Constantinos Villias

Multiple giant diverticula of the jejunum causing intestinal obstruction: report of a case and review of the literature.

Multiple diverticulosis of jejunum represents an uncommon pathology of the small bowel. The disease is usually asymptomatic and must be taken into consideration in cases of unexplained malabsorption, anemia, chronic abdominal pain or discomfort. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction appear in 10-30% of the patients increasing morbidity and mortality rates. We herein report a case of a 55 year-old man presented at the emergency department with acute abdominal pain, vomiting and fever. Preoperative radiological examination followed by laparotomy revealed multiple giant jejunal diverticula causing intestinal obstruction. We also review the literature for this uncommon disease.

Multiarticular chronic tophaceous gout with severe and multiple ulcerations: a case report

IntroductionGout is a common inflammatory arthritis caused by articular precipitation of monosodium urate crystals. It usually affects the first metatarsophalangeal joint of the foot and less commonly other joints, such as wrists, elbows, knees and ankles.Case presentationWe report the case of a 75-year-old Caucasian man with tophaceous multiarticular gout, soft-tissue involvement and ulcerated tophi on the first metatarsophalangeal joint of the left foot, on the first interphalangeal joint of the right foot and on the left thumb.ConclusionUlcers due to tophaceous gout are currently uncommon considering the positive effect of pharmaceutical treatment in controlling hyperuricemia. Surgical treatment is seldom required for gout and is usually reserved for cases of recurrent attacks with deformities, severe pain, infection and joint destruction.

Primary retroperitoneal mucinous cystadenoma of borderline malignancy in a male patient. Case report and review of the literature

BackgroundPrimary retroperitoneal mucinous cystadenoma of borderline malignancy represents a rare tumor, with unclear histogenesis, concerning almost exclusively women. Only two cases concerning male patients have been reported.Case reportWe herein report a case of a 37 year old man undergone laparotomy for a sizable retroperitoneal tumor resulting after the histological examination to a primary retroperitoneal mucinous cystadenoma of borderline malignancy.ConclusionThis is the third case of primary retroperitoneal mucinous cystadenoma of borderline malignancy in a male patient reported in the literature. The preoperative diagnosis is impossible. Laparotomy constitutes the only diagnostic and curative approach.

Human subcutaneous dirofilariasis caused by Dirofilaria immitis in a Greek adult

Human dirofilariasis is a zoonotic infection caused by worms of the genus Dirofilaria. Most reported cases involve Dirofilaria repens, and D. immitis infection has been rarely reported. Canines act as a reservoir for the infection, while human infections are sporadic. Human dirofilariasis has been widely reported in South Europe; however, the worldwide distribution constantly changes. We herein report an extremely rare case of subcutaneous trunk dirofilariasis in a 45-year-old immunosuppressed woman, caused by D. immitis. The parasitic infection was detected using ultrasonography. The infection was confirmed by a polymerase chain reaction-based method and was attributed to D. immitis.

Amyopathic dermatomyositis‐associated bilateral elbow ulcers successfully treated with autologous platelet‐rich plasma

in 1997 to clarify its embryonic origin and distinguish it from other lesions located elsewhere. The cervical chondrocutaneous branchial remnant reveals male predominance and is typically not bilateral in nature. It is located in the lateral neck with prevalence of location anterior to the sternocleidomastoid muscle. Histologically, it consists of a central cartilage core with normal overlying skin containing hair follicles, sebaceous glands, adipose tissues, and skeletal muscles. The lesion is usually thought to be originated from the second branchial arch. Primitive branchial embryonic tissues migrate into a final lateral facial position to form adult derivatives of the head and neck; but, cervical chondrocutaneous branchial remnant is left behind during the migratory process and persists after birth. Malignant degeneration of cervical chondrocutaneous remnant has not been reported. However, a high rate of associated anomalies has been reported, such as cleft palate, cardiac malformations, and hydronephrosis. Thus, extensive physical examinations including genitourinary tract ultrasonography are recommended. Treatment of choice is complete excision. We also propose that cervical chondrocutaneous branchial remnant is considered for diagnosis of the solitary soft nodule on the neck.

Multicystic Hepatocarcinoma Mimicking Liver Abscess

The diagnosis of hepatocellular carcinoma (HCC) became easier in relation to the improved radiological examinations; however, the neoplasm may occur under atypical presentations mimicking other benign or malignant processes. Multicystic HCC mimicking a liver abscess associated with septic-type fever and leukocytosis is rare, has a poor prognosis, and poses diagnostic and therapeutic dilemmas. We present the case of an 80-year-old patient, who presented with fever, leukocytosis, and large cystic masses involving right and left lobes of the liver initially considered abscesses and finally diagnosed as HCC after open drainage and liver biopsy. Although the patient died on the tenth postoperative day due to pulmonary oedema, the authors emphasize the high index of suspicion needed in the diagnosis of this unusual presentation of HCC.

Pneumoperitoneum, Retropneumoperitoneum, Pneumomediastinum, and Diffuse Subcutaneous Emphysema following Diagnostic Colonoscopy.

Colonoscopy is a widely used diagnostic and curative procedure. Extraperitoneal perforation with pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema combined with intraperitoneal perforation is an extremely rare complication. We report a case of a 78-year-old woman presented to the emergency department with abdominal pain and diffuse abdominal, chest, neck, and facial swelling appeared after a diagnostic colonoscopy. Diagnostic and therapeutic modalities are discussed.

Strangulated intestinal hernia through a drain site

INTRODUCTION Intra-abdominal drains have been widely used in order to prevent intra-abdominal fluid accumulation and detection of anastomotic leakage. PRESENTATION OF CASE We herein report a case of small bowel herniation followed by strangulation in an 82 year old woman who had undergone sigmoidectomy for colorectal cancer. DISCUSSION Although several complications related to drain usage such as drainsite infection, hemorrhage and intestinal perforation may occur, intestinal incarceration through drain site is rarely reported. CONCLUSION Drains must be used with caution and only if indicated. Careful insertion, regular post-operative or post-removal inspection is strongly recommended.

Superficial subungual angiomyxoma: case report and review of the literature.

To the Editor: Superficial angiomyxoma is a rare, cutaneous, acquired, benign, soft tissue neoplasm that can arise as a single tumor or multiple tumors. Histologically, it is characterized by the presence of a prominent vascular pattern and moderate inflammatory infiltrate within the myxoid matrix. Subungual location of angiomyxoma is very rare; to our knowledge, this is the fourth case. A 45-year-old male was referred in our department because of the appearance of clubbed nail deformity of the left thumb fingernail. The lesion had gradually increased in size during the last 5 months (Figure 1). The affected nail was slightly erythematous, sensitive when submerged in cold water, and occasionally painful; however, palpation did not produce any pain or fluctuant swelling. Additionally, the lesion did not limit the activity of the distal interphalangeal joint. No recent trauma of the affected fingernail was reported. According to the personal history, he used the computer daily. Radiographic examination of the digit demonstrated minimal soft tissue swelling that slightly elevated the nail plate. The tumor was removed 3 weeks after the initial examination in an outpatient setting. The lesion was oval with a myxoid texture, almost 2 cm in diameter. Histologic examination revealed a circumscribed lobulated mass with a prominent capillary network and spindleand stellateshaped cells (Figure 2). Immunohistochemical staining was positive for CD34 and negative for S-100. These findings were compatible with subungual angiomyxoma. Two months later, the surgical site healed, with an excellent cosmetic and functional result. No recurrence was seen at the 12-month follow-up visit. The bulbous digital deformity known as clubbing has been related to cardiac, pulmonary, and other systemic diseases. Isolated forms are due to local injury, whitlow, lymphangitis, or subungual neoplasms. The disorders that produce nail deformity may be malignant (melanoma, squamous cell carcinoma) or benign (mucous cyst, fibrokeratoma, exostosis, glomus tumor, keratoacanthoma, pyogenic granuloma, nerve sheath giant cell tumor). Cutaneous myxomas are well-demarcated nodules of the dermis or subcutis. Myxoma and superficial angiomyxoma are rare, benign, cutaneous neoplasms usually seen on the digits and also on the head, neck, trunk, and genital region. They are more sharply circumscribed and more vascular than cutaneous focal mucinosis. Histologically, these tumors express vimentin with variable positivity for CD34 and are usually negative for S-100 protein. Although the histologic features of superficial angiomyxoma are distinctive, its existence seems not to be widely accepted. Thus, some authors believe that ‘‘angiomyxoma’’ and ‘‘myxoma’’ are synonyms, whereas others consider superficial angiomyxoma to be a term used to describe cutaneous myxomas with more prominent vascularity. In 1988, Allen and colleagues presented 30 cases of superficial angiomyxoma and reported its differentiation from myxoma, based on the presence of collagenous diaphragms, rich vascularity, and inflammatory cell infiltrate in a mucoid matrix seen in angiomyxoma. Calonje and colleagues also supported the concept of superficial angiomyxoma as a distinct entity. Superficial angiomyxoma affects all ages, with a peak incidence in the third to fourth decade of life. Superficial angiomyxoma has been reported as a solitary lesion, usually less than 5 cm in diameter, or in association with Carney complex (skin and cardiac myxomas, spotty skin pigmentations, endocrine overactivity, and endocrine tumors), NAME syndrome (nevi, atrial myxoma, myxoid neurofibroma and ephelides), or LAMB syndrome (mucocutaneous lentigines, atrial myxomas, mucocutaneous myxomas, and blue nevi). Angiomyxomas in unusual positions, such as the floor of the mouth, eyelid, and epididymis, have also been described. Sanusi described a case of subungual myxoma in 1982. The first case of subungual superficial angiomyxoma was reported in 2002. Two cases of subungual angiomyxomas occurring on the thumb and the fifth toe were reported in 2005, and the fourth case is the present. Misago and colleagues also reported a fibrokeratoma-like lesion on the radial lateral side of the proximal interphalangeal joint of the right index finger. Clubbed nail deformity was the clinical presentation manifestation in all cases of subungual myxomas and angiomyxomas. Pain has rarely been reported in subungual myxoma, whereas a previous history of trauma of the fingernail was reported in one case of subungual myxoma. DOI 10.2310/7750.2011.10036

Malignant fibrous histiocytoma masquerading as gluteal abscess.

To the Editor: Soft tissue sarcomas are rare tumors. They involve various types of connective tissue and account for approximately 1% of adult malignancies. Malignant fibrous histiocytoma (MFH) is a form of malignant sarcoma with a tendency to metastasize to distant areas of the body, especially the lungs. The treatment and outcome of this condition depend on the stage, type, and metastatic behavior of the tumor. We describe an interesting case of MFH that presented as a gluteal abscess. An 85-year-old female was referred to our department because of fever (39.4uC), erythema, and swelling of the left buttock. A clinical examination revealed a warm and painful abscess, 2 3 2 cm in diameter. Routine laboratory tests showed leukocytosis (17,000 mL), and anemia (hemoglobin 10.1 mg/dL). A chest radiograph, an abdominal sonogram, and urine and blood cultures were within normal ranges. The abscess was drained under local anesthesia, and surgical débridement was performed. Bacteriologic examination from the pus revealed the presence of Staphylococcus aureus, and according to the antibiogram, the patient was treated with doxycycline 100 mg twice daily for 10 days postoperatively. Forty-five days after the drainage, the patient was referred to the emergency department because of the rapid development of a sizable, friable, hemorrhagic mass arising from the site of the gluteal abscess that had been treated (Figure 1). Laboratory investigation revealed anemia (hemoglobin 8 mg/dL) and abnormal coagulation parameters (international normalized ratio 5). Axial contrastenhanced computed tomographic images demonstrated an increasingly hyperdense lesion. The center of the lesion was hypodense and probably necrotic, with irregular borders. The lesion was extending from the subcutaneous tissue, invading the adjacent gluteus maximus, gluteus medius, and piriformis muscles. Cytoreduction under epidural anesthesia was performed, and the resected specimen measured 17 3 15.5 3 4.5 cm in diameter. Histologic examination showed a variable morphologic pattern with storiform and pleomorphic areas. Storiform areas consisted of atypical spindle cells with medium or large irregular vesicular nuclei and prominent nucleoli. Pleomorphic areas contained plumper fibroblastic cells, with large vesicular clear nuclei and eosinophilic cytoplasm. Extensive necrosis was also present. Immunohistochemical stains revealed immunoreactivity for vimentin (Figure 2) and no reaction for pankeratin, desmin, HMB-45, smooth muscle actin, and S100. The histologic picture was compatible with MFH. Unfortunately, the patient died 15 days after the excision of the tumor because of pulmonary edema owing to chronic atrial fibrillation. Although the reason for the fatal outcome was unrelated to MFH, we believe that the delayed diagnosis of the tumor played a significant role in the patient’s poor condition. The incidence of MFH is estimated as 17% of soft tissue sarcomas, and the storiform-pleomorphic histologic variant represents 70% of MFH cases. Soft tissue sarcomas are usually asymptomatic, described as indolent, unmoveable masses. Rarely, they may mimic a hematoma or an abscess, and these uncommon presentations further delay diagnosis and treatment, as in our case. The development of an abscess has been commonly attributed to trauma, injection, or infection of underlying seborrheic cysts. Drainage of abscesses, often followed by débridement, is commonly performed under local anesthesia. Surgical excision of the lesion is the treatment of choice. Additional radiotherapy and/or chemotherapy should be individualized.