Bronchial lobar obstruction from a sucralfate tablet: a rare cause of acute respiratory insufficiency]

In 1995, the Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) published a position paper on atlantoaxial instability in children with Down syndrome in which a previous statement on the same subject published in 1984 (Table) was retired. The 1995 statement includes several arguments that disfavor screening of children with Down syndrome for atlantoaxial instability. Whereas some of these arguments are well founded, other lack substantive evidence that would support the statement. In the following discussion, I attempt to analyze some of these arguments made in the 1995 statement and provide a viewpoint that favors radiologic examinations of the cervical spine of children with Down syndrome.     

A rare case of primary malignant mesothelioma originating from the rectovaginal tissue

A 35 year-old female patient with pelvic malignant mesothelioma is described. The patient underwent total pelvic exenteration due to a pelvic tumor. Macroscopically, the resected tumor was located in the rectovaginal lesion with invasion into the rectal and vaginal wall, and around the internal urethral ostium. Light microscopically, the tumor predominantly consisted of sheets of plump round cells with acidophilic cytoplasm, and focally of tumor cells showing papillary growth pattern. The tumor cells showed remarkable cellular pleomorphism, and were both alcian blue and periodic acid-Schiff stain negative. Electron microscopically, these tumor cells had numerous long bush-like microvilli on their surface with increased length/width ratios. Positive staining with epithelial membrane antigen, cytokeratin, and vimentin, and negative staining with the carcinoembryonic antigen and S-100 protein were observed immunohistochemically. Based on these histological and immunohistochemical estimations, the tumor was diagnosed as a primary malignant mesothelioma originating from the rectovaginal tissue. Review of the literature confirmed the rarity of pelvic malignant mesothelioma. The possibilities of the pathogenesis of the tumor include the tumor's arising from the peritoneal remnant in the rectovaginal tissues, or from the epithelium of the secondary Mullerian system, which shares the same ancestry with the peritoneum.     

Large right atrial aneurysm: rare cause of recurrent pulmonary embolism]

Case report on a 72 year old female patient presenting with collapse and progressive dyspnea. X-ray of the chest showed a marked enlargement of the heart extending to the right. Echocardiography revealed an impressive displacement of the heart chambers to the left caused by a large aneurysm (11 x 5 x 5 cm) located anteriorly and medially from the right heart communicating with the right atrium. Pronounced compression of the basal part of the right ventricle was present. Within the aneurysmatic cavity several highly mobile thrombi and extensive spontaneous echo contrast were demonstrated. On magnetic resonance imaging and right heart angiocardiography the aneurysm was visualized as well. Coronary angiography revealed a marked curved displacement of the right coronary artery to the left side. Perfusion lung scanning suggested bilateral segmental pulmonary embolism proven by digital substraction angiography. With long-term oral anticoagulation the patient remained symptom-free during follow-up of now more than four years.     

Congenitally short trachea with compression of the left mainstem bronchus: MRI findings

The MRI features of congenitally short trachea in a patient presenting with respiratory distress are presented. Compression of the left mainstem bronchus by the aortic arch, a recognised complication of this anomaly, could be demonstrated by MRI, obviating the need for other imaging modalities.     

A rare cause of dysphonia: laryngeal rhabdomyoma

The authors report their finding concerning the frequency of postoperative pulmonary thromboembolism in an autopsy series of subjects who had died with 15 days of surgery. In all cases the relationship was evaluated between death and age, sex, the underlying pathology and the type of surgery.     

A rare cause of obstructive jaundice: peripancreatic pseudoaneurysm

We report the case of a 54-year-old-man with alcoholic calcified chronic pancreatitis complicated by jaundice and abdominal pain. Investigations (Doppler ultrasonography examination and computed tomography scan) showed peripancreatic pseudoaneurysm of the posterior and inferior pancreatico-duodenal artery and a dilatation of the common bile duct. Selective embolization of the pseudoaneurysm resulted in rapid regression of both jaundice and abdominal pain. Common bile diet compression is a rare complication of peripancreatic pseudoaneurysm. Selective embolization seems to be the first line treatment in this indication.     

Lusorian artery lesion as rare cause of severe upper gastrointestinal tract bleeding

A patient in an intensive care unit experienced severe esophageal bleeding caused by erosion of a lusorian artery. The lusorian artery is a rare variant of the right subclavian artery. It originates in the descending aortic arch and crosses behind the esophagus to the right, sometimes generating esophageal compression. The patient's condition required respirator therapy and placement of a duodenal tube. At the point of crossing over of the lusorian artery and the esophagus, the duodenal tube caused esophageal necrosis, leading to erosion of the lusorian artery. This resulted in extensive esophageal bleeding, which at last required surgical intervention. To attain proper treatment and to avoid unnecessary diagnostic and therapeutic approaches, a lusorian artery lesion has to be included in the differential diagnosis of upper gastrointestinal bleeding.     

The right inferior supraazygous recess: a cause of upper esophageal pseudomass on double-contrast esophagography

OBJECTIVE: Our purpose was to characterize the radiographic features of a pseudomass impression on the upper thoracic esophagus, to determine the frequency of such a pseudomass both on double-contrast esophagography and on CT, and to elucidate the anatomic basis for this finding. MATERIALS AND METHODS: Our study group consisted of 135 patients whose double-contrast esophagograms were reviewed retrospectively for the presence or absence of an extrinsic indentation on the right posterolateral wall of the upper thoracic esophagus. In another patient group, 50 CT scans of the chest were also reviewed for the presence or absence of a prominent right inferior supraazygous recess and an associated indentation on the upper thoracic esophagus. RESULTS: Thirteen (9.6%) of the 135 barium studies revealed a smooth, gently sloping indentation on the right posterolateral wall of the upper thoracic esophagus. The indentations ranged from 5 to 10 cm in length and extended inferiorly from the thoracic inlet to or just below the aortic arch. Twenty-four (48%) of the 50 CT scans revealed a prominent right inferior supraazygous recess projecting behind the esophagus. In five cases (10%), this recess also caused a smooth indentation on the upper thoracic esophagus. CONCLUSION: A pseudomass impression was seen on double-contrast radiography as a smooth, gently sloping indentation on the right posterolateral wall of the upper thoracic esophagus in approximately 10% of patients. The indentation probably represents a normal anatomic variant (i.e., an unusually prominent right inferior supraazygous recess) that should not be mistaken for adenopathy or other masses in the mediastinum impinging on the esophagus.     

A rare cause of respiratory failure: Echinococcus of the pulmonary artery

To combine the advantages of the standard technique and the bicaval technique of orthotopic heart transplantation, we use a muscular flap of recipient heart right atrium for connecting the superior vena cava with the donor heart right atrium. The results in respect to the maintenance of atrioventricular valve competence as well as atrial conduction are promising.     

Bird's nest inferior vena caval filter migration into the duodenum: a rare cause of upper gastrointestinal bleeding

PURPOSE: To report the first case of a potentially catastrophic complication of vena caval interruption with a bird's nest filter. METHODS AND RESULTS: A 55-year-old Saudi patient presented with hypovolemic shock from massive upper gastrointestinal hemorrhage. Endoscopy identified a metallic object penetrating the duodenum. Five years earlier, the patient had a bird's nest vena caval filter inserted for recurrent pulmonary embolism. During emergent laparotomy, a broken filter wire was found projecting into the duodenum, where it had induced three profusely bleeding ulcers. The wire was transected and the ulcers oversewn. A hook projecting from the inferior vena cava (IVC) was also cut flush with the vessel wall, but the IVC was not opened nor the filter replaced. The patient's postoperative course was complicated by deep venous thrombosis, but he recovered and is asymptomatic on warfarin anticoagulation after 1 year. Computed tomography (CT) at 1-year follow-up confirmed no further migration of the filter. CONCLUSION: This event reinforces the need to monitor patients with IVC filters over the long term, preferably using CT scanning, and to consider filter migration as a possible cause of upper gastrointestinal bleeding.     

Neuralgic amyotrophy: A rare cause of bilateral diaphragmatic paralysis

In 1994, 171 (27%) of all positive blood cultures in our hospital were due to Acinetobacter species. Of these, 138 cultures were considered significant, 91 (66%) were community-acquired and 47 (34%) were nosocomial. Most acinetobacter bacteraemia in children < or = 1 year old was community-acquired, while nosocomial infection was more common in children > 1 year old (P = 0.01). Most children < or = 5 years old were severely malnourished. The incidence of bacteraemia was lowest during the post-monsoon to early winter months. Acinetobacter bacteraemia associated mortality was twice (16%) that of all other patients (7.7%, P < 0.0005) and accounted for 4.5% of all hospital deaths during the study period. Bacteraemia caused by Acinetobacter species is an important cause of morbidity and mortality among our patient population with diarrhoeal disease.     

A rare cause of urinary frequency]

Induction and maintenance of peripheral tolerance are important mechanisms to maintain the balance of the immune system. In addition to the deletion of T cells and their failure to respond in certain circumstances, active suppression mediated by T cells or T-cell factors has been proposed as a mechanism for maintaining peripheral tolerance. However, the inability to isolate and clone regulatory T cells involved in antigen-specific inhibition of immune responses has made it difficult to understand the mechanisms underlying such suppression. Here, we show that chronic activation of both human and murine CD4+ T cells in the presence of interleukin (IL)-10 gives rise to CD4+ T-cell clones with low proliferative capacity, producing high levels of IL-10, low levels of IL-2 and no IL-4. These antigen-specific T-cell clones suppress the proliferation of CD4+ T cells in response to antigen, and prevent colitis induced in SCID mice by pathogenic CD4+CD45RBhigh splenic T cells. Thus IL-10 drives the generation of a CD4+ T-cell subset, designated T regulatory cells 1 (Tr1), which suppresses antigen-specific immune responses and actively downregulates a pathological immune response in vivo.     

Tracheal bronchus: a cause of prolonged atelectasis in intubated children

Tracheal bronchus is a common anomaly that occurs in approximately 2% of people. Two children with multiple medical problems which led to endotracheal intubation are described. The hospital course for each child was complicated by persistent right upper lobe atelectasis. The presence of a tracheal bronchus was not recognized in either case initially; identification of this anatomic variant allowed appropriate changes in airway management. The potential for tracheal bronchus to cause, or be associated with, localized pulmonary problems is reviewed. The diagnosis of tracheal bronchus should be considered early in the course of intubated patients with right upper lobe complications.     

Undiagnosed bronchus carcinomas as the cause of sudden and unexpected fatalities

Cases of sudden death accompanied by impressive external bleeding may arouse suspicion of violence. On the other hand fatal hemorrhages from the respiratory tract can be caused by injuries as well as by diseases. In the age of successfully treated tuberculosis the majority of pulmonary hemorrhages is based on bronchogenic carcinomas. Examples of fatal bleeding from malignant tumours of the bronchus show the variety of morphological substrates giving rise to these hemorrhages: e.g. aneurysma-like dissection of pulmonary arteries infiltrated by bronchogenic carcinoma, leukocytoclastic destruction of vessel walls surrounded by tumour necrosis, and arrosion of small arteries in the tumour region which leads to massive hemorrhage owing to anticoagulant therapy.     

A gonadotrophin dependent stromal luteoma: a rare cause of post-menopausal virilization

A stromal luteoma is an uncommon ovarian tumour in post-menopausal women, which presents rarely with hyperandrogenism and virilization. We present the case of a 64-year-old woman referred for evaluation of virilization which had developed over 5 years. Testosterone, FSH and LH were markedly inhibited following the administration of a GnRH analogue, suggesting a gonadotrophin dependent, testosterone secreting ovarian tumour, which could not be localized with imaging techniques. Surgery revealed normal sized ovaries with no apparent lesions, but microscopic examination showed a small stromal luteoma in the right ovary and severe stromal hyperthecosis in the adjacent and contralateral ovarian stroma. We conclude that stromal luteoma is an uncommon cause of virilization in post-menopausal women. This case illustrates, to our knowledge for the first time, that a stromal luteoma is not autonomous but is gonadotrophin dependent.     

Mesenteric cysts: rare cause of abdominal pain

For about two years a now 47-year-old woman had been suffering from heartburn, diarrhoea and constipation, at times also abdominal colic and a pressure sensation in the right lower abdomen. Physical examination and biochemical tests were according to age, except for an raised erythrocyte sedimentation rate of 25/50 mm. Ultrasound revealed an intraperitoneal echo-free multi-chambered structure, 11 x 5 x 2 cm, with dorsally increased echo density and smooth entry echo, apparently arising from the mesentery. Computed tomography confirmed these findings and at laparoscopy a cyst, 12 x 8 x 5 cm, was identified. It was filled with yellow clear fluid and arose from the mesentery of the ascending colon. The cyst was scooped out surgically. Histological examination showed a single-layered mesothelial coat. The postoperative course was unremarkable. At re-examination 8 months later the patient had remained symptom-free.     

Melanocanthoma: a rare cause of oral hyperpigmentation

The oral features of a black woman with melanocanthoma of the oral mucosa are detailed, and the current literature of melanocanthoma of the oral mucosa is briefly reviewed.