Thai Woman Research Articles

The Largest Phyllodes Breast Tumor in The World: A Case Report

Phyllodes tumor of the breast is an uncommon fibroepithelial neoplasm constituting 0.3% to 0.5% of female breasttumors. Complete wide local excision is frequently used for treatment and risk reduction in local recurrence. This article aims to report the largest phyllodes breast tumor ever reported worldwide. We report the case of a 24-year-old Thai woman was admitted to our hospital with a massive ulcerofungating right breast mass. Her physical examination revealed a 59 cm diameter mass over her right upper body, in which most parts were infected and ulcerated. A right mastectomy was then performed after the patient had already been treated with intravenous antibiotics for infection control and when her nutrition status had improved. This was followed by Vacuum-Assisted closure of the wound, and split-thickness skin graft, which could be performed after there was a good granulation growth at the wound base. Additionally, after histopathology examination, a 59x53x26 cm malignant Phyllodes tumor with free margins, weighing 14,500 grams, in which there was around 20% tumor necrosis, 12/10 high power fields (HPFs) of Mitosis, and the unaffected nipple was observed. The patient was discharged from the hospital after 45 days, and there was no evidence of local and distant recurrence after a one-year follow-up. Phyllodes tumors are considered unusual fibroepithelial breast tumors that have various biological behaviors, in which surgical resection is a major option for treatment.

Internuclear ophthalmoplegia as a presentation of procedural stroke: a case report

BackgroundCardiac catheterization and endovascular procedures are extensively used in modern medicine, and procedural stroke is one of the major complications that the catheterization laboratory team may face in their everyday work. Recognizing the signs and symptoms of procedural stroke is crucial to ensuring appropriate management. We herein report a case of internuclear ophthalmoplegia that caused blurred vision, diplopia, and dizziness on lateral gaze as an unusual presentation of procedural stroke.Case presentationA 60-year-old Thai woman underwent right partial colectomy and was diagnosed with stage IV diffuse large B-cell lymphoma. Pre-chemotherapy echocardiography revealed mild left ventricular systolic dysfunction, and she therefore underwent diagnostic catheterization. Coronary angiography revealed normal coronary arteries, leading to a diagnosis of non-ischemic cardiomyopathy. After the procedure, she immediately developed dizziness and diplopia. During the right lateral gaze, she exhibited impaired adduction of the left eye and horizontal nystagmus of the right eye. A diagnosis of left internuclear ophthalmoplegia was made. Magnetic resonance imaging revealed a tiny area exhibiting characteristics of an acute infarct in the left paramedian midbrain, including the left medial longitudinal fasciculus, which explained the clinical picture. Another region of restricted diffusion indicating an acute infarct was detected in the right inferior cerebellar hemisphere. Magnetic resonance angiography revealed no significant cerebral artery disease. The patient achieved full neurological recovery 6 weeks after symptom onset.ConclusionThis report describes an uncommon presentation of procedural stroke that is likely to be misdiagnosed, especially by medical staff unfamiliar with internuclear ophthalmoplegia. Despite the good prognosis of internuclear ophthalmoplegia, appropriate stroke care is crucial in patients with procedural stroke because of the risk of multiple brain infarcts.

Til death do us part? End-of-life care for ageing Western husbands in Thailand

After a few decades of large-scale transnational marriages and migration of Thai women to countries in the Global North, the phenomenon has matured and Western-Thai married couples have aged, particularly the men who tend to be older than their Thai wives. This article examines the understudied topic of Western man – Thai woman couples in their old age, focusing on those who decide to spend their late life in Thailand. Ageing in Thailand as non-citizens, many Western husbands fall through the net of social protection and rely on their Thai spouses as the only source of care. This study examines the implications of caring for frail Western husbands on Thai wives, drawing on biographical narrations of three Thai women. Located at the intersection of local and global care configurations, Thai wives are expected to perform the gendered role of spousal care givers with little support from either sending or receiving states. With different life trajectories and resources, the women do not engage with this gendered expectation in the same way, leading to different decisions on end-of-life care for their Western husbands. Their stories speak to the complexity of ageing, care arrangement and social protection in the context of global mobility.

Midterm outcome after en bloc resection of C2 chordoma with transoral mandibular split and mesh cage reconstruction: a case report

IntroductionChordomas are rare, locally aggressive tumors that often occur in the axial spine, especially in the sacrum. The treatment of chordomas located in the upper cervical spine is challenging. En bloc resection is the preferred surgical option for total tumor removal.Case presentationWe report the case of a C2 chordoma in a 47-year-old Thai woman. She was treated with a two-stage, anterior–posterior, C2 total spondylectomy with titanium mesh cage reconstruction and radiotherapy. The first stage involved posterior stabilization from the occiput to C5, a total laminectomy, and removal of the posterior rings of the bilateral foramen transversarium to preserve the bilateral vertebral arteries. The second stage comprised a transoral mandibular split with en bloc resection of C2, followed by titanium mesh cage reconstruction and kick-off anterior cervical plating. At the 5 year follow-up, no tumor recurrence was identified on magnetic resonance imaging. The patient had no neurological deficits but still had minor complications from the anterior transoral mandibular split.ConclusionsExcellent midterm results were obtained using a transoral mandibular split with reconstruction and posterior spinal fusion from the occiput to the lower cervical spine coupled with adjuvant radiotherapy. We recommend this approach as the treatment of choice for chordoma in the upper cervical spine.

Prospective screening for δ-hemoglobinopathies associated with decreased hemoglobin A2 levels or hemoglobin A2 variants: A single center experience

Backgroundδ-hemoglobinopathies may lead to misdiagnosis of several thalassemia syndromes especially β-thalassaemia carrier, it is important to evaluate the δ-globin gene defects in areas with high prevalence of globin gene disorders. We describe a prospective screening for δ-hemoglobinopathies in a routine setting in Thailand. MethodsStudy was done on a cohort of 8,471 subjects referred for thalassemia screening, 317 (3.7%) were suspected of having δ-globin gene defects due to reduced hemoglobin (Hb) A2 levels and/or appearance of Hb A2-variants on hemoglobin analysis. Hematologic and DNA analysis by PCR and related assays were carried out. ResultsDNA analysis of δ-globin gene identified seven different δ-globin mutations in 24 of 317 subjects (7.6%). Both known mutations; δ−77(T>C) (n = 3), δ−68(C>T) (n = 1), δ−44(G>A) (n = 8), Hb A2-Melbourne (n = 5), δIVSII−897(A>C) (n = 5), and Hb A2-Troodos (n = 1) and a novel mutation; the Hb A2-Roi-Et (n = 1) were identified. This Hb A2-Roi-Et, results from a double mutations in-cis, δCD82(AAG>AAT) and δCD133(GTG>ATG), was interestingly found in combination with an in trans, 12.6 kb deletional δβ0-thalassemia in an adult Thai woman who had no Hb A2 and elevated Hb F. A multiplex-allele-specific PCR was developed to detect these novel δ-globin gene defects. ConclusionsThe result confirms a diverse heterogeneity of δ-hemoglobinopathies in Thailand which should prove useful in a prevention and control program of thalassemia in the region.

Gastric villous adenoma: a case report and review of the literature

BackgroundVillous adenoma is the one subtype of adenomatous polyp that is very uncommon in the stomach. Data regarding clinical characteristics, natural history, and prognosis were scarce.Case presentationThis report presented an 87-year-old Thai woman with a large gastric villous adenoma incidentally revealed in a computed tomography of chest for the evaluation of right pleural effusion. The esophagogastroduodenoscopy demonstrated a huge, glossy, proliferative polypoid mass involving gastric cardia, fundus, and a lesser curve of the upper body. The pathological report confirmed villous adenoma with low grade dysplasia. Although surgical resection was suggested, the patient denied any treatment due to advanced age and multiple comorbidities. She was generally well after 12 months of clinical and radiologic surveillance.ConclusionFrom literature review, only 14 cases of gastric villous adenoma were reported to date. Most of the lesions were large and symptomatic. Malignancy presented in 43% of the cases. Nevertheless, our patient remained asymptomatic without surgical removal following a 12-month period.

Inadvertent filtering bleb due to extracapsular cataract extraction wound reopening after mitomycin C use: a case report

Background Mitomycin C has been used adjunctively in various procedures, including pterygium excision. Delayed wound healing, the long-term complication of mitomycin C, can occur several years later and may rarely cause a subsequent inadvertent filtering bleb. However, conjunctival bleb formation from the reopening of an adjacent surgical wound after mitomycin C use has not been reported.Case presentationA 91-year-old Thai woman had undergone pterygium excision 26 years ago, with adjunctive mitomycin C, as well as an uneventful extracapsular cataract extraction in the same year. The patient developed a filtering bleb without glaucoma surgery or trauma approximately 25 years later. Anterior segment ocular coherence tomography illustrated a fistula connected between the bleb and anterior chamber at the scleral spur. The bleb was observed without further management, as no hypotony or bleb-related complications occurred. The symptoms/signs of bleb-related infection were advised.Conclusions This is a case report of a rare novel complication of mitomycin C application. Conjunctival bleb formation from the reopening of surgical wound, which was related to the previous mitomycin C use, could occur after a few decades.

Placental Transfer Immunity to the Newborns in a Twin Pregnant Women Vaccinated with Heterologous CoronaVac-ChAdOx1

Pregnant women who receive the COVID-19 vaccine develop anti-SARS-CoV-2 antibodies, which can be transferred to the fetus. However, the effectiveness of placental transfer has not been evaluated in twin pregnancy, especially in cases vaccinated with heterologous CoronaVac (Sinovac)-ChAdOx1 (Oxford-AstraZeneca) regimen, which was commonly used in many countries. Case: A 34-year-old Thai woman with a twin pregnancy attended our antenatal care clinic at 21 + 2 weeks of gestation and requested COVID-19 vaccination. Her medical history and physical examination were unremarkable. She had not received COVID-19 vaccination before. Ultrasound screening for fetal anomaly revealed a dichorion diamnion twin pregnancy. Both twins showed no structural anomaly. She received the CoronaVac vaccine at 21 + 2 weeks of gestation without serious side effects and the ChAdOx1 vaccine at 24 + 2 weeks of gestation. Cesarean delivery was performed at 36 + 5 weeks of gestation, giving birth to the two healthy babies. The levels of anti-spike protein IgG levels (BAU/mL) in maternal blood just before delivery and umbilical cord blood of the two newborns were 313.349, 678.219, and 874.853, respectively. The levels of % inhibition (wild-type and delta) in the two newborns were also higher than those in the mother. In conclusion, heterologous CoronaVac-ChAdOx1-S vaccination in a twin pregnancy could effectively provide protective immunity to both twin newborns. The antibody levels in both were approximately two times higher than those in the mothers. This case report may serve as a reference in counseling couples with a twin pregnancy, while the studies on placental transfer of vaccine-derived antibodies in twin pregnancy are currently not available, especially in countries experiencing a vaccine shortage or unavailability of mRNA vaccines.

Machine learning's performance in classifying postmenopausal osteoporosis Thai patients

This work investigates the performance of different machine learning (ML) methods for classifying postmenopausal osteoporosis Thai patients. Our dataset contains 377 samples compiled retrospectively using the medical records of a Thai woman in the postmenopause stage from the obstetrics and gynecology clinic, Ramathibodi Hospital, Bangkok, Thailand. Missing data imputation, feature selection, and handling imbalanced techniques are independently applied as pre-processing approaches. The performance of different ML algorithms, including k-nearest neighbors (k-NN), neural network (NN), naïve Bayesian (NB), Bayesian network (BN), support vector machine (SVM), random forest (RF), and decision tree (DT), is compared between the pre-processed and original data. The results demonstrate that different ML algorithms combined with pre-processing techniques achieve varying results. In terms of accuracy, the three best-performing methods are the NN, NB, and RF models when a wrapper approach is used with an appropriate learner. In terms of specificity, the DT model achieves the best performance when the synthetic minority oversampling technique method is applied. When feature selection techniques are applied, the k-NN, BN, and SVM algorithms obtain the best sensitivity, whereas the NN shows the best area under the curve. Overall, in comparison with the original dataset, the pre-processed approaches improved model performance. Therefore, proper pre-processing techniques should be considered when developing ML classifiers to identify the best appropriate model.

Lung abscess and empyema in a heart transplant recipient from Thailand.

The case discussed involves a 69-year-old Thai woman who underwent orthotopic heart transplantation 9 months before this event. She presented with fever without localizing signs or symptoms. However, her chest images revealed mass-like consolidation in the left upper lobe. Blood culture and lung tissue identified Rhodococcus equi. She was successfully treated with a combination of antimicrobial therapy, optimization of immunosuppressants, and surgical resection.

ODP531 Worsening of pretibial myxedema following repeated doses of radioiodine treatment in a patient with hyperthyroid Graves’ disease

Abstract Introduction The development of new-onset pretibial myxedema following radioiodine (RAI) treatment has been occasionally reported from the probable influences of thyrotropin receptor antibodies (TRAbs) similar to the RAI-associated Graves’ ophthalmopathy (GO). However, the worsening of pre-existing pretibial myxedema after RAI treatment has never been reported. Herein, we report an interesting case of fluctuating clinical course of pretibial myxedema following treatments of hyperthyroid Graves’ disease for over 3 years. Case Report A 49-year-old Thai woman with underlying hyperthyroid Graves’ disease with GO and pretibial myxedema for 1 year came to our hospital for relapsed hyperthyroidism and active, moderate-to-severe GO in 2019. A plague form of pretibial myxedema with indurated hyperpigmented lesion was found on both legs. Intravenous pulse methylprednisolone (IVMP) was given to control her active GO. Both GO and pretibial myxedema significantly improved after IVMP treatments. Then, RAI (30 mCi) was administered at 1 month later as a definitive treatment. Low dose of oral prednisolone (20 mg/ day) was also given before and after RAI treatment. Transient hypothyroidism developed at 4 months post-RAI and the estimated weights of the thyroid decreased from 60 grams to 30 grams. However, hyperthyroidism relapsed again within 6 months post-RAI treatment. At that time, her pretibial myxedema flared up slightly but her GO was still inactive. Eventually, a second dose of RAI (20 mCi) was given at 11 months apart from the first RAI administration. Low dose of oral prednisolone was also given. She developed post-radiation thyroiditis at 4 months after RAI with worsening of pretibial myxedema and mild exacerbation of GO. Topical corticosteroid ointment was given for pretibial myxedema and only local supportive measures was applied to treat GO. Finally, permanent hypothyroidism was achieved at 6 months after the second course of RAI. Currently, her pretibial myxedema is stable without further flareup. Conclusion Our case highlights the potential of RAI treatment to precipitate both GO and pretibial myxedema in patients with pre-existing skin lesions. Low dose prednisolone prophylaxis might not ensure preventative effect in exacerbation. Whether the risk of worsening of pretibial myxedema is higher in patients with persistent hyperthyroidism requiring a second dose of RAI is a question that warrants further studies. Presentation: No date and time listed

Autoimmune Hemolytic Anemia After Inactivated Virus COVID-19 Vaccination: A Report of 2 Cases

Very few cases of autoimmune hemolytic anemia (AIHA) have been reported after mRNA COVID-19 vaccinations. But herein we found 2 cases of AIHA after inactivated virus COVID-19 vaccination. Case 1: a 47-year-old Thai woman suffered from malaise, fatigue, and feverish feeling since the evening of the day of the first dose of inactivated virus COVID-19 vaccination (Sinopharm). She did not have any serious health problem prior this illness. Physical examination revealed marked pallor and body temperature was 38.1°C. Blood tests showed hemoglobin (Hb) 55 g/L, white blood cell (WBC) 12.2 × 109/L, platelet 310 × 109/L, nucleated red blood cell (RBC) 8/100 WBC, reticulocyte count 25.0%, direct antiglobulin test-4+ positive, indirect antiglobulin test-2+ positive. She was diagnosed with severe AIHA and well responsive to steroid therapy. Case 2: a 78-year-old Thai woman felt fatigue without fever 3 days after the second dose of inactivated virus COVID-19 vaccine (Sinopharm). Her underlying disease was anemia of the elderly with alpha thalassemia-1 heterozygosity. Her averaged Hb concentration before transfusion was 85 ± 3 g/L and she always needed transfusion every 2 months. Physical examination revealed only pallor. Blood test showed Hb 79 g/L, WBC 3.7 ×109/L, platelet 104 × 109/L, direct antiglobulin test-4+ positive, indirect antiglobulin test-4+ positive. She was diagnosed with AIHA and treated with cyclophosphamide and blood transfusion. Although the association between the inactivated virus COVID-19 vaccination and AIHA could not be simply concluded and the mix-and-match combination of different COVID-19 vaccines is promoted by Thai government, both of our patients chose to postpone the next dose of any kind of COVID-19 vaccine.

Hypertriglyceridemia as a main feature associated with 17q12 deletion syndrome-related hepatocyte nuclear factor 1β-maturity-onset diabetes of the young.

SummaryHepatocyte nuclear factor 1β (HNF1B) gene is located on chromosome 17q12. It is a transcription factor implicated in the early embryonic development of multiple organs. HNF1B-associated disease is a multi-system disorder with variable clinical phenotypes. There are increasing reports suggesting that the 17q12 deletion syndrome should be suspected in patients with maturity-onset diabetes of the young type 5 (MODY5) due to the deletion of HNF1B gene. In contrast to classical 17q12 syndrome in childhood with neurological disorders and autism, patients with HNF1B-MODY deletion rarely had neuropsychological disorders or learning disabilities. The diagnosis of 17q12 deletion syndrome highlighted the phenotypic heterogeneity of HNF1B-MODY patients. In this study, we report the clinical course of a Thai woman with young-onset diabetes mellitus and hypertriglyceridemia as a predominant feature due to HNF1B deletion as part of the 17q12 deletion syndrome. Our findings and others suggest that hypertriglyceridemia should be considered a syndromic feature of HNF1B-MODY. Our case also highlights the need to use sequencing with dosage analyses to detect point mutations and copy number variations to avoid missing a whole deletion of HNF1B.Learning pointsMaturity-onset diabetes of the young type 5 (MODY5) may be caused by heterozygous point mutations or whole gene deletion of HNF1B. Recent studies revealed that complete deletion of the HNF1B gene may be part of the 17q12 deletion syndrome with multi-system involvement.The length of the deletion can contribute to the phenotypic variability in patients with HNF1B-MODY due to whole gene deletion.Using next-generation sequencing alone to diagnose MODY could miss a whole gene deletion or copy number variations. Specialized detection methods such as microarray analysis or low-pass whole genome sequencing are required to accurately diagnose HNF1B-MODY as a component of the 17q12 deletion syndrome.Molecular diagnosis is necessary to distinguish other acquired cystic kidney diseases in patients with type 2 diabetes which could phenocopy HNF1B-MODY.Hypertriglyceridemia is a possible metabolic feature in patients with HNF1B-MODY due to 17q12 deletion syndrome.

The role of shoulder arthroplasty after chronic brucellosis of glenohumeral joint septic arthritis. A case report and literature reviews.

IntroductionThe main socioeconomic area in Thailand has been the agricultural endemic area, where brucellosis infection, one of the bacterial infectious diseases has been an overlooked diagnose.Presentation of caseA 50-year-old Thai woman was admitted to the hospital with pain and limited motion in her left shoulder. These symptoms have been prolonging with progressive clinical for two years. The physical examination revealed stiffness in all directions. The glenohumeral joint appeared to be narrowing on radiographic evaluation. The multiple loculate mass and septic glenohumeral joint arthritis were seen by magnetic resonance imaging (MRI). Furthermore, the Brucellosis investigation specificity was Brucella IgM/IgG positive. This patient was treated with a combination of surgery and oral antimicrobial medication. We decided to perform a total shoulder arthroplasty because the patient was still in pain and stiff from secondary arthritis.DiscussionAs a result of the late treatment for osteoarticular involvement, secondary osteoarthritis develops until leading to significant cartilage loss. Therefore, even medical treatment and surgical debridement, the patient still suffers from secondary osteoarthritis, which causes pain and limited activity. The arthroplasty treatment method plays a role in the treatment of function following secondary osteoarthritis infection.ConclusionThe role of arthroplasty was selected in the treatment of brucellosis osteoarticular involvement, which is an uncommon and difficult to identify condition that can lead to maltreatment. So that this case report offers the treatment option if the patient was not responsible for the medical and surgical debridement therapy with secondary osteoarthritis at the glenohumeral joint, even though the brucellosis infection condition had completely resolved.

Livedoid Vasculopathy Secondary to Protein C Deficiency: A Case Successfully Treated With Rivaroxaban

Introduction: Livedoid vasculopathy is a chronic noninflammatory skin disease secondary to hypercoagulable states. No therapeutic guideline has yet been established for livedoid vasculopathy. We herein report a case of livedoid vasculopathy secondary to protein C deficiency that was successfully treated with rivaroxaban. Case presentation: A 31-year-old Thai woman who had been diagnosed with livedoid vasculopathy 10 years previously presented with a 2-month history of worsening leg ulcers and failure to respond to aspirin, colchicine, and pentoxifylline. Further investigations confirmed protein C deficiency. Rivaroxaban was initiated, and clinical improvement was achieved in 8 weeks. Discussion: When livedoid vasculopathy is confirmed by skin biopsy, additional investigations for hypercoagulable states should be performed to exclude secondary causes. Identification of the causes of livedoid vasculopathy can direct physicians to therapeutic options based on previously reported cases of successful treatment. Our patient, whose livedoid vasculopathy was caused by protein C deficiency, responded well to rivaroxaban. Conclusion: Protein C deficiency results in a hypercoagulable state, and affected patients can present with livedoid vasculopathy. The anticoagulant rivaroxaban has been beneficial in the treatment of livedoid vasculopathy.

Maternal septicemia caused by Streptococcus mitis: a possible link between intra-amniotic infection and periodontitis. Case report and literature review

BackgroundIntra-amniotic infection has a strong causal association with spontaneous preterm birth and preterm prelabor rupture of membranes (PPROM). The most common route of intra-amniotic infection is the ascending pathway in which microorganisms from the vagina gain access to the amniotic cavity. Distant microorganisms such as those from the oral cavity have been reported in intra-amniotic infection through hematogenous spreading.Case presentationA 31-year-old gravida 1, para 0 Thai woman at 33+6 weeks’ gestation presented with leakage of vaginal fluid and irregular uterine contraction. She developed fever at 4 h after admission and was later diagnosed with acute chorioamnionitis. A Cesarean section was performed to terminate pregnancy. In addition to a blood culture, the cultures of amniotic fluid, vaginal and chorioamniotic membrane swabs were positive for Streptococcus mitis with identical susceptibility profiles. After the delivery and antibiotic prescription, oral examination showed dental caries and chronic periodontitis.ConclusionsThis is the first case report demonstrating maternal septicemia and intra-amniotic infection caused by S. mitis which might be attributed to periodontitis in women presenting with preterm PROM. We highlighted the association of periodontal disease and preterm labor/PROM syndrome. Oral cavity examination should be included in the prenatal care to ensure good dental hygiene.

Concomitant myocarditis and painless thyroiditis after AstraZeneca coronavirus disease 2019 vaccination: a case report

BackgroundIncidence of myocarditis following messenger RNA coronavirus disease 2019 vaccination has been widely described, but this clinical scenario after adenoviral vector coronavirus disease 2019 vaccination has only been rarely reported. In addition, a few case reports of thyroiditis after adenoviral vector coronavirus disease 2019 vaccination have been published.Case presentationA 55-year-old Thai woman presented with palpitation without neck pain 14 days after receiving AstraZeneca coronavirus disease 2019 vaccination. Electrocardiography revealed sinus tachycardia. Her blood tests showed elevation of cardiac troponin and free triiodothyronine with suppressed serum thyroid stimulating hormone, reflecting a hyperthyroid status. Evidence of myocardial inflammation and necrosis from cardiac magnetic resonance imaging supported the diagnosis of recent myocarditis. Laboratory results and imaging findings were consistent with thyroiditis. After 3 weeks of symptomatic treatment, her symptom and blood tests had returned to normal.ConclusionsThis case demonstrates that the adenoviral vector coronavirus disease 2019 vaccine could possibly cause myocarditis and painless thyroiditis. Clinicians should have a high index of suspicion and promptly evaluate these conditions, despite minimal symptoms.

Cerebral Gnathostomiasis: An Unusual Course of Recurrent Hemorrhagic Stroke.

Cerebral Gnathostomiasis: An Unusual Course of Recurrent Hemorrhagic Stroke.

Hematogenous dissemination of pulmonary mucormycosis manifested as multiple subcutaneous nodules: a case report and review of the literature

BackgroundDisseminated mucormycosis presenting with multiple subcutaneous nodules is a rare condition with a poor prognosis, and delayed diagnosis and treatment is common.Case presentationWe report a case of 64-year-old Thai woman with colorectal cancer who initially presented with Acinetobacter baumannii pneumonia and respiratory failure. Following 10 days after her admission to the intensive care unit, she developed hospital-acquired pneumonia. Five days later, multiple subcutaneous nodules appeared on both arms and both legs. Bronchoalveolar lavage and skin biopsy cultures both grew Mucor spp. She was diagnosed with disseminated mucormycosis and was treated with liposomal amphotericin B at a dose of 5 mg/kg/day. Despite treatment, our patient succumbed to septic shock and multiorgan failure on the third day after definitive diagnosis.ConclusionsThis case demonstrates that the subcutaneous nodules caused by hematogenously disseminated mucormycosis are unusual in a patient with a solid tumor. Clinicians should be aware of this atypical presentation of mucormycosis in patients with solid tumors.

Concurrent myasthenia gravis-related cervical thymoma in a patient with diffuse large B-cell lymphoma: a case report\xa0

BackgroundCervical thymoma is a rare thymic epithelial neoplasm. Evidence supports an increased risk of second primary malignancies in patients with thymoma. We report a rare case of a patient with synchronous cervical thymoma and diffuse large B-cell lymphoma.Case presentationAn 81-year-old Thai woman was referred for further treatment of diffuse large B-cell lymphoma at Siriraj Hospital, Bangkok, Thailand. While waiting for a review of the original pathological examination of a mass in the left neck and a mass in the left arm, the attending physician noticed ptosis of the upper eyelids, which was proven to be caused by myasthenia gravis. The final pathology review confirmed that the arm mass was diffuse large B-cell lymphoma, but the neck mass was cervical thymoma, type B1, not diffuse large B-cell lymphoma. Interestingly, the patient reported that the arm mass had been present for 2 years, while the neck mass had grown rapidly in the past month. A diagnostic challenge had arisen when the initial morphological evaluation was not performed with care, causing the first pathologist to misinterpret that the neoplastic cells in both masses were the same.ConclusionConcurrent cervical thymoma and diffuse large B-cell lymphoma were proven after a careful pathology review, leading to better clinical management.