Shahin Zandieh

Synovial hemangioma of the knee joint in a 12-year-old boy: a case report

IntroductionSynovial hemangioma is a rare condition and is frequently misdiagnosed, leading to a diagnostic delay of many years.Case presentationWe present a case of an atypical synovial hemangioma in a 12-year-old Caucasian boy with a diagnostic delay of 3 years.ConclusionIt is important to know that synovial hemangioma mostly affects the knee joint, showing recurrent bloody effusions without a history of trauma. If there are no intermittent effusions, the diagnosis will be even more difficult. In cases of nonspecific symptoms and longstanding knee pain the diagnosis of a synovial hemangioma should also be considered in order to avoid diagnostic delay. Magnetic resonance imaging is the main diagnostic tool to evaluate patients with synovial hemangioma, showing characteristic lace-like or linear patterns.Angiography can identify feeder vessels and offers the possibility of embolisation in the same setting. Surgical excision, either done per arthroscopy or per arthrotomy, is recommended as soon as possible to avoid the risk of damage to the cartilage.

Analysis of the Metabolic and Structural Brain Changes in Patients With Torture-Related Post-Traumatic Stress Disorder (TR-PTSD) Using 18F-FDG PET and MRI

AbstractMany people exposed to torture later suffer from torture-related post-traumatic stress disorder (TR-PTSD). The aim of this study was to analyze the morphologic and functional brain changes in patients with TR-PTSD using magnetic resonance imaging (MRI) and positron emission tomography (PET).This study evaluated 19 subjects. Thirteen subcortical brain structures were evaluated using FSL software. On the T1-weighted images, normalized brain volumes were measured using SIENAX software. The study compared the volume of the brain and 13 subcortical structures in 9 patients suffering from TR-PTSD after torture and 10 healthy volunteers (HV). Diffusion-weighted imaging (DWI) was performed in the transverse plane. In addition, the 18F-FDG PET data were evaluated to identify the activity of the elected regions.The mean left hippocampal volume for the TR-PTSD group was significantly lower than in the HV group (post hoc test (Bonferroni) P < 0.001). There was a significant difference between the gray matter volume of the patients with TR-PTSD and the HV group (post hoc test (Bonferroni) P < 0.001). The TR-PTSD group showed low significant expansion of the ventricles in contrast to the HV group (post hoc test (Bonferroni) P < 0.001). Diffusion-weighted imaging revealed significant differences in the right frontal lobe and the left occipital lobe between the TR-PTSD and HV group (post hoc test (Bonferroni) P < 0.001).Moderate hypometabolism was noted in the occipital lobe in 6 of the 9 patients with TR-PTSD, in the temporal lobe in 1 of the 9 patients, and in the caudate nucleus in 5 of the 9 patients. In 2 cases, additional hypometabolism was observed in the posterior cingulate cortex and in the parietal and frontal lobes.The findings from this study show that TR-PTSD might have a deleterious influence on a set of specific brain structures. This study also demonstrated that PET combined with MRI is sensitive in detecting possible metabolic and structural brain changes in TR-PTSD.

Ball and socket ankle joint in connection with bilateral tarsal synostosis in a boy with congenital absence of the portal vain: a novel malformation complex

BackgroundContracted valgus flat foot in the adolescent is frequently caused by tarsal synostosis or synchondrosis. These synostoses are prevalently symptomatic during adolescence, when by ossifying they block the subtalar joint in valgus. Careful and detailed examinations might reveal additional abnormalities.Case presentationA 16-year-old boy of Austrian origin presented with contracted valgus foot associated with tarsal hypomobility and pain. Talonavicular synostosis with ball and socket ankle joint was detected via lateral radiographs and 3 DCT scan. Preoperative laboratory investigations revealed leucocytopenia, and thrombopenia. Computerised abdominal tomography showed portal vein atresia and portopulmonary hypertension.ConclusionClinical research is the corner stone to elucidate the aetiological understandings in patients with malformation complex. The latter is a critical task for the development of scientific bases for preventive strategies. Careful examination for these abnormalities should lead the clinician to earlier referral of patients for additional examination by a specialised medical team. This often enables more focused care for the individual and better characterisation/documentation of the malformation complex. The association of tarsal synostosis and the previously unreported associated occurrences of congenital absence of the portal vein, portopulmonary hypertension, cardiomegaly and splenomegaly have been encountered. We stress that our present patient illustrates and supports the pathophysiological hypotheses that have previously proposed for the concurrent existence of absent portal vein, hepatic nodular hyperplasia and portopulmonary hypertension. Nevertheless, no previous single report signifies the existence of tarsal synostosis in connection with the above-mentioned abnormalities.

Bone Involvement in Rosai-Dorfman Disease (RDD): a Case Report and Systematic Literature Review

Purpose of ReviewRosai-Dorfman disease (RDD) is a rare histiocytic disorder typically presenting as painless cervical lymphadenopathy. Extranodal involvement is common and may also affect bones. Here, we present a patient with typical nodal disease and multifocal bone manifestations. Further, a systematic literature review was performed to better understand the phenotype, clinical course and treatment options of such patients.Recent FindingsRDD is a nonmalignant, classically sporadic histiocytosis. Nevertheless, increasing evidence also suggests familial forms of the disease. According to our literature review, bone involvement is exceedingly rare and heterogeneous. Clinical outcome in terms of mortality seems to be favorable in most cases. Currently, therapy strategies include surgical and immunosuppressive treatments, but the optimal treatment of osseous RDD remains to be defined.SummaryPatients with osseous RDD may present to rheumatologists with arthralgia or arthritis. Due to the rarity of the disease, diagnosis and treatment remain challenging.

Radiographic and Tomographic Analysis in Patients with Stickler Syndrome Type I

Objective: To further investigate the underlying pathology of axial and appendicular skeletal abnormalities such as painful spine stiffness, gait abnormalities, early onset osteoarthritis and patellar instability in patients with Stickler syndrome type I. Radiographic and tomographic analyses were organized. Methods: From a series of Stickler syndrome patients followed from early life to late childhood. Ten patients (6 boys and four girls of different ethnic origins were consistent with the diagnosis of Stickler syndrome type I ). Phenotypic characterization was the baseline tool applied for all patients and genotypic correlation was performed on four families Results: A constellation of axial abnormalities namely; anterolateral ossification of the anterior longitudinal spinal ligament with subsequent fusion of two cervical vertebrae, early onset Forestier disease (progressive spinal hyperostosis with subsequent vertebral fusion on top of bridging osteophytes and “Bamboo-like spine” resembling ankylosing spondylitis) and severe premature spine degeneration were evident. Appendicular abnormalities in connection with generalized epiphyseal dysplasia were the underlying aetiology in patients with Intoeing gait and femoral anteversion, early onset severe osteoarthritis of the weight bearing joint. Remarkable trochleo-patellar dysplasia secondary to severe osteoarthritis causing effectively the development of patellar instability was additional pathology. Mutation of COL2A1 has been confirmed as the causative gene for Stickler syndrome type I Conclusion: We concluded that conventional radiographs and the molecular determination of a COL2A1 in patients with (Stickler syndrome type I) are insufficient tools to explain the reasons behind the tremendous magnitude of axial and appendicular skeletal abnormalities. We were able to modify the criteria of the clinical phenotype as designated by Rose et al in accordance with the novel axial and appendicular criteria as emerged from within our current study.

Oncocytic adenomas of thyroid-mimicking benign or metastatic disease on 18F-FDG-PET scan

Background The literature is sparse concerning 18F-fluorodeoxyglucose (18F-FDG) accumulation in the Hürthle cell neoplasm (HCN) of the thyroid. Given the difficulty of accurately diagnosing HCN, even with ultrasound (US) and fine needle aspiration biopsy (FNAB), the ability to accurately characterize these lesions by 18F-FDG positron emission tomography (PET) would be of value. Purpose To describe six cases of oncocytic proliferation in the thyroid gland that mimics the presence of metastatic disease and was detected incidentally by an 18F-FDG PET scan. Material and Methods We conducted whole-body 18F-FDG PET examinations for cancer staging in 1862 oncological patients from 2012 to 2013. Among them, six subjects (4 women, 2 men; age range, 45–85 years) with focal-enhanced 18F-FDG accumulation in the thyroid gland were selected from the study population. This study group was further investigated using 99 m-Tc-pertechnetate scintigraphy, US, and FNAB. Two experienced nuclear physicians reviewed the images. Gray-scale US and color Doppler (CD) sonographic examinations of the thyroid were undertaken for all subjects using a sonographic device Logiq 5 Expert (GE Medical Systems, Osaka, Japan) equipped with a 7–12 MHz linear array transducer. Results In all six cases, abnormal 18F-FDG uptake was found locally in the thyroid. The average SUVmax of the HCN was 5.8 (range, 2.6–16). In all six cases, 99 m-Tc-pertechnetate scintigraphy showed a cold spot. Compared with normal parenchymal vascularity, five of the six masses were shown to be hypervascular by CD ultrasonography. Conclusion On PET scans, oncocytic proliferations of the thyroid may mimic metastases of other malignancies. The focal-enhanced uptake of 18F-FDG PET may be associated with a focal increase in the metabolic activity of the thyroid parenchyma due to the presence of oncocytes. Our study emphasizes the importance of obtaining cytological evidence before making a diagnosis of metastatic disease.

Hypophosphatemia, Severe Bone Pain, Gait Disturbance, and Fatigue Fractures After Iron Substitution in Inflammatory Bowel Disease: A Case Report

Intravenous infusions of different iron formulations are recognized as a cause of hypophosphatemia. Chronic hypophosphatemia can alter bone metabolism and bone material structure. As a consequence, osteomalacia may develop and lead to bone fragility. Herein, we report a patient with Crohns disease presenting with persistent hypophosphatemia and insufficiency fractures while receiving regular iron infusions due to chronic gastrointestinal bleeding. Previously, the patient regularly received vitamin D and also zoledronic acid. The patient underwent bone biopsy of the iliac crest that showed typical signs of osteomalacia with dramatically increased osteoid volume and decreased bone formation. Analysis of the bone mineralization density distribution (BMDD) revealed a more complex picture: On the one hand, there was a shift to higher matrix mineralization, presumably owing to low bone turnover; on the other hand, a broadening of the BMDD indicating more heterogeneous mineralization due to osteomalacia was also evident. This is the first report on changes of bone histomorphometry and bone matrix mineralization in iron‐induced osteomalacia.

An Incidentally Found Inflamed Uterine Myoma Causing Low Abdominal Pain, Using Tc-99m-Tektrotyd Single Photon Emission Computed Tomography-CT Hybrid Imaging

We report the case of a 50-year-old woman presented with a history of right hemicolectomy due to an ileocecal neuroendocrine tumor and left breast metastasis. Owing to a slightly elevated chromogranin A-level and lower abdominal pain, single photon emission computed tomography-computer tomography (SPECT-CT) was performed. There were no signs of recurrence on the SPECT-CT scan, but the patient was incidentally found to have an inflamed intramural myoma. We believe that the slightly elevated chromogranin A-level was caused by the hypertension that the patient presented. In the clinical context, this is a report of an inflamed uterine myoma seen as a false positive result detected by TC-99m-Tc-EDDA/HYNIC-Tyr3-Octreotide (Tektrotyd) SPECT-CT hybrid imaging.

99mTc-tektrotyd SPECT/MRI in the diagnosis of a gastroenteropancreatic neuroendocrine tumor.

Tc-tektrotyd is a recently developed tracer for imaging neuroendocrine tumors. We report the case of a patient with a history of prostate cancer and chronic lymphocytic leukemia, who presented with a liver biopsy showing leukemic infiltration associated with chromogranin and CDX2 positivity, suggestive of metastases from an intestinal neuroendocrine tumor. While diagnostic CT did not detect the primary tumor and showed only some liver metastases, Tc-tektrotyd SPECT/MRI fusion identified a pancreatic head tumor and several liver metastases. This case illustrates the feasibility and clinical value of SPECT/MRI fusion using Tc-tektrotyd in neuroendocrine tumor patients.

Multiple Leberherde und Eosinophilie – ein Fallbericht einer Fasciola hepatica -Infektion

Fascioliosis is a zoonotic disease caused by Fasciola hepatica (common liver fluke). Initial clinical symptoms are frequently non-specific. Even after the development of liver tumors, a range of different underlying disorders will have to be considered. The rare cause of a parasitosis is not always included in the differential diagnostic work up. We report on a 41-year-old truck driver from Middle East who was admitted at our hospital due to ongoing upper abdominal pain, fatigue, night sweat and nausea lasting for weeks. Diagnostic investigation showed leucocytosis, high erythrocyte sedimentation rate, elevated liver values and IgE as well as blood eosinophilia. Radiological findings of the computed tomography were bilateral pulmonary lesions 3 mm in size and multiple hepatic lesions up to 4.5 cm in diameter. Due to the suspicion of a malignant disease, a liver biopsy was planned but cancelled after parasitological serology (Western blot and ELISA) revealed IgG-antibodies against F. hepatica. Detailed history gave evidence of a recent parasitological infection during a stay in Turkey with consumption of vegetable which were grown and washed with water from the local river. Eggs of the parasite could neither be found in analysis of duodenal secretion nor in examination of fecal culture. However, confirmation for the infection with F. hepatica was proved with another positive serology. The treatment with Triclabendazole (Egaten(®)) for two days with a total dosage of 2000 mg was followed by a remarkable recovery of the patients symptoms and decrease of eosinophilia in the blood count just one month after treatment and normalization after four months.SummaryFascioliosis is a zoonotic disease caused by Fasciola hepatica (common liver fluke). Initial clinical symptoms are frequently non-specific. Even after the development of liver tumors, a range of different underlying disorders will have to be considered. The rare cause of a parasitosis is not always included in the differential diagnostic work up. We report on a 41-year-old truck driver from Middle East who was admitted at our hospital due to ongoing upper abdominal pain, fatigue, night sweat and nausea lasting for weeks. Diagnostic investigation showed leucocytosis, high erythrocyte sedimentation rate, elevated liver values and IgE as well as blood eosinophilia. Radiological findings of the computed tomography were bilateral pulmonary lesions 3 mm in size and multiple hepatic lesions up to 4.5 cm in diameter. Due to the suspicion of a malignant disease, a liver biopsy was planned but cancelled after parasitological serology (Western blot and ELISA) revealed IgG-antibodies against F. hepatica. Detailed history gave evidence of a recent parasitological infection during a stay in Turkey with consumption of vegetable which were grown and washed with water from the local river. Eggs of the parasite could neither be found in analysis of duodenal secretion nor in examination of fecal culture. However, confirmation for the infection with F. hepatica was proved with another positive serology. The treatment with Triclabendazole (Egaten®) for two days with a total dosage of 2000 mg was followed by a remarkable recovery of the patients symptoms and decrease of eosinophilia in the blood count just one month after treatment and normalization after four months.ZusammenfassungDie Fasziolose ist eine Krankheit, die durch Fasciola hepatica (Großer Leberegel) verursacht wird. Die anfänglichen klinischen Beschwerden sind in der Regel unspezifisch und weisen nicht immer auf eine parasitologische Ursache hin. Auch nach Ausbildung von Leberherden stellen sich klinisch unterschiedliche Differentialdiagnosen, wobei die seltene Ursache eines Parasitenbefalls nicht immer mit einbezogen wird. Wir stellen den Fall eines 41-jährigen Patienten vor, der wegen wochenlang anhaltender Übelkeit, Oberbauchschmerzen, Müdigkeit und Nachtschweiß im November 2010 im Hanusch-Krankenhaus in Wien stationär aufgenommen wurde. Auswärtige Befunde des Patienten (Gastroskopie, Lungenröntgen, Lungenfunktionstest) zeigten keine Auffälligkeiten. In der Computertomographie des Abdomen stellten sich multiple, bis zu 4,5 cm durchmessende Rundherde in der Leber als auch mehrere 3 mm große Raumforderungen bilateral in der Lunge dar. Im Labor waren eine Leukozytose mit einer Eosinophilie, erhöhte Blutsenkung, Leberwerte und IgE auffällig. Wegen des Verdachts auf eine mögliche maligne Grunderkrankung wurde eine Leberbiopsie geplant, die jedoch nach Vorliegen der parasitologisch-serologischen Untersuchungsergebnisse wieder abgesetzt wurde: Im Serum des Patienten konnten spezifische Antikörper gegen F. hepatica-Antigen festgestellt werden. Ein kurz zurückliegender Auslandsaufenthalt in der Türkei mit Genuss von Vegetabilen, die mit Wasser aus dem lokalen Fluss bewässert und gewaschen worden waren, machte eine Infektion mit F. hepatica auch anamnestisch sehr wahrscheinlich. Trotz des hohen Antikörperspiegels konnten im Stuhl bzw. in der Duodenalflüssigkeit keine Eier von F. hepatica nachgewiesen werden. Der Patient wurde mit insgesamt 2000 mg Triclabendazol (Egaten®) über 2 Tage behandelt. Schon bei der ersten Kontrolle, ein Monat nach der Therapie, war der Patient klinisch beschwerdefrei und die Eosinophilie im Blutbild deutlich rückläufig.