Ultimate Diagnosis Research Articles

MRI to differentiate multiple sclerosis, neuromyelitis optica, and myelin oligodendrocyte glycoprotein antibody disease.

Differentiating multiple sclerosis (MS) from other relapsing inflammatory autoimmune diseases of the central nervous system such as neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is crucial in clinical practice. The differential diagnosis may be challenging but making the correct ultimate diagnosis is critical, since prognosis and treatments differ, and inappropriate therapy may promote disability. In the last two decades, significant advances have been made in MS, NMOSD, and MOGAD including new diagnostic criteria with better characterization of typical clinical symptoms and suggestive imaging (magnetic resonance imaging [MRI]) lesions. MRI is invaluable in making the ultimate diagnosis. An increasing amount of new evidence with respect to the specificity of observed lesions as well as the associated dynamic changes in the acute and follow-up phase in each condition has been reported in distinct studies recently published. Additionally, differences in brain (including the optic nerve) and spinal cord lesion patterns between MS, aquaporin4-antibody-positive NMOSD, and MOGAD have been described. We therefore present a narrative review on the most relevant findings in brain, spinal cord, and optic nerve lesions on conventional MRI for distinguishing adult patients with MS from NMOSD and MOGAD in clinical practice. In this context, cortical and central vein sign lesions, brain and spinal cord lesions characteristic of MS, NMOSD, and MOGAD, optic nerve involvement, role of MRI at follow-up, and new proposed diagnostic criteria to differentiate MS from NMOSD and MOGAD were discussed.

Comparison of Characteristics among Suspected ACS Patients by Normal and Elevated Hs-Troponin Levels

Background: Acute coronary syndrome (ACS) is a life-threatening condition that requires prompt diagnosis and treatment. However, some patients with ACS may have normal levels of high-sensitivity cardiac troponin (hs-cTn), a biomarker of myocardial injury, at presentation. This study aimed to compare the characteristics and outcomes of ACS patients with normal and elevated hs-cTn levels using different assays and thresholds. Material & Methods: This 2-year retrospective observational study was conducted in Bangladesh, using data from hospital records of 420 suspected ACS patients. Patients were divided into two groups based on their Hs-Troponin levels, with group 1 having 60 patients with Hs-Troponin ≤0.014 ug/L, and group 2 having 360 patients with Hs-Troponin >0.014 ug/L. Patients less than 18 years old and those with incomplete records were excluded. Ethical approval was obtained, and SPSS v.25 was used for analysis. Results: Group 1 had a significantly younger mean age of 41.8±14.3 compared to Group 2’s mean age of 68.4±12.6, with a p-value less than 0.001. Group 2 had a higher percentage of male patients (70.56%) compared to Group 1 (31.67%), with a p-value of less than 0.01. Group 2 had a significantly higher mean heart rate of 80.18±20.64 beats per minute compared to Group 1’s mean heart rate of 71.02±12.21, with a p-value less than 0.001. There were no significant differences between the two groups in terms of systolic blood pressure, diastolic blood pressure, BMI, history of smoking, history of AMI, hypertension, and diabetes mellitus. Group 1 had a significantly lower percentage of patients with hypercholesterolemia (55.00%), but a higher percentage of patients with a history of ACS (25.00%), and a family history of CAD (70.00%) compared to Group 2, with p-values less than 0.001. Group 2 had a significantly higher percentage of patients with known renal failure (21.67%) compared to Group 1 (1.67%), with a p-value less than 0.001. Creatinine levels were significantly higher in Group 2 (98±53 µmol/L) compared to Group 1 (76±17 µmol/L) with a p-value of less than 0.001, and eGFR was significantly lower in Group 2 (76±27 mL/min/1.73 m2) compared to Group 1 (97±23 mL/min/1.73 m2) with a p-value of less than 0.001. The cardiac Troponin T (cTnT) levels were significantly higher in Group 2 (0.28±1.68 ug/L) compared to Group 1 (0.01±0.01 ug/L) with a p-value of less than 0.001, indicating worse kidney function and cardiac damage in Group 2 compared to Group 1. Conclusion: The study found that very few patients presenting with ACS symptoms had normal Hs-Troponin levels, and ultimate diagnosis proved that they did not have ACS, indicating the usability of Hs-Troponin as a biomarker for ACS. Significant differences were observed in age, gender, heart rate, hypercholesterolemia, family history of ACS, family history of CAD, and renal failure between the two groups. The study also found a consistent association between elevated creatinine levels and lower eGFR with higher Hs-Troponin levels.

A Case Report of Chronic Diarrhoea and Itchy Rash- are We Missing Something?

A proper and complete history is very important to reach the ultimate diagnosis and complete evaluation of a patient. Otherwise, the typical presentation can also be sometimes missed which leads to delay or even miss the actual diagnosis of a patient. However, we hereby present a case of a HIV (Human Immunodeficiency) patient where an incomplete history put the physician into a diagnostic dilemma and hindrance. The patient was a migrant worker and had history of sexual exposure and previous blood transfusion. Initially, he did not disclose his personal history to his general and specialist physicians. Therefore, the several consulted physicians could not reach his true diagnosis. After getting admission, we became able to explore his personal history which guided us prompt reaching in his proper diagnosis finally. Moreover, we sometimes fail to make a patient friendly environment to share everything due to social stigma, lack of welcoming environment, lack of good doctor-patient relationship. J Medicine 2023; Vol. 34, No. 2(1) Supplement: 222-223

Bladder metastasis from epidermal growth factor receptor mutant lung cancer: A case report

Bladder metastasis from lung cancer with epidermal growth factor receptor (EGFR) mutation is extremely rare. Here, we report a case of bladder metastasis from lung adenocarcinoma with EGFR mutation. A 53-year-old female patient was diagnosed with advanced lung adenocarcinoma with EGFR exon 19 deletion. Multiple nodules on the bladder wall were found by regular examination of the pelvic cavity through computed tomography during targeted therapy. Further cystoscopy and histological examination of bladder biopsy tissues confirmed the bladder metastasis from lung adenocarcinoma. In addition, genetic analysis of the bladder metastasis revealed EGFR T790M mutation. The patient achieved a good response to a third-generation EGFR tyrosine kinase inhibitor. During routine follow-up of lung cancer patients, imaging examination of the pelvic cavity should be performed to avoid missing bladder metastasis. The ultimate diagnosis of bladder metastasis sill depends on the pathological result of biopsy tissues.

Syncopal storm in an elderly patient: unraveling the mechanism—a case report

BackgroundMultiple episodes of syncope in rapid succession are extremely rare, and syncope in the elderly has multiple potential mechanisms. Even though the electrophysiology study has little role in patients with syncope who have structurally normal hearts, the history of syncope preceded by palpitations was a red-flag symptom that made us go ahead with the electrophysiology study (EP) that revealed the ultimate diagnosis of typical atrioventricular nodal reentry tachycardia (AVNRT), which was documented to be associated with critical hypotension.Case presentationA 78-year-old man with a history of hypertension experienced a ‘Syncopal Storm,’ with four episodes within 15 min. There was no history to suggest common etiologies like postural hypotension or vasovagal syncope. The examination, ECG, and echocardiogram were normal. In view of the nasty sequence and a history of syncope preceded by palpitations, we conducted an electrophysiology study. Surprisingly, typical AVNRT at 190 bpm was easily and repeatedly induced with atrial extrastimuli. During the AVNRT, the systolic BP fell from 160 to 40 mm Hg with the development of presyncope. No ventricular tachycardia was inducible despite vigorous ventricular stimulation protocol. Radiofrequency ablation was performed successfully. The patient was symptom-free after 6 months of follow-up.ConclusionWe report a unique case of a syncopal storm due to AVNRT in the setting of a structurally normal heart. The syncopal storm is a rare but ominous presentation of AVNRT. The cause of syncope was a combination of a high heart rate, loss of atrioventricular synchrony, and an impaired autonomic vasomotor response, causing severe hypotension.

Etiologies of Poor Weight Gain and Ultimate Diagnosis in Children Admitted for Growth Faltering

Growth faltering (GF) (previously failure to thrive) is a common reason for hospital admission, but there is little data on whether diagnoses made during initial admission remain accurate in follow-up. We sought to characterize infants admitted for isolated GF and identify diagnoses at discharge and ultimate diagnoses determined over 2 years of follow-up, to determine how diagnoses changed. We also sought to identify patient factors on admission associated with ultimate diagnosis. We conducted a retrospective study of children aged 2 weeks to 2 years with index admissions for GF from 2013 to 2017. We reviewed clinical data and documentation to determine discharge and ultimate diagnosis, and identify factors associated with ultimate diagnosis. Of 497 patients, 292 (59%) had insufficient intake, 103 (20%) had organic disease including 36 genetic disorders, 52 (11%) had mechanical feeding difficulties, and 50 (10%) had mixed or unknown diagnoses 2 years after admission. Over 90% of cases of insufficient intake were diagnosed during admission. Sixty-five percent of organic diseases, and only 39% of genetic disorders, were diagnosed during admission. Patient factors associated with genetic disorders included previous NICU stay, low birth weight, dysphagia, hypotonia, and dysmorphisms. Insufficient intake remains the most common diagnosis, and this diagnosis was accurately made during admission. Organic disease, especially genetic disease, was often not diagnosed during admission. Better tools are needed to identify patients with organic disease. We identified patient factors on admission associated with ultimate diagnosis, which could be used to prioritize evaluation and expedite follow-up.

Authorship and individualization in the digital public sphere

Authorship and individualization in the digital public sphere

Fatal acquired coagulation factor V deficiency after hepatectomy for advanced hepatocellular carcinoma as a possible immune checkpoint inhibitor-related adverse event: a case report

BackgroundAtezolizumab plus bevacizumab therapy was recently introduced as the first line for unresectable advanced hepatocellular carcinoma (HCC), but immune-related adverse events (IrAEs) due to atezolizumab are a great concern. Here, we report the case of a patient who developed fatal acquired coagulation factor deficiency after hepatectomy for HCC, treated with atezolizumab and bevacizumab before surgery.Case presentationA 70-year-old man received right trisegmentectomy of the liver with hepaticojejunostomy for advanced HCC with bile duct invasion, after atezolizumab and bevacizumab therapy. The patient suffered the sudden onset of severe multiple coagulation factor deficiency (II, V, VII, VIII, IX, X, XI and XII) immediately following reoperation for anastomotic leakage of hepaticojejunostomy, 7 days after hepatectomy. The coagulation factor deficiency did not reverse even with intensive treatment, and the patient died of uncontrollable bleeding 32 days after hepatectomy. An IrAE due to atezolizumab was suspected because the patient had developed the possible IrAE of enthesitis of the right gastrocnemius muscle before surgery, and specific inhibitors against factor V and anti-factor V autoantibodies were detected, leading to an ultimate diagnosis of autoimmune FV/5 deficiency (AiF5D).ConclusionSevere acquired coagulopathy should be recognized as a possible life-threatening IrAE when using atezolizumab and bevacizumab for HCC.

Indeterminate Thyroid Nodules: When to Worry?

Indeterminate thyroid nodules can present a confounding scenario for both provider and patient. Once a diagnosis of an indeterminate thyroid nodule is made, appropriate management can range from conservative observation to surgical resection. A thorough evaluation, including a dedicated history and physical examination, biochemical profile, pathologic information from a seasoned pathologist, and thyroid ultrasound by an experienced radiologist can help point health-care providers in the right direction. However, the ultimate diagnosis cannot be rendered unless surgical excision is performed. Provider and patient must agree on a personalized risk vs. benefit profile for the indeterminate thyroid nodule.

Bacteriological Profile and Antibiotic Susceptibility Patterns of Gram-negative Bacilli Isolated from Lower Respiratory Tract Infections

Background: Lower respiratory tract infections (LRTIs) are one of the most frequent infections seen in humans. Bacterial etiology of these infections is one of the major causes of morbidity and mortality. The emergence of drug resistance among bacteria is increasing throughout the world causing more severe infections because of their continuous mutation and multidrug resistance nature. Objectives: This study was focused on obtaining a comprehensive insight into the Gram-negative bacillary profile of LRTIs, their prevalence, and their antibiotic susceptibility patterns. Materials and Methods: The study was conducted for a duration of 6 months. Samples were obtained from patients of all ages and both sexes presenting with symptomatology suggestive of LRTIs. Following conventional culture, the isolated organisms were identified by various preliminary identification methods and biochemical tests. Antimicrobial sensitivity testing of Gram-negative isolates was performed by standard methods as recommended by CLSI 2019. Results: Out of the 1724 LRT specimens evaluated, 307 (17.80%) were culture positive. Our study showed that Gram-negative bacilli are the predominant cause (97.70%) of LRTIs with Klebsiella pneumoniae (42%) as the major pathogen followed by Escherichia coli (31.66%), Pseudomonas aeruginosa (25.33%), and Acinetobacter baumannii (1%). Extended-spectrum beta-lactamase production was detected in 3.33% and metallo-beta-lactamase in 2% of the total GNB pathogens. Conclusion: For effective management of LRTIs, an ultimate and detailed bacteriological diagnosis along with antimicrobial susceptibility testing is required to overcome the global problem of antibiotic resistance.

Thrombocytosis in children

We aimed to investigate the frequency and causes of thrombocytosis in patients admitted to the Department of Pediatric Hematology and Oncology of Elazig Fethi Sekin City Hospital, Elazig, Turkey. Between 2019 and 2021, the laboratory parameters of 2,500 patients admitted to the Hematology Department were studied. During this examination, 319 (12.76%) patients were found to have thrombocytosis. Demographic characteristics (age and gender), hematologic parameters (hemoglobin, white blood cells, and platelets), and ultimate diagnoses ot the cases were recorded from their files. Of these 319 patients with thrombocytosis, 197 (1.8%) were male and 122 (38.2%) were female, and the mean age was 72.0±69.0 (1-216) months. The median platelet count of the patients was 590.43±280.12/μL (450,000-750,000). The most common cause of secondary thrombocytosis was infection, accounting for 37.9% of all patients. Other common causes were sickle cell anemia (21%), iron deficiency anemia (15.4%), colloid tissue disease (6.6%), hemolytic anemia (5.0%), splenectomy (4.5%), and other causes (9.7%). In our study, infections were the most common cause of thrombocytosis. In addition to infections, sickle cell anemia and iron deficiency anemia should also be considered in the differential diagnosis of thrombocytosis.

Dermoscopy: the ultimate tool for diagnosis of nail psoriasis? A review of the diagnostic utility of dermoscopy in nail psoriasis

Dermoscopy is a highly practical noninvasive diagnostic tool. Several dermoscopic algorithms have been proposed in the evaluation of skin diseases, which allow clinicians not only to identify and make differential diagnosis, but also to determine the treatment choices in challenging clinical circumstances. Over the years, we have witnessed a rapid increase in the utilization of dermoscopy in the assessment of nail disorders. However, to assess the diagnostic utility of dermoscopy in inflammatory nail diseases, current evidence is insufficient. Nail psoriasis is a significant challenge because of the difficulties in its diagnosis. Detection of nail involvement is of utmost importance in psoriasis because it is highly associated with arthritis, which is an indication for systemic treatment. Dermoscopy holds promise as a potential tool in the diagnosis of nail psoriasis, capable of providing characteristic clinical findings without any delay and discomfort. This review summarizes current evidence regarding the unique dermoscopic features of nail psoriasis. It addresses whether dermoscopy may serve as the gold-standard diagnostic tool, excluding the necessity of histopathological examination for the ultimate diagnosis of nail psoriasis.

A challenging case of granulomatosis with polyangiitis with cardiac involvement: a rare case report

Granulomatosis with polyangiitis (GPA), a systemic antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, is characterized by inflammation of the small arteries, arterioles, and capillaries classically manifesting with glomerulonephritis and necrotizing granulomatous lesions of the upper and lower respiratory tract. With an incidence of approximately 12 cases per one million individuals per year it is an uncommon diagnosis that typically presents as frequent pulmonary and sinus infections; however, if left without definitive treatment progresses to more severe manifestations specifically hemoptysis and hematuria. This case report highlights a 15-year-old woman who had both classic and non-classic findings making the diagnosis challenging. Specifically, her age of presentation, improvement with anti-microbials, and coronary dilation were not classic. Additionally, her lab work was negative for the cytoplasmic subset antineutrophil cytoplasmic autoantibody (c-ANCA), but positive for serum anti-proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA) which further delayed the ultimate diagnosis as this is typically c-ANCA positive. Other systemic vasculitides, such as mucocutaneous lymph node disease, are associated with cardiac pathology necessitating further medical management and follow-up to prevent increased morbidity and mortality. Knowing this, we conclude that further evaluation for cardiac pathology would be prudent as part of the initial workup of patients with a diagnosis of GPA. Included is a brief review of available literature on GPA to emphasize the typical presentation, lab findings, and importance of early diagnosis.

Lipoma arborescence of knee joint in an adolescent male patient: a case report

<p>A very uncommon benign synovial membrane tumor is called lipoma arborescens. It often affects a single articulation, the knee. Despite a conventional imaging assessment, the lesion’s histological analysis is still required for the ultimate diagnosis. A 15-year-old boy attended the outpatient clinic of the Lahore General Hospital Lahore, Pakistan with pain and swelling in his left knee that had been steadily worsening over the previous 4 years. There were no concomitant prodromal symptoms, and the swelling was soft and non-tender while also inhibiting knee flexion. Soft tissue shadows were observed on radiographs. A large amount of subarticular erosion in the nearby tibial and femoral condyle was caused by the frond-like proliferation of fatty synovium, according to magnetic resonance imaging. Only the left knee joint showed focused areas of unusually elevated radionuclide uptake during the Technetium (Tc99m) bone scan. After an open synovectomy, the specimen underwent histological analysis, which revealed villiform fatty tissue, a hallmark of Lipoma arborescens coated by somewhat thicker synovium. Although infrequent, open synovectomy is currently the preferred course of treatment for lipoma arborescens, which should be taken into account when making a differential diagnosis of knee diseases. Approximately 3 months after surgery, the patient underwent his most recent follow-up and was asymptomatic with a small amount of joint effusion.</p>

Benign and Malignant Diseases of The Prostate - A Clinicohistopathological Study

Background: Neoplastic and non-neoplastic prostate gland lesions are the main reasons for morbidity and mortality throughout the world. The risk of diseases increases with age. Basically, Prostate biopsy is a test which detects malignant and other benign conditions of the prostate in patients who have urinary symptoms. Other modalities of diagnosis also have been developed, comprising of radiological modalities and prostatic biomarkers. However, biopsy with microscopic examination is the gold standard for the ultimate diagnosis.
 Objectives: The present study was done to recognize and determine the different histopathological patterns of prostatic diseases and their clinical presentation correlations.
 Patients and methods: Reviewing of 194 patient specimens of prostatic tissues in the department of pathology, faculty of medicine, university of Benghazi from January to December 2009 was conducted. The received specimens were fixed in 10% neutral buffered formalin and routine paraffin processing followed by hematoxyline and eosin staining was done. All the specimens were analysed with following parameters: type of specimen, age of patient, histopathological pattern and final diagnosis. With application of modified Gleason scoring for grading.
 Results: 131 TURP, 42 needle biopsies, and 21 prostatectomy specimens were assessed, they were grouped into benign, premalignant, and malignant disorders. Modified Gleason`s Scoring was used to score the prostatic adenocarcinoma. The Mean of all patient's age was 70.7 years. 153 (78.87%) were benign, 7 (3.6%) were premalignant and 34 (17.53%) cases were malignant. Malignant to benign ratio (1: 4.7). Age ranged was 24-100 years. The most frequent disease encountered was BPH, mainly in the sixth decade. Glandular-stromal pattern was more frequently seen (86.8%), followed by glandular predominance (13.2%). Concomitant conditions such as prostatitis, Basal cell hyperplasia, squamous metaplasia, and atypical adenomatous hyperplasia (AAH) (premalignant) were observed. Among the malignant conditions, acinar adenocarcinoma was the commonest disease seen in sixth and seventh decades by (91%), and Gleason`s score 7 was the commonest. One of the cases was metastatic TCC from urinary bladder.
 Conclusion: Benign lesions of prostate are more common than malignant lesions, most commonly encountered in age group of 61 to 70 years. There is a major difference in symptoms between malignant and benign conditions. More studies are needed in future to identify environmental and social factors contributing prostate disease.

Frequency of NMOSD misdiagnosis in a cohort from Latin America: Impact and evaluation of different contributors

Background: Neuromyelitis optica spectrum disorder (NMOSD) misdiagnosis (i.e. the incorrect diagnosis of patients who truly have NMOSD) remains an issue in clinical practice. We determined the frequency and factors associated with NMOSD misdiagnosis in patients evaluated in a cohort from Latin America. Methods: We retrospectively reviewed the medical records of patients with NMOSD, according to the 2015 diagnostic criteria, from referral clinics in six Latin American countries (Argentina, Chile, Paraguay, Colombia, Ecuador, and Venezuela). Diagnoses prior to NMOSD and ultimate diagnoses, demographic, clinical and paraclinical data, and treatment schemes were evaluated. Results: A total of 469 patients presented with an established diagnosis of NMOSD (73.2% seropositive) and after evaluation, we determined that 56 (12%) patients had been initially misdiagnosed with a disease other than NMOSD. The most frequent alternative diagnoses were multiple sclerosis (MS; 66.1%), clinically isolated syndrome (17.9%), and cerebrovascular disease (3.6%). NMOSD misdiagnosis was determined by MS/NMOSD specialists in 33.9% of cases. An atypical MS syndrome was found in 86% of misdiagnosed patients, 50% had NMOSD red flags in brain and/or spinal magnetic resonance imaging (MRI), and 71.5% were prescribed disease-modifying drugs. Conclusions: NMOSD misdiagnosis is relatively frequent in Latin America (12%). Misapplication and misinterpretation of clinical and neuroradiological findings are relevant factors associated with misdiagnosis.

Mimics of Pediatric Small Vessel Primary Angiitis of the Central Nervous System.

Small vessel primary angiitis of the central nervous system is a rare and often severe disease characterized by central nervous system-restricted inflammatory vasculitis on histopathology. Diagnosis requires brain biopsy for confirmation and is suggested prior to starting immunotherapy when feasible. However, emerging evidence suggests that other neuroinflammatory conditions may have a clinical and radiographic phenotype that mimics small vessel primary angiitis, at times with overlapping pathologic features as well. Such diagnoses, including myelin oligodendrocyte glycoprotein antibody-associated disease and central nervous system-restricted hemophagocytic lymphohistiocytosis, can be non-invasively diagnosed with serum antibody or genetic testing that would prompt different monitoring and treatment paradigms. To determine the ultimate diagnosis of patients who were suspected prior to biopsy to have small vessel primary angiitis, we reviewed the clinical, radiographic, and pathological features of a cohort of patients at a single center undergoing brain biopsy for non-oncologic indications. Clinical data were retrospectively extracted from the medical record. Pathology and neuroimaging review was conducted. We identified 21 patients over a 19-year time-period, of whom 14 (66.7%) were ultimately diagnosed with entities other than small vessel primary angiitis that would have obviated the need for brain biopsy. Diagnoses included anti-myelin oligodendrocyte glycoprotein antibody associated disease (n=9), central nervous system-restricted hemophagocytic lymphohistiocytosis (n=3), anti-GABAA receptor encephalitis (n=1), and Aicardi-Goutières syndrome (n=1). This study highlights the importance of pursuing now readily available non-invasive testing for mimicking diagnoses before performing a brain biopsy for suspected small vessel primary angiitis of the central nervous system. ANN NEUROL 2023;93:109-119.

Ascaris lumbricoides Infestation of Bile Ducts: Case Report

Background: Ascariasis is a common helminthic disease that affects the gastrointestinal tract of human beings and is caused by the Ascaris lumbricoid worm. Most of the time, this parasite resides in the intestinal lumen, but it can occasionally travel to the biliary tract through the ampulla of Vater. The most serious and potentially fatal complication of intestinal ascariasis is biliary ascariasis, which can appear in different ways.
 Case Report: A non-diabetic, non-alcoholic female reported to the emergency department with a one-day history of abdominal pain and vomiting with worms. The pain began gradually with a score of 7/10 and rapidly deteriorated during the day, reaching 10/10 at the hospital presentation. The patient also had a significant medical history. Before papillotomy, she underwent endoscopic retrograde cholangiopancreatography with the removal of one common bile duct (CBD) stone, but no stent was implanted. She had her laparoscopic cholecystectomy done as well. Laboratory examination revealed normal liver function tests and C-reactive protein. While abdominal ultrasound confirmed the presence of hepatic pericholangitis and on ultrasound imaging, the CBD was found to be enlarged approximately 7 mm in diameter and had a linear tubular structure with centre faint echogenicity and periphery tubularity. The ultimate diagnosis of the patient was cholangitis brought on by Ascaris lumbricoides. After the diagnosis, endoscopic retrograde cholangiopancreatography showed sphincterotomy with CBD dilation. The worm was extracted by grasping it with biopsy forceps and pulled out of the papilla using a balloon catheter. The length of the worm was 18 centimeters.
 Conclusion: Ascaris is the most frequently occurring disease that can cause biliary complications, such as cholangitis. This case report suggests that cholangitis caused by Ascaris lumbricoides can be successfully treated with the endoscopic approach, indicating that endoscopy could be a viable option to manage ascaris.

Is Contrast-Enhanced Computed Tomography Redundant for Suspected Intracranial Infection in the Emergency Setting?

There are currently no guidelines for when to use intravenous contrast with head computed tomography (CT) when there is suspected acute intracranial infection. The purpose of our study was to determine the proportion of cases with enhancing findings on CT that also have conspicuous correlating associated findings on noncontrast CT, which would have on their own merited further evaluation with magnetic resonance imaging, the criterion standard for evaluating central nervous system pathology. A retrospective keyword search of the history and clinical information fields in radiology reports for CT examinations of the head without and with contrast from the period January 1, 2004, to October 31, 2021 was performed. Patients with prior head surgery or a history of cancer were excluded. For remaining patients, the noncontrast CT was reviewed for vasogenic edema or mass effect as markers of a possible acute infection, and the presence of background hypodense white matter changes was noted and graded as either absent, mild/scattered, or confluent. Subsequently, the companion contrast-enhanced CT was reviewed for an enhancing abnormality. Chart review was performed to confirm that an infectious process was the ultimate clinical diagnosis in patients with enhancing abnormalities. Of 343 patients meeting study inclusion/exclusion criteria, 39 had acute infections with an enhancing abnormality on CT (prevalence 11.3%). Thirty-two of these 39 patients also had correlative findings on the noncontrast CT. Noncontrast CT had a positive predictive value of 100%, negative predictive value of 97.7%, sensitivity of 82.1%, specificity of 100%, and accuracy of 98.0% for detecting markers (vasogenic edema and/or mass effect) associated with an enhancing abnormality. Vasogenic edema was the most common noncontrast CT finding in patients who had an infectious enhancing lesion (32 of 39), followed by mass effect (22 of 39). The 7 cases where the acute infection was occult on noncontrast CT were due to leptomeningitis (n = 3), confluent background white matter changes masking the vasogenic edema surrounding intra-axial lesions (n = 3), and a small 0.5 cm extra-axial abscess. Most acute intracranial infections with an enhancing CT finding also have a correlative conspicuous noncontrast finding that on its own would merit further evaluation with magnetic resonance imaging, the criterion standard for investigating central nervous system disease, and therefore, in the setting of suspected intracranial infection, contrast-enhanced CT is redundant in most cases. Contrast-enhanced CT primarily provides diagnostic benefit in patients with confluent background white matter changes that may mask vasogenic edema on noncontrast CT.

IGG4-RELATED LUNG DISEASE MASKING LUNG CANCER

IGG4-RELATED LUNG DISEASE MASKING LUNG CANCER