Junaid Nabi

Incidental detection of adrenal myelolipoma: a case report and review of literature.

Introduction. Adrenal myelolipoma is a rare tumor that is benign in nature, usually asymptomatic, unilateral, and nonsecreting. It is composed of variable mixture of mature adipose tissue and hematopoietic elements and develops within the adrenal gland. With the widespread use of cross-sectional imaging modalities such as ultrasonography and computed tomography, the incidental detection of these tumors is increasing in frequency. Case Presentation. We report a case of adrenal myelolipoma in a 63-year-old Kashmiri male, who presented with pain in the right upper abdomen. Physical examination was unremarkable. Ultrasound abdomen showed the presence of a hyperechoic mass in the right suprarenal region with undefined margins. Contrast-enhanced computed tomography (CECT) scan of abdomen revealed a well-defined, round lesion in the right suprarenal region with heterogeneous attenuation suggesting the possibility of myelolipoma. The patient was subjected to right adrenalectomy and his postoperative course was uneventful. The histopathological evaluation of the mass confirmed the initial diagnosis of adrenal myelolipoma. Conclusion. Although mostly discovered as an “incidentaloma”, the diagnosis of adrenal myelolipoma warrants thorough diagnostic study. Imaging techniques such as ultrasonography and CT scans as well as biochemical studies are useful for indicating the best treatment taking into account the size of the mass and possible hormone production. Surgical resection is advocated through extraperitoneal approach as it minimizes postoperative complications and leads to quicker recovery.

A Case of Large Phyllodes Tumor Causing “Rupture” of the Breast: A Unique Presentation

Introduction. Phyllodes tumors are rare fibroepithelial tumors which constitute less than 1% of all known breast neoplasms. The importance of recognizing these tumors lies in the need to differentiate them from fibroadenomas and other benign breast lesions to avoid inappropriate surgical management. We report a case of large phyllodes tumor which caused rupture of the breast and presented as an external fungating breast mass, a presentation which is exceedingly rare. Case Presentation. A 32-year-old female presented with a 1-year history of a mass in her right breast and eruption of the mass through the skin for the last 3 months. On physical examination, an ulcerated, irregular, and nodular mass measuring 9 × 8 cms was found hanging in the lower and outer quadrant of the right breast. Ultrasonography revealed an exophytic mass with heterogeneous echotexture and vascularity. Under general anesthesia, the tumor was excised. The resected specimen was 9.5 × 8.5 × 4.5 cm in size and the tumor was not invasive to the surrounding tissues. Histological examination confirmed a benign case of Phyllodes tumor. Conclusion. Clinicians should be aware of the myriad ways in which Phyllodes can present. A rapidly growing breast mass in a female should raise strong suspicion for Phyllodes. It is necessary to differentiate it from fibroadenomas to avoid inappropriate surgical management which may lead to local recurrence.

Neurofibromatosis Type 1 Associated with Hashimoto’s Thyroiditis: Coincidence or Possible Link

Introduction. Hashimotos thyroiditis is a common form of chronic autoimmune thyroid disease (AITD) and often coexists with other autoimmune diseases, but Hashimotos thyroiditis associated with an autosomal dominant neurofibromatosis type 1 is exceedingly rare. Case Presentation. A 30-year-old Bengali woman presented to the OPD with complaints of aching pain and tingling sensation in her hands and feet. Physical examination revealed dysmorphic facies, nodular swelling in the neck, cafe-au-lait spots, and neurofibromas covering the entire surface of her body. Her thyroid hormones were within normal limits. Thyroid ultrasound revealed a cystic area in the left lobe of the gland, and ultrasound-guided fine needle aspiration cytology revealed lymphocytic infiltration of the gland, suggesting Hashimotos thyroiditis. High levels of autoimmune antibodies such as antithyroglobulin and antimicrosomal antibodies confirmed the diagnosis. Conclusion. When encountered with a patient of Neurofibromatosis type 1, a physician should be careful about the possibility of a concomitant autoimmune disease. Clinical presentation of neurofibromatosis and Noonan syndrome often overlaps and recent studies have implicated a mutation in NF1 gene in the etiology of NFNS. More extensive reports and further investigations of such patients having combination of neurofibromatosis type 1 and autoimmune thyroiditis will certainly provide better understanding of this link in the near future.

Atypical presentation of myoepithelial hamartoma in the antrum of the stomach, mimicking a gastrointestinal stromal tumor: a case report

IntroductionA myoepithelial hamartoma is a very uncommon submucosal tumor of the stomach. In an atypical presentation in our case, it mimicked the clinical presentation of a gastrointestinal stromal tumor. To the best of our knowledge, it is the first case of a hamartoma of the stomach reported from Bangladesh and one of few cases described in the literature.Case presentationWe describe the case of a 35-year-old Bengali man with recurrent epigastric pain and occasional vomiting with radiographic findings of a gut mass. An upper gastrointestinal endoscopy revealed a healed duodenal ulcer, deformed ‘D’ bulb and a submucosal swelling in his antrum. Ultrasonography and a contrast-enhanced computed tomography scan confirmed the presence of a well-defined, oval gut mass in his upper abdomen, compressing his duodenum. The mass had a mixed density and was considered to probably be a gastrointestinal stromal tumor. Ultrasonography-guided fine needle aspiration cytology was inconclusive. After resection at laparotomy, a histopathological examination revealed a myoepithelial hamartoma. These tumors are characterized by hypertrophic smooth muscle bands surrounding varied epithelial elements, which may be arranged in diverse patterns such as simple glandular structure, Brunner’s gland, pancreatic ducts and sometimes pancreatic acini. This case report is complemented by a literature review relating to the atypical presentation.ConclusionGut masses need to be investigated thoroughly and the possibility of rare tumors should not be excluded. Although the recommended treatment for such lesions is limited resection, radical procedures such as a pancreaticoduodenectomy are often performed when the lesion occurs in the periampullary area because of preoperative misdiagnosis as a carcinoma. Therefore, it is essential for clinicians to maintain current knowledge of the lesion to avoid inaccurate diagnosis and prevent unnecessary surgery.

Endogenous Cushing’s Syndrome with Precocious Puberty in an 8-Year-Old Boy due to a Large Unilateral Adrenal Adenoma

Adrenocortical tumors (ACTs) causing Cushings syndrome are extremely rare in children and adolescents. Bilateral macronodular adrenocortical disease which is a component of the McCune-Albright syndrome is the most common cause of endogenous Cushings syndrome. We report the case of a boy with Cushings syndrome who presented with obesity and growth retardation. The child was hypertensive. The biochemical evaluation revealed that his serum cortisol levels were 25.80 μg/dL, with a concomitant plasma ACTH level of 10.0 pg/mL and nonsuppressed serum cortisol on high-dose dexamethasone suppression test (HDDST) to be 20.38 μg/dL. Computed tomography of the abdomen demonstrated a 8 × 6 × 5 cm left adrenal mass with internal calcifications. Following preoperative stabilization, laparotomy was carried out which revealed a lobulated left adrenal mass with intact capsule weighing 120 grams. Histopathological examination revealed a benign cortical neoplastic lesion, suggestive of adrenal adenoma; composed of large polygonal cells with centrally placed nuclei and prominent nucleoli without capsular and vascular invasion. On the seventh postoperative day, cortisol levels were within normal range indicating biochemical remission of Cushings syndrome. On followup after three months, the patient showed significant clinical improvement and had lost moderate amount of weight and adrenal imaging was found to be normal.

Myiasis as a Rare Complication of Male Circumcision: A Case Report and Review of Literature

Introduction. Circumcision is a common procedure carried out around the world. Due to religious reasons, it is routinely done in Bangladesh, by both traditional as well as medically trained circumcisers. Complications include excessive bleeding, loss of foreskin, infection, and injury to the glans penis. Myiasis complicating male circumcision appears to be very rare. Case Presentation. In 2010, a 10-year-old boy presented to the OPD of Dhaka Medical College Hospital with severe pain in his penile region following circumcision 7-days after. The procedure was carried out by a traditional circumciser using unsterilized instruments and dressing material. After examination, unhealthy granulation tissue was seen and maggots started coming out from the site of infestation, indicating presence of more maggots underneath the skin. An emergency operation was carried out to remove the maggots and reconstruction was carried out at the plastic surgery department. Conclusion. There is scarcity of literature regarding complications following circumcision in developing countries. Most dangerous complications are a result of procedure carried out by traditional circumcisers who are inadequately trained. Incidence of such complications can be prevented by establishing a link between the formal and informal sections of healthcare to improve the safety of the procedure.

Multiple Isolated Intracranial Tuberculomas Masquerading as Brain Metastases on Radiological Imaging: Success of a Therapeutic Trial

Tuberculosis is endemic in Bangladesh. It remains a resilient public health concern. Reports on presentation and management of intracranial tuberculoma from Bangladesh are sparse. Despite being potentially remediable, tuberculomas are still a cause of significant morbidity and mortality in developing nations. Intracranial tuberculomas can occur as solitary or multiple lesions. Multiple isolated intracranial tuberculomas are rare, and difficult to discern from brain metastases. A unique case of intracranial tuberculomas is presented, which masqueraded as brain metastases on imaging studies and was diagnosed and treated with a trial of antitubercular chemotherapy. A 43-year-old Bengali male presented to the OPD with headaches and blurring of vision for four months. He was provided symptomatic treatment at his regional hospital, which did not abate his condition and was later referred to our center when he developed severe vomiting. Routine investigations including chest radiograph were clean. CT scan showed bilateral edema in cerebral hemispheres and MRI revealed rounded signal change areas of right frontal lobe and left parietal lobe posteriorly, strongly suggestive of brain metastases. Patient declined biopsy. In view of his past history, a full course of antitubercular chemotherapy was prescribed. Following the medication, patient’s condition improved and at 24 months follow-up, there was complete resolution of the lesion.

Intraductal Papillary Mucinous Neoplasm (IPMN) of the pancreas: a case study and review of literature

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is one of the two entities which come under the realm of non-inflammatory cystic lesions of the pancreas, the other one being mucinous cystic neoplasm. The clinco-pathological features of intraductal papillary mucinous neoplasm of the pancreas are unique. The patient had a long history of symptoms suggestive of chronic pancreatitis. Endoscopic retrograde cholangiopancreatography revealed dilatation of the main duct, ultrasonography showed cystic dilatation interpreted as pseudocyts. Current thinking suggests that at best IPMN represents a premalignant condition and, as such, surgical intervention is recommended. The aim should be to resect all gross disease while attempting to achieve a negative surgical margin, which in the majority of cases can be achieved by a partial or subtotal pancreatectomy, which was performed on the patient. Histologically, they demonstrate a spectrum of cellular atypia ranging from minimal mucinous hyperplasia to frank invasive carcinoma. Although the neoplasms are less aggressive as a group than conventional pancreatic ductal adenocarcinoma, patients with IPMNs may pursue a deadly course, even in the absence of identifiable invasive carcinoma thus emphasizing the importance of recognizing IPMNs and initiating optimal modalities of treatment.