Wall Lesions Research Articles

Retrospective analysis of endoscopic ultrasound-guided fine needle data from a tertiary referral center in western India

Objectives:To analyze our data of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) done over the last 3 years.Methods:All cases referred for EUS-guided FNA were studied retrospectively. FNA was performed with a 22-gauge needle in the mediastinum and stomach. A 25-gauge was used for FNA from the duodenum. Core biopsy was taken from mediastinum and stomach with a 19-gauge needle and duodenum with a 22-gauge needle. All cystic lesions were aspirated with the 19-gauge needle. The first pass was made with a stylet and the subsequent passes were made without a stylet.Results:Total number cases – 344, pancreatic space-occupying lesion (SOL) – 142, pancreatic cystic lesions – 22, lymph nodes – 77, common bile duct (CBD) and ampullary masses – 42, gall bladder masses – 7, mediatinal masses – 9, liver SOL – 7, others – 39, Others: Antral mass – 3, gastric wall thickening – 6, porta masses – 5, para-aortic masses – 5, submucosal gastric mass – 15, posterior rectal mass – 2, retroperitoneal masses – 3. Findings: (1) In West India, pancreatic tumors and lymphadenopathies are the most common indications. (2) Core biopsy is a short coming for cases which require immunohistochemistry, for example, neuroendocrine tumor, lymphoma, and mediastinal tumors. (3) EUS is the most important tool for pancreatic cystic lesions. (4) EUS is an important tool for diagnosis of CBD and gallbladder masses. EUS gives accurate diagnosis in gastric submucosal lesions, infiltrative gastric wall lesions, and retroperitoneal masses.Conclusions:EUS has changed the paradigm in management of difficult to treat diseases such as pancreatic masses, cystic lesions of the pancreas, and lymphadenopathy in Western India.

Real-Time Fusion Imaging of Ultrasound and CT for Chest Wall Liposarcoma via Automatic Liver Registration as an Anchor

Real-time fusion imaging can reconstruct pre-acquired CT or MR and fuse them with ultrasound to simultaneously display ultrasound and its corresponding CT or MR images. This method has been widely reported in the diagnosis and intervention of focal liver lesions, and its use has been demonstrated by studies for diseases of breast, extremities, and prostate. Recently, automatic registration can use algorithms to automatically extract 3D spatial coordinates from liver vasculature or surface contour, and simplify the work for a precise imaging fusion of liver. Liposarcoma is one of the most common soft tissue tumors but its involvement of chest wall is rare. Complete resection is usually considered the treatment of choice for liposarcoma to minimize local recurrence. However, precise preoperative localization can be challenging for inconspicuous lesions in chest wall. Pre-acquired contrast enhanced CT from chest to liver was imported, processed, and reconstructed by the ultrasound machine (EPIQ 7, Philips). A manual sweep with the ultrasound transducer (C9-2, Philips) was performed to acquire a partial liver volume. The shapes of the diaphragm and liver surface were extracted, and then automatically aligned with that from the CT volume. Then real-time ultrasound was performed in conjunction with fused CT images to characterize chest wall lesions. A 61-year-old man with history of liposarcoma was presented with recurrence in right posterior chest wall. He had multiple resections for repeated recurrence in the trunk where the skin surface was extensively scarred. Fusion imaging with automatic registration was attempted. Real-time fusion imaging of ultrasound and CT revealed two hypoechoic nodules in the chest wall. The locations of recurrence were marked on the skin. The tumors were successfully exposed and removed upon exploration at the marks. The histopathological findings suggested that the removed chest wall tumors were dedifferentiated liposarcoma. This case demonstrates success of fusion imaging with ultrasound and CT for chest wall liposarcoma. The novel use of automatic liver registration as an anchor point for fusion is a feasible approach to identify chest wall soft tissue tumors. This method can be helpful in characterizing inconspicuous chest wall lesions and providing precise guides for further intervention.

Cholesteric liquid crystals in living matter.

Liquid crystals play an important role in biology because the combination of order and mobility is a basic requirement for self-organisation and structure formation in living systems. Cholesteric liquid crystals are omnipresent in living matter under both in vivo and in vitro conditions and address the major types of molecules essential to life. In the animal and plant kingdoms, the cholesteric structure is a recurring design, suggesting a convergent evolution to an optimised left-handed helix. Herein, we review the recent advances in the cholesteric organisation of DNA, chromatin, chitin, cellulose, collagen, viruses, silk and cholesterol ester deposition in atherosclerosis. Cholesteric structures can be found in bacteriophages, archaea, eukaryotes, bacterial nucleoids, chromosomes of unicellular algae, sperm nuclei of many vertebrates, cuticles of crustaceans and insects, bone, tendon, cornea, fish scales and scutes, cuttlebone and squid pens, plant cell walls, virus suspensions, silk produced by spiders and silkworms, and arterial wall lesions. This article specifically aims at describing the consequences of the cholesteric geometry in living matter, which are far from being fully defined and understood, and discusses various perspectives. The roles and functions of biological cholesteric liquid crystals include maximisation of packing efficiency, morphogenesis, mechanical stability, optical information, radiation protection and evolution pressure.

Metabolic response induced by parasitic plant-fungus interactions hinder amino sugar and nucleotide sugar metabolism in the host.

Infestation by the biotrophic pathogen Gymnosporangium asiaticum can be devastating for plant of the family Rosaceae. However, the phytopathology of this process has not been thoroughly elucidated. Using a metabolomics approach, we discovered the intrinsic activities that induce disease symptoms after fungal invasion in terms of microbe-induced metabolic responses. Through metabolic pathway enrichment and mapping, we found that the host altered its metabolite levels, resulting in accumulation of tetrose and pentose sugar alcohols, in response to this fungus. We then used a multiple linear regression model to evaluate the effect of the interaction between this abnormal accumulation of sugar alcohol and the group variable (control/parasitism). The results revealed that this accumulation resulted in deficiency in the supply of specific sugars, which led to a lack of amino sugar and nucleotide sugar metabolism. Halting this metabolism could hamper pivotal functions in the plant host, including cell wall synthesis and lesion repair. In conclusion, our findings indicate that altered metabolic responses that occur during fungal parasitism can cause deficiency in substrates in pivotal pathways and thereby trigger pathological symptoms.

A case of IgG4-related tubulointerstitial nephritis and membranous glomerulonephritis during the clinical course of gastric cancer: Imaging features of IgG4-related kidney disease

We describe an 81-year-old man with immunoglobulin G4-related disease (IgG4-RD) presenting with submandibular gland, lymph node, lung, kidney, aortic wall, and prostate lesions with concomitant gastric cancer. After curative surgical treatment of the gastric cancer, corticosteroid therapy for progressively decreasing renal function was started. Before starting steroid therapy, fluorodeoxyglucose positron emission tomography-computed tomography revealed multiple lesions of IgG4-RD but no metastasis of the cancer. However, the patient died 3 months after initiation of corticosteroid therapy because of recurrence of the gastric cancer. In this case, the imaging features of IgG4-tubulointerstitial nephritis dramatically changed during the clinical course of co-existing gastric cancer. The imaging features of the present case may provide clues to the pattern of spread of IgG4 lesions in the kidney.

Hepatobiliary Cystadenoma: A Pendulum in the Common Bile Duct

Background: Hepatobiliary cystadenoma is a rare benign tumor of the liver constituting less than 5% of the non-parasitic cystic lesions. Typically, these originate in the hepatic parenchyma, specifically in the right lobe. As they are difficult to diagnose radiologically, histopathology with surgical excision is required to confirm the diagnosis. Case Presentation: A 68-year-old Caucasian female with a past medical history of cholelithiasis presented with right upper quadrant abdominal pain and intermittent dark urine after a heavy fatty meal. Lab results showed minimal elevation of alkaline phosphatase. A right upper quadrant ultrasonogram revealed a cystic mass causing extrinsic compression on the common bile duct (CBD), bilateral intrahepatic dilation in addition to the patient's known history of cholelithiasis. Subsequently, a CT scan showed a thin walled cystic lesion encompassing almost the entire caudate lobe. However, when Endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy was performed, it revealed a 2cm cystic lesion with its stalk in the proximal right main hepatic duct. Close inspection and manipulation of the mass showed that it was mobile causing obstruction to the right and intermittently to the left system. As endoscopic removal was not feasible, she underwent common bile duct exploration to remove the tumor. Pathology was consistent with benign hepatobiliary cystadenoma. Patient did well post-op and was followed closely as outpatient. Discussion: Right upper quadrant abdominal pain and obstructive jaundice are the most common symptoms of cystadenomas. Our case is unique in that initially, it appeared that the Liver cyst was compressing the CBD but ERCP revealed a single mobile pedunculated tumor originating in the right main hepatic duct that caused bilateral obstruction. Much as a pendulum swings back and forth, this mass appeared to swing from the right main hepatic duct into the left causing intermittent obstruction of the left system as well, ultimately leading to the patient's presentation of jaundice. Biliary cystadenomas, while extremely rare, should be considered in the differential for obstructive jaundice. Complete surgical excision is required as these tumors have a high rate of recurrence and potential for malignant transformation.Figure 1Figure 2Figure 3

Eosinophilic Colitis Masquerading as Malignancy of Colon

A 78-year-old woman presented to the ER with the chief complaint of generalized, dull abdominal pain for three days duration. She described the pain to be continuous and not related to eating. The patient also reported multiple episodes of hematochezia for a week preceding the presentation. The patient noted weight loss of about 30 pounds over a six month period. The patient denied having any diarrhea. Her medical comorbidities included hypertension, diabetes mellitus type 2, coronary artery disease, bronchial asthma and End-stage Renal Disease (ESRD) requiring renal replacement therapy. Laboratory values were significant for normocytic normochromic anemia with hemoglobin of 11 grams/dL and mild eosinophilia with a count of 0.4x103/uL. Patient underwent a Computerized Tomography (CT) scan of abdomen and pelvis which showed a focal circumferential mass like thickening in the colon with paracolic infiltration (Figure-1). A colonoscopy revealed discontiguous areas of circumferential ulcerated, friable mucosa from hepatic flexure to descending colon (Figure-2). Biopsies from these areas showed numerous eosinophils within the lamina propria suggestive of eosinophilic colitis (Figure-3). EC (Eosinophilic colitis) is the rarest form of eosinophilic gastroenteritis. It is more commonly seen in neonates and children. However, there have been a few cases of EC reported in adults predominantly in their third and fourth decades of life. Estimating the true incidence of primary EC is challenging given its rare nature, and also since secondary EC can occur in a multitude of other chronic conditions such as food allergies and inflammatory bowel diseases. Symptoms of EC usually include abdominal pain, diarrhea, bleeding, weight loss, obstruction, and in more severe cases ascites. Transmural disease has been reported to be associated with intestinal obstruction, intussusception, and even perforation. Colonic distention, thickening of the bowel wall and ulcerated lesions mimicking Crohn disease have been reported, as seen in our patient. On colonoscopy, signs of colitis such as mucosal erythema, edema, and ulcerated lesions are often evident. The management of eosinophilic gastroenteritis varies, depending on the underlying condition. Eosinophilic gastroenteritis associated with peripheral eosinophilia and positive IgE- is often caused by food allergy and was shown to respond to diet restriction. For other etiologies, corticosteroids remain the mainstay of therapy.Figure 1Figure 2Figure 3

Gastric Plasmacytoid Subtype Neuroendocrine Tumor

A 76-year-old man presented to our institution for abnormal imaging. His complaint at the outside hospital was for abdominal pain. Evaluation included computed tomography (CT) which was notable for a gastric wall lesion of 28 mm in and serum tests revealed elevated gastrin level at >2000 raising concerns for gastrinoma. Esophagogastroduodenoscopy (EGD) was performed with endoscopic ultrasound (EUS). Findings were notable for a 27x25 mm hypoechoic submucosal lesion in the gastric antrum as well as separate 11x10mm gastric lesion. Additional EUS findings were left hepatic lobe hypoechoic area of 12x8mm concerning for metastatic lesion. Biopsies were taken via fine needle aspiration (FNA) and fine needle biopsy (FNB) of the larger antral mass and reviewed by on-site cytopathology and stains revealed chromogranin and synaptophysin positive but beta-catenin negative cells consistent with neuroendocrine tumor but more specifically a plasmacytoid cell neoplasm staged WHO Grade 1. Neuroendocrine tumors (carcinoid tumors) are often diagnosed based on staining with chromogranin A and synaptophysin being two of the four common positive stains. They are often divided into Gastroenteropancreatic Neuroendocrine Tumors (GEP-NET) and Pancreatic neuroendocrine tumors (PanNET). GEP-NET are often found in small intestine but more specific ileum. NETs associated with elevated gastrin level occur in 5% of gastric carcinoid tumors. NETs frequently metastasize to the liver. Treatment can consist of palliative surgery and sometimes chemotherapy in form of interferon, although gastrointestinal carcinoid tumors show 10-20% slow response to chemo. Overall survival for carcinoid tumors has increased from 2 years to 8 years.Figure 1

Morphologic and Functional Markers of Aortopathy in Patients With Bicuspid Aortic Valve Insufficiency Versus Stenosis

Bicuspid aortic valve (BAV)-associated aortopathy is heterogeneous and still insufficiently defined. We prospectively analyzed the morphologic and functional variables of aortopathy in patients undergoing operations for BAV insufficiency (BAV-AI) vs stenosis (BAV-AS). A total of 172 consecutive patients (71% male, 59 ± 10 years) underwent aortic valve replacement with orwithout proximal aortic operation for BAV-AS (n=137), and BAV-AI (n= 35) from January 2012 through December 2014. All patients underwent preoperative cardiac magnetic resonance imaging to evaluate morphologic and functional variables of the aortic root. Magnetic resonance imaging data were used to guide sampling of aortic tissue intraoperatively (ie, from the area where flow jet impacts on the aortic wall [jet sample] and the opposite aortic wall [control sample]). Aortic wall lesions were graded based on the histologic sum score (range, 0 to 21). Expression and severity of aortopathy were quantified by means of proximal aortic phenotype, indexed aortic diameters, and a sum score. Cross-sectional aortic diameters were significantly larger in the BAV-AI group vs the BAV-AS group (47 ± 8 mm vs 41 ± 8 mm, p= 0.001). Moreover, root dilatation phenotype was more frequent in the BAV-AI group (27% vs 6%, p= 0.01) and was associated with a significantly larger aortic annulus diameter (32 ± 3 mm vs 27 ± 3 mm, p < 0.001). The histologic sum score was significantly different between the study groups (3.7 ± 2.6 BAV-AI vs 2.5 ± 1.4 BAV-AS, p= 0.03). Logistic regression revealed a significant association between BAV-AI and indexed aortic diameter exceeding 22 mm/m2 (odds ratio, 4.7; p= 0.007). Our study demonstrates that BAV functional phenotype correlates significantly with the expression and severity of bicuspid aortopathy.

Sonographic diagnosis of intraosseous epidermoid cysts of the calvarium

Sonographic diagnosis of intraosseous epidermoid cysts of the calvarium

Imaging Evaluation of Malignant Chest Wall Neoplasms.

Neoplasms of the chest wall are uncommon lesions that represent approximately 5% of all thoracic malignancies. These tumors comprise a heterogeneous group of neoplasms that may arise from osseous structures or soft tissues, and they may be malignant or benign. More than 50% of chest wall neoplasms are malignancies and include tumors that may arise as primary malignancies or secondarily involve the chest wall by way of direct invasion or metastasis from intrathoracic or extrathoracic neoplasms. Although 20% of chest wall tumors may be detected at chest radiography, chest wall malignancies are best evaluated with cross-sectional imaging, principally multidetector computed tomography (CT) and magnetic resonance (MR) imaging, each of which has distinct strengths and limitations. Multidetector CT is optimal for depicting bone, muscle, and vascular structures, whereas MR imaging renders superior soft-tissue contrast and spatial resolution and is better for delineating the full extent of disease. Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is not routinely performed to evaluate chest wall malignancies. The primary functions of PET/CT in this setting include staging of disease, evaluation of treatment response, and detection of recurrent disease. Ultrasonography has a limited role in the evaluation and characterization of superficial chest wall lesions; however, it can be used to guide biopsy and has been shown to depict chest wall invasion by lung cancer more accurately than CT. It is important that radiologists be able to identify the key multidetector CT and MR imaging features that can be used to differentiate malignant from benign chest lesions, suggest specific histologic tumor types, and ultimately guide patient treatment. (©)RSNA, 2016.

Endometriosis of Extra-Abdominal Soft Tissues: A Tertiary Center Experience.

While endometriosis, defined as the presence of endometrial tissue in extrauterine sites, is most frequently encountered within the peritoneal cavity, a small but significant proportion of cases occur at extra-abdominal soft tissue sites, particularly in relation to previous abdominal surgery. We reviewed the cases of endometriosis of soft tissue sites seen at a tertiary soft tissue center. All cases of extra-abdominal soft tissue endometriosis diagnosed at this institution over a 13-year period were reviewed, and clinical and pathologic findings were recorded. Forty-five patients had diagnoses of soft tissue endometriosis and there were 34 diagnostic biopsies and 26 surgical excision specimens. All but 1 case were abdominal wall lesions, with 1 located in the upper arm. A total of 33 patients presented with lesions in scars of previous operations (31 in Pfannenstiel incisions for Caesarean sections, presenting with a median interval of 6 years (range 1-16 years) following surgery). The lesions ranged in size from 1 to 8 cm (median 3.5 cm). One case showed decidualized stroma with trophoblast cells, while 2 had secondary adenocarcinoma arising from endometriosis. Eighteen cases were tested for β-catenin expression immunohistochemically, of which 5 showed at least focal nuclear positivity in the surrounding fibrous tissue (although not within glands or stroma). Soft tissue endometriosis is seen most commonly in surgical scars, particularly following Caesarean sections. Spontaneous endometriosis also most commonly occurs in the abdominal wall, although can occur exceptionally at unusual sites, such as extremities. Secondary changes, including carcinomas, can arise from endometriosis. The differential diagnosis of these lesions includes fibromatosis, which may be erroneously diagnosed on small, nonrepresentative core biopsy specimens.

Failed bonded interfaces submitted to microcosm biofilm caries development

ObjectivesThis study aimed to evaluate the dentin wall carious lesion development of different composite-dentin interfaces in the presence of two adhesive bonding materials in the gaps, using a microcosm biofilm model. MethodsDentin samples were prepared (10.4mm2) and restored with a composite resin using two adhesive systems (etch-and-rinse and self-etch techniques). Different conditions with respect to composite-dentin interfaces were produced with a 200μm gap: failed bonded without ageing or after mechanical ageing, or non-bonded with or without the presence of adhesive material on the dentin wall. For cariogenic challenge, specimens were subjected to a biofilm microcosm model for 14days to create caries-like wall lesions. Before and after caries development, transverse wavelength-independent microradiography images were taken, and lesion depth and mineral loss were measured. Data were analysed with linear regression models (p<0.05). ResultsThe composite-dentin interface conditions significant influenced the caries development: lesion development was reduced by the presence of the adhesive material on dentin wall, while lesion development was increased by the mechanical ageing (p=0.019). There was no difference between the adhesive materials (p values>0.05). ConclusionDifferent composite-dentin interfaces influence wall lesion development in gaps, with the interfaces submitted to ageing showing less carious protection than those interfaces with the presence of adhesive covering the dentin. Clinical significanceThe presence of adhesive bonding material in the gaps plays a role on the wall caries lesion development.

High-resolution intracranial vessel wall MRI in an elderly asymptomatic population: comparison of 3T and 7T

ObjectivesSeveral intracranial vessel wall sequences have been described in recent literature, with either 3-T or 7-T magnetic resonance imaging (MRI). In the current study, we compared 3-T and 7-T MRI in visualising both the intracranial arterial vessel wall and vessel wall lesions.MethodsTwenty-one elderly asymptomatic volunteers were scanned by 3-T and 7-T MRI with an intracranial vessel wall sequence, both before and after contrast administration. Two raters scored image quality, and presence and characteristics of vessel wall lesions.ResultsVessel wall visibility was equal or significantly better at 7 T for the studied arterial segments, even though there were more artefacts hampering assessment. The better visualisation of the vessel wall at 7 T was most prominent in the proximal anterior cerebral circulation and the posterior cerebral artery. In the studied elderly asymptomatic population, 48 vessel-wall lesions were identified at 3 T, of which 7 showed enhancement. At 7 T, 79 lesions were identified, of which 29 showed enhancement. Seventy-one percent of all 3-T lesions and 59 % of all 7-T lesions were also seen at the other field strength.ConclusionsDespite the large variability in detected lesions at both field strengths, we believe 7-T MRI has the highest potential to identify the total burden of intracranial vessel wall lesions.Key Points• Intracranial vessel wall visibility was equal or significantly better at 7-T MRI• Most vessel wall lesions in the cerebral arteries were found at 7-T MRI• Many intracranial vessel wall lesions showed enhancement after contrast administration• Large variability in detected intracranial vessel wall lesions at both field strengths• Seven-tesla MRI has the highest potential to identify total burden of intracranial atherosclerosis

Nocardia Liver Abscess – An Uncommon Infection Post Liver Transplant

Background: Nocardiosis is a rare, localised or disseminated, bacterial infection caused by aerobic actinomyces. It commonly affects immunocompromised hosts. With increasing load of post transplant patients the world over, this infection has been reported with increasing frequency.Case Report: A 59-year-old gentleman underwent living donor liver transplant for ethanol related ESLD in our hospital. Immediate post OP period was uneventful. After 6 weeks post transplant he presented with abdominal pain and low grade fever. General examination was unremarkable except for minimal tenderness over right hypochondrium. His baseline laboratory evaluation revealed hemoglobin 8.7 gm%, leukocyte count 7170/cumm, platelets 176,000/cmm. Liver function revealed total bilirubin 0.46 mg/dL, AST 14 μ/L, ALT 25 μ/L, albumin 2.6 g/L, alkaline phosphatase 74 μ/L, GGT 78 μ/L and INR 1.2. Tacrolimus level 6 mg/dL. Ultrasound abdomen revealed well-defined thin walled hypoechoic lesion in segment VII measuring 53 mm × 58 mm liver abscess. CT scan of abdomen showed a 6.2 cm × 6 cm × 5.9 cm size multiloculated hypodense collection in segment VII of right lobe with perilesional edema. He underwent percutaneous drainage of collection, which revealed purulent aspirate. Microbiological examination of aspirates showed pus cells and occasional gram-positive branching filaments. Modified acid-fast stain was positive. Culture revealed Nocardai spp. MALDI-TOF test was positive for Nocardia farcinica. He was treated with trimethoprime-sulfamethoxazole, amikacin and imipenem for 2 weeks. He was kept on low immunosuppression. His fever subsided over next few days. Repeat ultrasound scan revealed collapsed abscess cavity with small remnant collection. He was discharged on oral antimicrobials and is under regular follow up.Conclusion: Nocardiosis should be suspected as a likely cause of liver abscess in the setting of immunocompromised patients. Long-term treatment with trimethoprime-sulfamethoxazole for up to 6 months improves survival.Conflicts of InterestThe authors have none to declare. Background: Nocardiosis is a rare, localised or disseminated, bacterial infection caused by aerobic actinomyces. It commonly affects immunocompromised hosts. With increasing load of post transplant patients the world over, this infection has been reported with increasing frequency. Case Report: A 59-year-old gentleman underwent living donor liver transplant for ethanol related ESLD in our hospital. Immediate post OP period was uneventful. After 6 weeks post transplant he presented with abdominal pain and low grade fever. General examination was unremarkable except for minimal tenderness over right hypochondrium. His baseline laboratory evaluation revealed hemoglobin 8.7 gm%, leukocyte count 7170/cumm, platelets 176,000/cmm. Liver function revealed total bilirubin 0.46 mg/dL, AST 14 μ/L, ALT 25 μ/L, albumin 2.6 g/L, alkaline phosphatase 74 μ/L, GGT 78 μ/L and INR 1.2. Tacrolimus level 6 mg/dL. Ultrasound abdomen revealed well-defined thin walled hypoechoic lesion in segment VII measuring 53 mm × 58 mm liver abscess. CT scan of abdomen showed a 6.2 cm × 6 cm × 5.9 cm size multiloculated hypodense collection in segment VII of right lobe with perilesional edema. He underwent percutaneous drainage of collection, which revealed purulent aspirate. Microbiological examination of aspirates showed pus cells and occasional gram-positive branching filaments. Modified acid-fast stain was positive. Culture revealed Nocardai spp. MALDI-TOF test was positive for Nocardia farcinica. He was treated with trimethoprime-sulfamethoxazole, amikacin and imipenem for 2 weeks. He was kept on low immunosuppression. His fever subsided over next few days. Repeat ultrasound scan revealed collapsed abscess cavity with small remnant collection. He was discharged on oral antimicrobials and is under regular follow up. Conclusion: Nocardiosis should be suspected as a likely cause of liver abscess in the setting of immunocompromised patients. Long-term treatment with trimethoprime-sulfamethoxazole for up to 6 months improves survival. Conflicts of InterestThe authors have none to declare. The authors have none to declare.

Evaluation of carotid intima-media thickness in children with migraine: a marker of subclinical atherosclerosis.

Migraine is a commonly seen neurovascular disorder during childhood. Inflammation induced by the activation of cytokines and neuropeptides is implied in its pathophysiology. There is an association between inflammation and atherosclerosis in patients with migraine. In addition, there is a strong correlation between early atherosclerotic wall lesions and carotid intima-media thickness (CIMT). The study population consisted of 57 migraine patients aged 5-17years, as well as 47 healthy children who served as the control group. Those migraine patients who were not receiving any medications at the interictal period were compared to healthy controls in terms of their measured lipid levels, thyroid function, vitamin B12 levels, serum iron levels, iron binding capacity, complete blood count, C-reactive protein (CRP) levels, and carotid intima-media thickness (CIMT) scores, which may comprise risk factors for atherosclerosis. When children in the migraine and control groups were compared in terms of those risk factors that are known to be related to vascular changes, no significant differences were found. However, a significant difference was detected in CIMT values (P<0.05). Atherosclerosis commences in childhood, and there is a long period of time before the onset of ischemic symptoms occurs. In children with migraine, an evaluation of CIMT can be used as a non-invasive imaging modality to detect atherosclerosis, which develops in the context of chronic inflammation. In this way, measures to reduce morbidity and mortality, which may result from cardiovascular diseases, can be implemented.

CORRELATIONS OF DIFFERENT STRUCTURAL AND FUNCTIONAL CHARACTERISTICS OF ARTERIAL WALL WITH TRADITIONAL CARDIOVASCULAR RISK FACTORS IN HEALTHY PEOPLE OF DIFFERENT AGE. PART 2

Detection of principal subclinical arterial wall lesions is one of the most important aspects of effective cardiovascular disease (CVD) primary prevention. Such lesions include: arterial wall thickening, increased rigidity, endothelial dysfunction development. However, the role of traditional CVD risk factors in the development of individual arterial wall lesions in CVD-free people is understudied. This is particularly so with people of older age. Aim. To study the role of traditional CVD risk factors in development of arterial wall lesions in relatively healthy individuals of different age. Material and methods. We have examined a total of 303 people aged 25-91 years, with no signs of CVD and other chronic diseases and without any regular medical treatment. Anthropometric parameters, blood pressure, fasting plasma glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides levels were detected in all the patients. Measurement of pulse wave velocity was conducted using SphygmoCor device (AtCorMedical,Australia). Carotid ultrasound to measure intima-media thickness and number of atherosclerotic plaques was conducted using linear transducer with ultra-high resolution 17-5 MHz (PHILIPS iU22, the Netherlands) in the B-mode. Endothelium-dependent vasodilation was assessed by the reactive hyperemia test. Results. Multivariate linear regression analysis has revealed fasting hyperglycemia and increased systolic blood pressure to be to a greater degree associated with arterial wall state in both age groups. According to the results of multivariate logistic regression analysis a relationship between risk factors and arterial wall parameters is stronger in the younger group as compared with the older one. Conclusion. Systolic blood pressure and fasting hyperglycemia must be the main targets of CVD primary prevention in older age group, while in younger age group other traditional risk factors must be taken into account as well.

Magnetic Resonance Imaging of Plaque Morphology, Burden, and Distribution in Patients With Symptomatic Middle Cerebral Artery Stenosis.

Intracranial atherosclerosis is a major cause of ischemic stroke worldwide. Intracranial vessel wall imaging is an upcoming field of interest to assess intracranial atherosclerosis. In this study, we investigated total intracranial plaque burden in patients with symptomatic middle cerebral artery stenosis, assessed plaque morphological features, and compared features of symptomatic and asymptomatic lesions using a 3T vessel wall sequence. Nineteen consecutive Chinese patients with ischemic stroke and transient ischemic attack (mean age: 67 years; 7 females) with a middle cerebral artery stenosis were scanned at 3T magnetic resonance imaging; the protocol included a time-of-flight magnetic resonance angiography and the T1-weighted volumetric isotropically reconstructed turbo spin echo acquisition sequence before and after (83%) contrast administration. Chi-square tests were used to assess associations between different plaque features. Statistical significance was set at P<0.05. Vessel wall lesions were identified in 18 patients (95%), totaling 57 lesions in 494 segments (12% of segments). Lesions were located primarily in the anterior circulation (82%). Eccentric lesions were associated with a focal thickening pattern and concentric lesions with a diffuse thickening pattern (P<0.001). When differentiating between asymptomatic and symptomatic lesions, an association (P<0.05) was found between eccentricity and asymptomatic lesions, but not for enhancement or a specific thickening pattern. Symptomatic lesions did not have any specific morphological features. Our results lead to a 2-fold conclusion: (1) The classification system of both thickening pattern and distribution of the lesion can be simplified by using distribution pattern only and (2) differentiation between symptomatic and asymptomatic atherosclerotic lesions was possible using intracranial vessel wall imaging.

Reparo de lesão penetrante em parede torácica de cão, ocasionada por javali (Sus scrofa scrofa), com flape unipediculado de músculo reto abdominal

RESUMO Lesões penetrantes no tórax causadas por interação animal são frequentes em cães e caracterizam-se por dano extenso e desvitalização dos tecidos moles adjacentes. Quando a musculatura local é insuficiente para a reconstrução, retalhos musculares podem ser mobilizados para reparar o defeito torácico. O presente relato tem como objetivo demonstrar uma alternativa para o reparo de defeito da parede torácica em um cão, ocasionada por interação com javali (Sus scrofa scrofa), utilizando flape unipediculado de músculo reto abdominal. Com base na literatura consultada, essa técnica reconstrutiva ainda não foi descrita. O flape de músculo reto abdominal mostrou-se uma alternativa viável no reparo de lesão extensa e infectada na parede torácica em cães.

CORRELATIONS OF DIFFERENT STRUCTURAL AND FUNCTIONAL CHARACTERISTICS OF ARTERIAL WALL WITH TRADITIONAL CARDIOVASCULAR RISK FACTORS IN HEALTHY PEOPLE OF DIFFERENT AGE. PART 1

Arterial wall status is determined by several characteristics, the main of them are as follows: pulse wave velocity (PWV), carotid arteries intima-media thickness (IMT), the presence of atherosclerotic plaques, endothelium-dependent vasodilation (EDVD). When these parameters change, the risk for cardiovascular disease (CVD) grows. The nature of relationship between these indices in people without CVD clinical signs is understudied, especially in those of older age. Aim. To estimate correlations between different parameters of arterial wall in patients of different age without CVD. Material and methods. A total of 303 people aged 25-91 years without any manifestations of CVD or other chronic diseases and without regular medical treatment were examined. PWV estimation, carotid ultrasound with IMT measurement and atherosclerotic plaques amount calculation and EDVD estimation using reactive hyperemia test were performed. Results. Patients without CVD clinical signs rather often reveal arterial wall lesions already in the younger age group (mean age 40.9±8.7): reduced EDVD – in 26% of the cases, the presence of atherosclerotic plaques – in 22%, increased PWV – in 15%, increased IMT – in 8%. The prevalence of arterial wall alterations in the older age group (mean age 61.19±8.5) increase many-fold. All arterial wall parameters correlate with age. The stronger correlation was revealed between IMT and the amount of atherosclerotic plaques: r=0.46 (р<0.001) in the younger group and r=0.47 (р<0.001) in the older one. We didn’t find any relationship between PWV and EDVD in the younger group and between PWV and the amount of atherosclerotic plaques in the older one. Thickened carotid intima-media increases the risk of arterial stiffness by 2.3 times. Conclusion. Estimation of the state of arterial wall in people of young age without CVD allows detecting individuals who require active CVD prevention. Increased stiffness of arterial wall and the development of subclinical atherosclerosis represent different phenotypes of alterations.