.

Case 131: Proteus Syndrome

A 21-year-old woman was referred for cerebral and craniofacial magnetic resonance (MR) imaging and computed tomographic (CT) examination because of the asymmetric appearance of the right side of her face and the consideration of facial paralysis. Neurologic examination revealed that the patient did not have facial nerve palsy and that her appearance was caused by facial asymmetry. Laboratory studies revealed no abnormality. There was no family history of congenital anomaly. Physical examination revealed an asymmetric soft-tissue prominence on the posterior part of her chest and abdomen. There was a history of a progressive course of asymmetry of the hands and feet and a hyperpigmented epidermal nevus on the left dorsal aspect of the trunk, (Asymmetric overgrowth of the patient's hands and feet was stabilized after puberty.) Radiographs of the pelvis, vertebrae. and extremities (not shown) were normal except for mild scoliosis. Unenhanced CT of the chest, abdomen, and pelvis was performed.