Unusual Appearance Research Articles

Unusual FDG PET Appearances in a Patient With Metastatic Breast Carcinoma

Abstract This was a case of a 52-year-old woman with a history of multiorgan, metastatic breast cancer, who underwent several lines of treatment. She had brain metastases, which were treated with gamma knife. She progressed at other organ sites with additional recurrence of brain metastases and leptomeningeal disease, which demonstrated an interesting pattern of intracranial FDG uptake with further seizure-related muscular uptake.

Bone Tumors of the Jaw - the "Blind Spot" for Radiologists Experienced with Tumors? - Part II.

Primary bone tumours of the jaw are rare tumoral entities and do substantially differ from other bone tumours of the human body with respect of their frequently encountered unusual radiological appearances. The reason for that may be confined to the co-existence of two closely neighbored but different anatomical structures (i.e., tooth-forming apparatus and jaw bones with adjacent gingiva) and some tumour pathologies which are nearly excusively encountered in the jaw bones only (e.g., ameloblastoma, ossifying fibroma, ghost cell carcinoma).This paper would like to highlight some basic principles of the diagnostic approach and possibilities of radiological differentiation of such tumour-suspicious changes within the gnathic system are elucidated and discussed.The paper presented here is substantially based on the most recent classification of odontogenic and maxillofacial tumours (5th edition, 2022) which serves as a scaffold for the selection of typical tumour entities. Due to the educational character of this paper, only important jaw tumours worth mentioning and their characteristics are subject to be extracted from the literature and further discussed.The main focus was put onto both the description of radiological tumoral appearance and the rational selection of a radiological diagnostic work-up. In order to better visualize this difficult field of tumour entities, much attention has been paid on a comprehensive pictorial essay.For radiologists, it is their foremast task to detect, describe, and to classify bone tumours of the jaw when they are found intentionally or accidentally, resp. A close co-operation with their clinical partners is of upmost importance to gain information about patient´s history and clinical presentation. It is readily reasonable that radiologists are mostly able to provide only a suggestion of the presented tumour entity but this expert opinion would be very helpful to further narrow down the list of potential differential diagnoses (e.g., differentiation of a cyst vs. solid tumour osteolysis, identification of jaw osteomyelitis vs. tumoral infiltration, recognizing of secondary tumour involvement of the jaw). · primary bone tumours of the jaw are very rare, moreover difficult to differentiate radiologically, and do need therefore histological proof;. · profound knowledge about tumour characteristics (location within the jaw, relationship to the tooth, bony destructive pattern) may allow a rough orientation and classification;. · matrix-forming tumours and dysplasias of the jaw facilitates their radiological differentiation and classification;. · in contrary, osteolyses should be thoroughly scrutinized for the more frequent gnathic cysts in differentiation of rather rare solid primary tumours;. · an interdisciplinary round-table discussion amongst well-experienced maxillofacial surgeons and specialized radiologists may be appropriate to avoid severe misinterpretations.. · Grieser T, Hirsch E, Tödtmann N. Tumours of the jaw bones - Part II. Fortschr Röntgenstr 2024; DOI 10.1055/a-2416-1282.

Bone Tumors of the Jaw - the "Blind Spot" for Radiologists Experienced with Tumors? - Part I.

Primary bone tumours of the jaw are rare tumoral entities and do substantially differ from other bone tumours of the human body with respect of their frequently encountered unusual radiological appearances. The reason for that may be confined to the co-existence of two closely neighbored but different anatomical structures (i.e., tooth-forming apparatus and jaw bones with adjacent gingiva) and some tumour pathologies which are nearly excusively encountered in the jaw bones only (e.g., ameloblastoma, ossifying fibroma, ghost cell carcinoma).This paper would like to highlight some basic principles of the diagnostic approach and possibilities of radiological differentiation of such tumour-suspicious changes within the gnathic system are elucidated and discussed.The paper presented here is substantially based on the most recent classification of odontogenic and maxillofacial tumours (5th edition, 2022) which serves as a scaffold for the selection of typical tumour entities. Due to the educational character of this paper, only important jaw tumours worth mentioning and their characteristics are subject to be extracted from the literature and further discussed.The main focus was put onto both the description of radiological tumoral appearance and the rational selection of a radiological diagnostic work-up. In order to better visualize this difficult field of tumour entities, much attention has been paid on a comprehensive pictorial essay.For radiologists, it is their foremast task to detect, describe, and to classify bone tumours of the jaw when they are found intentionally or accidentally, resp. A close co-operation with their clinical partners is of upmost importance to gain information about patient's history and clinical presentation. It is readily reasonable that radiologists are mostly able to provide only a suggestion of the presented tumour entity but this expert opinion would be very helpful to further narrow down the list of potential differential diagnoses (e.g., differentiation of a cyst vs. solid tumour osteolysis, identification of jaw osteomyelitis vs. tumoral infiltration, recognizing of secondary tumour involvement of the jaw). · primary bone tumours of the jaw are very rare, moreover difficult to differentiate radiologically, and do need therefore histological proof;. · profound knowledge about tumour characteristics (location within the jaw, relationship to the tooth, bony destructive pattern) may allow a rough orientation and classification;. · matrix-forming tumours and dysplasias of the jaw facilitates their radiological differentiation and classification;. · in contrary, osteolyses should be thoroughly scrutinized for the more frequent gnathic cysts in differentiation of rather rare solid primary tumours;. · an interdisciplinary round-table discussion amongst well-experienced maxillofacial surgeons and specialized radiologists may be appropriate to avoid severe misinterpretations.. · Grieser T, Hirsch E, Tödtmann N. Bone Tumors of the Jaw - the "Blind Spot" for Radiologists Experienced with Tumors? - Part I. Fortschr Röntgenstr 2024; DOI 10.1055/a-2415-8880.

Ocular myasthenia gravis and thyroid eye disease: double trouble.

A 60-year-old male patient with a previously unremarkable medical history presented with unilateral eyelid ptosis and binocular diplopia in the past year. Clinical and laboratory workup confirmed the diagnosis of ocular myasthenia gravis. In addition, further workup with orbital MRI performed due to exophthalmos and unilateral ophthalmoplegia demonstrated findings compatible with thyroid eye disease, which were further verified by antibody testing. The unusual concurrent appearance of ocular myasthenia gravis and thyroid eye disease is presented while illustrating the hallmark clinical, laboratory, and imaging findings relevant to both diseases.

Crocodile Skin Retinal Appearance: Miliary Distribution of Bilateral Idiopathic Multifocal Retinal Pigment Epithelial Detachments.

This report presents cases of an unusual appearance of bilateral idiopathic multifocal retinal pigment epithelial detachments (PEDs) in three patients, using multimodal imaging. Three patients with multiple PEDs, initially diagnosed as drusen, were referred for evaluation. They underwent comprehensive ophthalmic examination and multimodal imaging. All patients had a best-corrected visual acuity of 6/6 in both eyes. Fundoscopy revealed multiple idiopathic PEDs in a miliary distribution, resembling crocodile skin. Systemic workup excluded associated diseases, though one patient was pregnant. The pathogenesis and progression are poorly understood, but prognosis is favorable without intervention unless complications arise. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Freshwater jellyfish in northeastern Argentina: a risk to human health.

Although cnidarians are mostly marine organisms, the occurrence of freshwater jellyfish frequently arouses the interest of ecologists, due to their sudden and unusual appearances in natural and artificial water bodies around the world. This study describes a series of cases compatible with cnidarian envenomation that occurred coincidentally in time and space with the presence of Craspedacusta sowerbii Lankester, 1880 jellyfish in the province of Misiones (El Saltito stream) in January 2022. A year later, its presence was confirmed in another watercourse of this province (Cazador stream). Based on these findings, its possible toxicological consequences in humans were evaluated by characterizing the jellyfish extract using sodium dodecyl sulfate-polyacrylamide gel electrophoresis and enzymatic/toxic activities. We revealed the presence of proteolytic enzymes and cytolytic toxin(s), which-by means of activating the inflammatory cascade-could explain the stinging skin lesions observed in the suspected cases described. In addition to recording for the first time the occurrence of this cnidarian in northeastern Argentina, this work provides, for the first time, a toxinological explanation for the clinical observations after contact with the most widespread freshwater jellyfish species in the world, giving support to health professionals in the diagnosis and management of such accidents/envenomation.

Cross-fused Ectopic Kidney in a Term Neonate

We report on a term neonate with a birthweight of 2300g antenatally suspected to have an absent left kidney. Postnatally the right kidney was palpable, and ultrasound confirmed an enlarged right kidney with obstruction at the pelvic-ureteric junction and multiple renal cysts. The left kidney had an unusual appearance with its upper pole cross-fused with the lower pole of the left kidney suggestive of a cross-fused kidney, with the ureter of the crossfused kidney joining the bladder on the left side. The cross-fused kidney also showed pelvicalyceal dilatation and cystic changes’ and DMSA scans confirmed the non-functioning of the crossfused kidney with a normally functioning right kidney. MCU was normal. The neonate remained hemodynamically stable throughout the NICU stay with normal blood pressure and renal function tests. He is currently 6 months old and on regular follow-up with normal growth development. We describe the approach and management of this rare condition of crossfused kidney.

A false reactive hepatitis B surface antigen result due to dislodged gel from Vacutainer

Abstract: Preanalytical variables play a key role in the correctness of laboratory test results. We report a false reactive result for hepatitis B surface antigen (HBsAg) on serological testing with a relatively low OD. The pilot sample was collected in yellow top BD Vacutainer® (SST™ II Advance 5 mL tube) with separator gel and was marked for serological testing. It was centrifuged at 7000 rpm for 30 min. Serological testing was performed by chemiluminescence on Abbott Architect Plus i1000SR with Abbott kits for HBsAg, anti-HIV, and anti-HCV. This particular sample tested reactive for HBsAg with S/CO of 1.91, S/CO for HBsAgQ2NC (Negative kit control) being 0.19 and that of HBsAgQ2PC (Positive kit control) being 3.65. Repeat testing from the same Vacutainer was also reactive for HBsAg with S/CO of 2.10. Nucleic acid testing was performed and was found to be nonreactive. We repeated serological testing with a sample from fresh frozen plasma of the same donor unit. It was nonreactive. Cross contamination was ruled out by repeat testing of two serial samples before and after this unit number. The serum showed an unusual appearance on visual inspection after centrifugation. By exclusion, we concluded that the gel probably got partially dislodged into the serum, giving a relatively low reading and false reactive result for HBsAg. This highlights the possibility of inert gel not always being inert, the importance of repeat testing from a different sample in case of low reading, the importance of visual inspection, a need for manufacturers and laboratory personnel to consider such preanalytical variables which, though not much mentioned in literature, can affect test results. These results have a multi-fold impact on the donor or patient’s mindset, treatment outcome and/or fate of blood donation. These are definitely preventable if more such guidelines are made available for handy reference in handling such results.

Unexpected rare uterine carcinosarcoma with neuroendocrine differentiation: Reflections on clinical diagnosis and treatment of a case report.

Uterine carcinosarcoma (UCS) is a rare and highly invasive malignant tumor.It exhibits an ectopic growth pattern of the uterus,and its histological features are biphasic differentiation of malignant epithelial components (cancer) and malignant mesenchymal components (sarcoma). The pathological pattern of high-component neuroendocrine differentiation is extremely rare. Due to the inherent heterogeneity of tumors, it increases the difficulty of accurate identification and diagnosis. The author introduces a rare case of primary endometrial carcinosarcoma (heterologous) with small cell neuroendocrine carcinoma (SCNEC) components. There is limited literature on this rare pathological differentiation pattern and a lack of guidelines for the best treatment methods, which prompts reflection on the diagnosis, optimal treatment strategies, and how preoperative diagnosis can affect patient prognosis for endometrial carcinosarcoma with neuroendocrine differentiation. The patient is an elderly woman who presents with abnormal vaginal bleeding after menopause. Transvaginal ultrasound examination shows that the uterus is slightly enlarged, and there is a lack of homogeneous echogenicity in the uterine cavity. Subsequently, a hysteroscopic curettage was performed, and a space-occupying lesion was observed on the anterior wall of the uterine cavity. Preoperative endometrial biopsy revealed SCNEC of the endometrium. The patient underwent radical hysterectomy, and the postoperative pathological results showed that UCS (heterologous) was accompanied by SCNEC components (about 80%). The patient received radical hysterectomy, followed by adjuvant chemotherapy. After 7 months of follow-up, no tumor recurrence or metastasis was found at the time of writing this article. The histological type of UCS (heterologous) with cell neuroendocrine carcinoma components is rare and highly invasive, with a high misdiagnosis rate in preoperative biopsy. There are currently no effective treatment guidelines for this type of case. The unusual appearance of SCNEC components in this case poses a challenge for both pathologists and surgeon. The rare differentiation pattern of this case exposes the complexity of its management and the necessity of prospective trials to determine the optimal treatment plan.

Early evolution of the ecdysozoan body plan.

Extant ecdysozoans (moulting animals) are represented by a great variety of soft-bodied or articulated organisms that may or may not have appendages. However, controversies remain about the vermiform nature (i.e. elongated and tubular) of their ancestral body plan. We describe here Beretella spinosa gen. et sp. nov. a tiny (maximal length 3 mm) ecdysozoan from the lowermost Cambrian, Yanjiahe Formation, South China, characterized by an unusual sack-like appearance, single opening, and spiny ornament. Beretella spinosa gen. et sp. nov has no equivalent among animals, except Saccorhytus coronarius, also from the basal Cambrian. Phylogenetic analyses resolve both fossil species as a sister group (Saccorhytida) to all known Ecdysozoa, thus suggesting that ancestral ecdysozoans may have been non-vermiform animals. Saccorhytids are likely to represent an early off-shot along the stem-line Ecdysozoa. Although it became extinct during the Cambrian, this animal lineage provides precious insight into the early evolution of Ecdysozoa and the nature of the earliest representatives of the group.

Early evolution of the ecdysozoan body plan

Extant ecdysozoans (moulting animals) are represented by a great variety of soft-bodied or articulated organisms that may or may not have appendages. However, controversies remain about the vermiform nature (i.e. elongated and tubular) of their ancestral body plan. We describe here Beretella spinosa gen. et sp. nov. a tiny (maximal length 3 mm) ecdysozoan from the lowermost Cambrian, Yanjiahe Formation, South China, characterized by an unusual sack-like appearance, single opening, and spiny ornament. Beretella spinosa gen. et sp. nov has no equivalent among animals, except Saccorhytus coronarius, also from the basal Cambrian. Phylogenetic analyses resolve both fossil species as a sister group (Saccorhytida) to all known Ecdysozoa, thus suggesting that ancestral ecdysozoans may have been non-vermiform animals. Saccorhytids are likely to represent an early off-shot along the stem-line Ecdysozoa. Although it became extinct during the Cambrian, this animal lineage provides precious insight into the early evolution of Ecdysozoa and the nature of the earliest representatives of the group.

Perspectives of Fishers on the Incident of Fish Kills in Coastal Waters in Rivers State, Nigeria

This study was conducted to assess fishermen's perspectives on the massive fish kill incident in coastal waters in Rivers State, Nigeria. Primary data were collected using questionnaires from 101 randomly selected fishermen and the data were evaluated using descriptive statistics. The results showed that fishing was the main occupation of the respondents and the interviewed fishermen have fishing experience in the region studied and knowledge of their fishery. The results showed that 53.3 percent of fishermen attributed the strange phenomenon to pollution, while 19.8 percent of fishermen cited infection and disease as the cause of the fish kills. The majority of respondents (94%) reported that croaker fish species were particularly affected in the study area. Other observations include fish swimming on the surface or jumping onto shore and affected fish washing up on shore. The unusual appearances of the dead fish commonly reported by respondents were as follows: fin rot, open mouth, disease spots and deep blue gills. About half of the respondents (50.5%) gave a range of 1,000 - 5000 dead fish and a size class of the dead fish of more than 30 cm. Most respondents (79.2%) indicated that the government has not taken any action. Few of those surveyed reported government action on sea clean-up exercises to remove dead fish, end oil spillage and bunkering as measures put in place by the government. The study recommended partnerships between the government and fishermen and fishermen's groups as stakeholders are required to address the concerns about marine waters.

An Augmented Reality Application for Wound Management: Enhancing Nurses’ Autonomy, Competence and Connectedness

The use of Augmented Reality glasses opens up many possibilities in hospital care, as they facilitate treatments and their documentation. In this paper, we present a prototype for the HoloLens 2 supporting wound care and documentation. It was developed in a participatory process with nurses using the positive computing paradigm, with a focus on the improvement of the working conditions of nursing staff. In a qualitative study with 14 participants, the factors of autonomy, competence and connectedness were examined in particular. It was shown that good individual adaptability and flexibility of the system with respect to the work task and personal preferences lead to a high degree of autonomy. The availability of the right information at the right time strengthens the feeling of competence. On the one hand, the connection to patients is increased by the additional information in the glasses, but on the other hand, it is hindered by the unusual appearance of the device and the lack of eye contact. In summary, the potential of Augmented Reality glasses in care was confirmed, and approaches for a well-being-centered system design were identified but, at the same time, a number of future research questions, including the effects on patients, were also identified.

Perspectives of fishers on the incident of fish kills in Rivers State Coastal Waters, Nigeria

This study was conducted to assess fishermen's perspectives on the massive fish kill incident in coastal waters in Rivers State, Nigeria. Primary data were collected using questionnaires from 101 randomly selected fishermen and the data were evaluated using descriptive statistics. The results showed that fishing was the main occupation of the respondents and the interviewed fishermen have fishing experience in the region studied and knowledge of their fishery. The results showed that 53.3 percent of fishermen attributed the strange phenomenon to pollution, while 19.8 percent cited infection and disease as the cause of the fish kills. The majority of respondents (94%) reported that croaker fish species were particularly affected in the study area. Other observations include fish swimming on the surface or jumping onto shore and affected fish washing up on shore. The unusual appearances of the dead fish commonly reported by respondents were as follows: fin rot, open mouth, disease spots and deep blue gills. About half of the respondents (50.5%) gave a range of 1,000 - 5000 dead fish and a size class of the dead fish of more than 30 cm. Most respondents (79.2%) indicated that the government has not taken any action. Few of those surveyed reported government action on sea clean-up exercises to remove dead fish and end oil spillage and bunkering as measures put in place by the government. The study recommended partnerships between the government and fishermen and fishermen's groups as stakeholders are required to address the concerns about marine waters.Keyword: Coastal waters; Fishers; Mass fish mortality; Nigeria

P024 Dermatomyositis, a blurred clinical picture

Abstract Background/Aims We present a case of MDA5 dermatomyositis(DM) in a 25-year-old male, initially presenting with seronegative inflammatory polyarthritis affecting the hands. No classic features of DM were noted and CK was normal. Sulfasalazine was started and subsequently stopped after an ALT rise. Lung-function performed prior to planned methotrexate was abnormal. A CT neck, thorax and abdomen showed unusual pulmonary appearances with focal basal ground glass opacities with reverse halo, without widespread interstitial lung disease(ILD). A bronchoscopy excluded atypical infection. He then developed scaly lesions over the extensor PIPJs, periungual lesions, periorbital swelling and sicca symptoms. CK remained normal, extended myositis screening was negative. LDH and troponins were elevated. A skin biopsy of the hand rash was consistent with dermatomyositis. Methods Muscle pain persisted and an MRI proximal muscles showed muscle oedema and inflammation. A muscle biopsy was requested but not performed as he developed an olecranon bursa with staphylococcal aureus infection. The bursa broke down, required wash-outs, antibiotics and was left to heal by secondary intention. A repeat myositis screen was positive for MDA5 antibody. Immunosuppression was delayed because of concerns that prednisolone, Mycophenolate mofetil(MMF) or Rituximab would cause further wound breakdown and increased risk of infection. The patient was monitored with serial lung-function but didn’t develop ILD. Dermatology confirmed there was active dermatomyositis in the wound edges. The wound only finally healed with additional IVIG therapy. The patient is now established on Rituximab, having been unable to tolerate MMF. Results This case highlights that continued reassessment of the evolving clinical picture is vital to reach the correct diagnosis, and that one should not be reassured by a normal CK. Instead the ALT rise (along with mild elevations of LDH and troponin) was likely reflecting muscle inflammation, not liver inflammation secondary to Sulfasalazine. The repeatedly infected olecranon bursa and large open wound raised concerns about immunosuppressive agents. However, the lack of healing was due to active DM and escalation of treatment was required rather than treatment delay. IVIG was given with excellent and rapid effect. This is licensed for refractory skin involvement in DM, to be considered when infection concern is high. Conclusion The pulmonary involvement with reverse halo sign was felt by the MDT to be nonspecific initially, with a wide differential. In the clinical context, this was reflecting an atypical presentation of MDA5 positive ILD. This antibody can be associated with rapidly progressive ILD and death in approximately one third of cases. Had our patient shown evidence of significant pulmonary progression, high dose immunosuppression would have been commenced despite potential infection risk. Not all patients testing positive for MDA5 develop rapidly progressive ILD but clinical suspicion should be high with frequent serial monitoring of lung function and radiology. Disclosure L. Maltas: None. J. Vila: None. A. Ray: None.

INVASIVE CERVICAL RESORPTION OF UNCOMMON ORIGIN: A CASE REPORT WITH 14-YEAR FOLLOW-UP

Background: Invasive cervical resorption (ICR) is a complex, relatively uncommon, and insidious phenomenon. Its occurrence is associated mainly with local predisposing factors, but systemic risk factors may be involved as well. An ICR lesion that develops in the absence of an identifiable cause is termed 'idiopathic'. Case report: This study presents the surgical management and very long-term follow-up results of an "idiopathic" Class 3 ICR lesion in the maxillary central incisor. The case provides a unique insight into an uncommon ICR lesion that exhibited an unusual appearance and features. For the repair material, a sandwich technique was applied using mineral trioxide aggregate (MTA) covered with glass ionomer cement (GIC). At the 14-year follow-up, the tooth was symptom-free and functional; however, the disadvantages of both materials were clearly demonstrated. From that perspective, the study highlighted the discoloration potential of the white form of MTA-Angelus and the lack of regenerative properties of the GIC used. Remarkably, 12 years after the surgery, the patient was diagnosed with Familial Mediterranean fever, a rare systemic disease. However, the connection between this genetic disease and the initiation of ICR remains an open question for now. Conclusion: The clinician should be alert for the occurrence of ICR lesions, especially in patients with concomitant systemic disorders. The right choice of appropriate repair material is a key factor for the healing outcome of ICR lesions in the anterior zone.

Unusual cystic appearance of torsion of appendix testis: Report of three cases

Unusual cystic appearance of torsion of appendix testis: Report of three cases

Squamous Cell Carcinoma: Unusual Dermoscopic Appearance

Squamous Cell Carcinoma: Unusual Dermoscopic Appearance

An Unusual Radiologic Appearance in Pulmonary Hydatid Cyst: Diffuse Calcification

An Unusual Radiologic Appearance in Pulmonary Hydatid Cyst: Diffuse Calcification

Aristotle’s Difference

This essay revisits one of the most acclaimed paintings of Rembrandt van Rijn’s later years, Aristotle with the Bust of Homer (1654; The Metropolitan Museum of Art). The painter’s approach to the subject of this work owes much to visual precedents and to the reception of Aristotle among early modern men of letters, including within the intellectual circles of seventeenth-century Holland. The unusual appearance of the philosopher, which has often led to conflicting interpretations, becomes much clearer when considered against the long-standing perception of his cultural “otherness.” The stance and gesture of this Aristotle not only affirm his identity but point to key aspects of his epistemology, focusing on the role of touch as the first step toward knowledge.