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CASE 247: INTRAHEPATIC AVM, Dr PHAN THANH HAI, Dr NGUYEN CAO CUONG, Dr TRAN NGAN CHAU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

April 10, 2014, 9:53 pm
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A 31-year-old male patient complained about 3-day mild fever, right subcostal abdominal pain. He did not have any other symtomps such as voimiting, diarrhea and no history of abdominal surgery, trauma, liver biopsy or alcohol abuse. On physical examination, no mass in the right subcostal. B-mode ultrasound (US) findings showed a cystic structure (21x21mm) in the sixth segment, it communicated with 2 parallel –dilated - tubular - structure (d = 8 and 9mm) originated from the right portal vein and right hepatic vein.
Doppler US showed yin-yang sign, right portal vein flow and right portal vein flow in the cystic structure.
MSCT Angio comfirmed the AVM in right lobe of liver.
The patient underwent an abdominal laparoscopic surgery for resection the AVM.
The patient remains well postop. Wait for microscopic result.
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CASE 248: GASTRIC WALL TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

April 14, 2014, 4:59 am
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Woman 75 yo vomiting, endoscopy detected  tumor extragastric fundus (see  pictures).


Ultrasound of abdomen showed one hypoechoic mass with size of 4 cm, well-bordered at the hilus of  spleen ( see 2 ultrasound pictures).



MSCT with CE  found out this mass bending the wall of great curvature of stomach, very slow CE enhancement (see 3 CT pictures).





Blood tests of all  markers are normal.
What is your suggestion of diagnosis?
Open surgery removed the tumor easily. It grew from gastric fundus wall, its structure was hard.


.Wait for  microscopic report.
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CASE 249: RLAQ MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

April 19, 2014, 8:30 pm
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Woman 56 yo, pain in RLAQ for 2 weeks, fever and GI tract trouble with diarrhea was treated  by  antibiotics.
Ultrasound detected one mass at RLAQ, suspected appendicular abscess or coecum tumor (see 4 US pictures).





Blood test  WBC= 17K with 17% neutro.
MSCT with CE  shows  this mass  being wall-off  by  instestine,  central part is  liquide as pus collection (see 3 CT pictures).




What is your suggestion of diagnosis and what is  the another test needed for make sure diagnosis?. 
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CASE 250: LOST of DENTAL PROSTHESIS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

April 21, 2014, 7:38 am
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Man 68 yo (photo) after  drinking a lot of  alcohol, he detected  lost of  dental prosthesis  and dysphasia and apnea,  like  cardiac  ischemia.




 He  came seeing cardiologist for dissolve his cardiac problem, but it was not getting better (echocardio image).






Chest XRay on PA  was normal, but  on LATERAL VIEW  there was something  in retrocardiac space (chest  XRay).



MSCT scan detected  foreign body in the midlle of his esophagus ( see 4 CT  pictures).






Endoscopy  detectedat themiddleesophagus  one dental  prosthesis made stuck  this site (see photo).



Treatment   emergency   at ENT  hospital. Endoscopy  removed  this  dental  prosthesis   that had lost 3 weeks  before.  Nasogastric  feeding, and wait for  progress. 

 

See  photo of dental prosthesis.


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CASE 251: PAIN at RIGHT HIP, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

April 26, 2014, 6:10 am
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Man 52 yo with history of pain at his right hip  joint 2 years prior, recently the pain is getting more severe, cannot walking (photo).


Plain XRay film of the pelvis looked like normal right and left hip joints.


Upon ultrasound  the right hip joint showed  widering of  the hip joint space with fluid collection, and abnormal echostructure of  the head of femoral bone (see 3 ultrasound pictures at right hip).  





Ultrasound examination of the right hip report was abnormal  in suggesting  arthrosis of right hip joint).
MRI of  the hip joint showed that right femoral head  in necrosis and hydarthrosis, and  small change also at left hip joint.





MRI report is aseptic necrosis of femoral  head  on right and left sides. 


Anatomy of vascular supply of femoral  head : 2  anterior  and posterior  pictures.



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CASE 252: NECK PAIN in LEMIERRE'S SYNDROME, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

April 30, 2014, 3:50 am
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Girl 13 yo, for one week sore throat and  fever, being  treated with antibiotics, now pain at right neck.
Ultrasound at the neck detected on right side some lymph nodes 2-3 cm at posterior SCM. And internal jugular vein dilated, big diameter 2, 2 cm black lumen, no flow,  cannot compressible (see US pictures of CCA and IJV on right side).






Meanwhile, on  the left neck,  there were normal flow of CCA and IJV ( see video clip).

CDI OF CCA AND IJV on R NECK







VIDEO 2: CROSSECTIONAL



What is your emergent thingking? What is the lab you must execute evaluation ?.

Blood tests: WBC= 15k.. neutro 40%, CRP=20mg/l  very high,   D-Dimer=500ng/ml  Bacteriology  bloodculture is on the way..
Based on CLINICAL INFECTION.and  LAB REPORTS, and ULTRASOUND  IMAGES.of  THROMBOSIS OF IJV, suggustion   LEMIERRE SYNDROME.
Urgent treatment with  IV ANTIBIOTICS and ANTICOAGULATION  DRUGS.

REF..HISTORY OF PROF  ANDRE ALFRED LEMIERRE.


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CASE 253: GOSSYPIBOMA (TEXTILOMA) POST CAESAREAN SECTION for a YEAR, Pham Hong Dong,M.D; Nguyen Duc Duy Linh,M.D; Phu Van Tuot,M.D; Nguyen Ngoc Xuan Giang,M.D., MEDIC Binh An Kien Giang Hospital

May 9, 2014, 8:45 pm
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A 26 year-old female patient who had complained mild pain at her pubic region  presented lower abdominal pain a month prior. She  overwent a caesarean section a year ago for delivery her child.
Ultrasound findings:A cystic mass (about 83x46 mm) containing distinct internal hyperechoic wavy, striped structures.    



           
CT Scan abdomen: A mass of 11 x 9 cm with thicken enhancing walls was seen in pelvis.






But diagnosis of gossypiboma was made and at laparotomy: a surgical sponge (18x22 cm) with adjacent inflammatory tissue and pus were removed successfully.



          
DISCUSSION:
A diagnosis of gossipiboma pre-op seems to be very difficult that always need skill and experience. Because of  imaging findings of gossypiboma are nonspecific and complexe so the right diagnosis in pre-op is still acchived about 1/3 of cases in literature.
But whenever an unknown mass into abdomen with exist surgical scare that should dissolve it may be a gossypiboma or not.


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CASE 254: CASTLEMAN DISEASE in COLONIC MESENTERY, Dr JASMINE THANH XUÂN, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

May 14, 2014, 4:47 pm
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A 22 yo female patient with a  mass of right abdomen which was detected by ultrasound check-up and thought to be a mesenteric tumor or a lymph node in mesentery. It was well-bordered and vascular structure without any symptom.
MSCT confirmed the 14x17mm mesenteric tumor in right abdomen with CE enhancement.


Open surgery removed the mass from posterior space of right colonic mesentery.

Microscopic result is a Castleman disease in mesentery, whichis an uncommon lymphoproliferative disorder that may be localized to a single lymph node (unicentric) or occur systemically (multicentric).


It was a  second case at Medic Center.
The first case of Castleman disease  was posted in 2010.
CASTLEMAN DISEASE in RETROPERITONEAL SPACE at MEDIC CENTER
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CASE 255: PERI-BREAST TUMOR, Dr PHAN THANH HẢI-Dr JASMINE THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

May 17, 2014, 8:30 pm
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Woman 34yo, in palpation detected herself at RUEQ one mass suspected breast tumor.
Mammography confirmed one mass   with  macrocalcification.. at 1h  site of right  breast with dense tissue (see 2 mammo pictures).




Ultrasound  scanning  at  right  breast  detected  one  hypoechoic ellypsoid mass with size of  3cmx2cm  in major pectoralis muscle, Upon CDI  scan  this mass was  hypovascular, and elastoscan  was  hard tissue, no  axillary  lymph node ( see  ultrasound scan B mode, CDI, elasto).





What is your suggestion of diagnosis ?.



MRI of mammary glands  were  done, this  mass  was  retromammary,  inside  major pectoralis muscle  on right site. The  signal  suggestion was hemangioma (see 2 MRI pictures).




FNAC report was compatible with retromammary hemangioma.
  

Operation removed completly this mass; microscopic report  was  cavernous hemangioma.
 
REF case   pdf.
 

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CASE 256: LIVER FUNGAL INFECTION in HIV-INFECTED PATIENT, Dr LÊ ĐÌNH VĨNH PHÚC, Dr VÕ NGUYỄN THÀNH NHÂN, MEDIC MEDICAL CENTER HCMC, VIETNAM

May 22, 2014, 4:25 pm
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A 30 year-old married woman, suffered from weight loss, fatigue, not fever, not abdominal pain. She has scanned by abdominal ultrasound at a province hospital detecting multifocal lesions in liver. Her doctor thought her liver hemangioma.

At MEDIC center, ultrasound scanning detected multi-hyperechoic masses with regular border, no vascular proliferative, no around liver parenchyma edema, no necrosis fluid, size of 0.5 to 2cm in right and left lobe.





CT Scan of liver was done with many reduced density lesions in the right and left lobe. The lesions were slight contrast enhancement. Some lesions were higher than in the center area.






Blood test with WBC normal, transaminases slight increase, HBsAg negative, anti-HCV negative. The important noticeable result is thatanti-HIV positive (ELISA).

The findings of ultrasound, CT Scan and blood test suggested liver fungal infection in HIV-infected patient. This patient was treated with anti-fungal drugs. Fungal infection is a common opportunistic disease in HIV-infected patient. Among the fungal opportunistic infections, Coccidioides immitis and Histoplasma capsulatum are those most likely to involve the liver [1]. Fungalliverabscessdiagnosisremains achallenge fordiagnostic imagingandclinical.

What is your suggestion of diagnosis?

References:
1. Anthony S. Fauci; H. Clifford Lane (2010). “Human immunodeficiency virus disease: AIDS and related disorders”. Harrison’s infectious diseases. Mc Graw Hill. p. 847







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CASE 257: KNEE PAIN, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

May 26, 2014, 2:14 am
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 Man 35 yo, 3 days ago, pain  at  right knee  cannot move, fever, no  history  of trauma. Clinical examination of right  knee:  hot and swelling at suprapatellar area (see photo).


Ultrasound first  scanned  at the right  knee, detecting  swelling of the  suprapatella recessus with homogeneous fluid  (2 ultrasound pictures).



MRI  of the  right knee  is  same   picture  report ( T1, T2).



Blood test  confirmed this infectious status  with  rising  WBC and  CRP.
For make sure  the  diagnosis: puncture of  the knee joint with  ultrasound guided..removing  the  yellowish  synovial fluid.
LAB analysis report  were  hight WBC and  negative gram stained bacteria  present in this fluid.


Diagnosis of  this case is acute  bacteria  infection of  the knee  joint, emergency  treated  with  antibotic and analgesic drugs.
DISCUSSION: in acute  case  ultrasound   guided  puncture of the  joint is fast action  for fast  diagnosis.

REFERENCE:



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CASE 258: Multiple Intraabdomen Nodules, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

May 30, 2014, 2:54 am
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Man 54 yo,  2 years after operation.for  acute obstruction of small  bowel by  tumor of  intestine, unknown microscopic  report.
Now he had  pain in the pelvis. (photo of  the skin scar operation).


Ultrasound  report   were  multiple  nodules  in  pelvis  looked like  grappe fruit
adherence  over  urinary bladder wall (2 ultrasound pictures).



MSCT CE of abdomen  detected   multiple  intramesenteric round tumors looked like  lymph nodes.




All blood test  and cancer markers were  normal.

Open laparotomy removed the mass which were  multiple  round tumors  adherent  to  great omentum and pedunculated (see  macro1, 2).



Microscopic report this tumor is  malignant  GIST recurrence.



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CASE 259: PLEURAL EFFUSION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

June 6, 2014, 6:15 am
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Woman  23 yo  for one  month cough  and  dyspnea, no  fever.
Ultrasound of the thorax detected left  pleural  effusion with collapsed lung and  one mass covered  anterior mediastinum to external pericardium (see 3 ultrasound pictures of the left lung).

 



MSCT  with CE of   the  chest confirmed a  big  mediastinal  tumor   with  pleural effusion  which displaced  the heart to the right side (see 3 CT pictures).




Blood test and all  cancer markers  were normal. 


Transthoracic biopsy of this tumor with  ultrasound guiding. Pathology report  with immuno-histochemitry  is  B CELL  LYMPHOMA.


This  patient is  going to treat with chemotherapy.

REFERENCE:   Mediastinal Tumor


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CASE 260: ODDI TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

June 10, 2014, 7:35 pm
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Man 40 yo  pain at  RUQ  with  dark urine.
Ultrasound  first   detected  big gallbladder  with  very think wall, no stone, CBD in dilatation just to   end  of CBD, no tumor of  pancreas (2 ultrasound images).



MSCT CE detected  dilated biliary system intra and extrahepatic ( 3 CT images).




Gastro-duodenal  endoscopy  found out a round tumor at Oddi  area (see photo),  biopsy was done.



Blood tests, CEA, CA-19-9 were normal.
What is  your suggestion for   diagnosis and your next step ? 

ERCP not successful.
Biopsy of the tumor but the microscopic result was negative.

Ooen operation for exploration, surgeon detected a hard massat the head of pancreas.
Whipple operation was performed  (specimen of tumor of Oddi).


Microscopic report was  adenocarcinoma ( patho images)


REFERENCE  from Meditoons



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CASE 261: HARD BREAST like AMBARELLA FRUIT, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

June 14, 2014, 6:37 am
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Woman 47 yo, she herself detected at the right breast one mass, slow growth, painless like one AMBARELLA fruit.
Ultrasound  first detected  this mass in size of 4 cm, at 10 am clock at  the right breast, with  many  white spots  as  calcification. Color Doppler finding also was a hypovascular mass.




Using elastoultrasound, the mass was  very hard,  scale  blue green color on elastogram, no detected  axillary  lymph nodes.




Mammography also detected  mass and microcalcification.




Core biopsy with ultrasound guided reports microscopic  INTRADUCTAL CARCINOMA, STAGING T2N0MX.


SUMMARY: BREAST CANCER IS  EASY DIAGNOSED BY ULTRASOUND WITH  ELASTOSCAN of  THIS VERY HARD  TUMOR  LIKE  GREEN AMBARELLA FRUIT.




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CASE 262: BIG ABDOMEN, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

June 17, 2014, 6:30 am
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 Man 50 yo, one week ago, onset periumbilical pain and abdominal distension, no defecation nor fever.
Chest Xray, and  abdomen standing  plain film showed  the  water-air level in  intestine, suggesting  bowel obstruction.


Ultrasound  found out colon dilatation, filling water and moving circular around with hyperperistalsis (see video).


MSCT of  abdomen in  emergency detected dilated right colon and  small intestine, retroperitoneum edema  arround the pancreas and radiologist  suggested  that pancreatitis.






Blood test: WBC  rising 12k, amylasemia normal.
Operation  laparotomy detected  all  bowel in dilatation but  no  necrosis, no tumor obstruction. 
Many white spots like candle   intra peritoneum.
Retroperitoneal space edema. Surgeon said chronic pancreatitis.


Discussion of this case:  clinical findings were abdominal pain and distension for one week. XRay  and  ultrasound found out  bowel obstruction and CT  detected  pancreatitis, but  blood test amylasemia was 17 unit.
Surgeon decided operation by bowel obstruction.
Now  report  is  chronic pancreatitis, it is  a rare  case with normal amylasemia in acute  pancreatitis.

REFERENCE:  case report


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CASE 263: BUFFALO'S NECK, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

June 20, 2014, 6:59 am
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Man 27 yo, dental  pain  on right mandibular  for one week, he detected  the right side of neck along  SCM muscle getting hot and swelling, pain and fever (see photo).


He was treated  with antibiotics and went to ultrasound scanning. Sonologist detected this neck mass beeing   like abscess by fluid collection on right and left neck (see 3 photo and video).







MSCT found out the right mass along SCM muscle and one other mass on left side nearby thyroid gland.





Puncture this mass  removed the pus but  direct examination  with gram stain no bacteria. 
Operation for drainage. 




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CASE 264: ASCITES, Dr PHAN THANH HẢI, Dr LÝ VĂN PHÁI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

June 29, 2014, 6:22 am
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Woman 31yo  3 days ago epigastric pain.

She came to MEDIC  for  gastroscopy and result was  gastritis, but ultrasound of abdomen  detected free  fluid of ascites around border of liver  and  small stone in gallbladder (see  ultrasound  images).



Liver was normal,  and ultrasound  at pelvis detected  one mass  on the left side of uterus, round,  5cm diameter, solid mass  with  small vessel  inside  and  RI low ( see  ultrasound images). Sonologist  susgested  an ovary tumor  in rupture.




MSCT with CE of this mass on  left lateral of uterus...with  CE enhance  like a  nidus of  pregnancy in rupture with  a lot of blood  clots  in abdomen ( see 3 CT pictures).





Blood tests  :  CA-125  rising 125 UI/mL  and  betaHCG  rising 134UI/mL
WBC 15K  with neutro 75%, Hct  29%.

Emergency  operation  in  BINH DAN hospital  detected  hemoperitoneum due to rupture of  tubal pregnancy (photo).



DISCUSSION: 
Epigastric pain is a common indication to gastroscopy that was not available for this case.
ULTRASOUND of  ABDOMEN  MUST BE  FIRST CHOICE for CASE.
BLOOD TEST  CA-125 RISING  NO  MEANING TO  OVARY  CANCER.
Beta HCG was  most  sensitive  for  diagnosis of this case.


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CASE 265: FISH BONE IN GALLBLADDER: Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

July 2, 2014, 11:49 pm
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Man 49 yo, pain in RUQ one week ago like gastric ulcer.

Ultrasound of  abdomen  suggested  gastric cancer  invasive to gallbladder and liver.

Gastroscopy and biopsy ruled out gastric cancer.

MSCT with CE detected  abscess due to perforated fundus of gallbladder and  one  foreign body like a fish bone, 3cm in length,  intra gallbladder (see 3 CT pictures).





Ultrasound of  abdomen again for verify diagnosis.also  made  same  information which was  abscess  due to  fish bone  penetrated through gallbladder wall to liver border.
(see 2 ultrasound images and video clip).



Blood tests were normal.



Operation  laparotomy removed abscess and gallbladder necrosis with fish bone inside abscess (see 3 photo).





REFERENCE: Case Report



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CASE 266: COLO-COLIC INTUSSUSCEPTION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

July 8, 2014, 12:55 am
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Man 38 yo, epigastric pain crisis on  periodic treatment  like gastritis but not response.

Ultrasound first in emergency  at MEDIC detected one mass  near  gallbladder with  multilayer cover as  OINION SIGN, and a central cyst.
This mass was  in transverse colon.  Sonologist  suggested a colocolic intussusception  (see 04  ultrasound  images and video clip).







Do you have any idea about the cyst in an intussusception mass?.

MSCT   with CE showed this  mass in transverse colon with cystic mass  looked like   appendicular mucocele.



Emergency laparotomy performed right hemicolectomy,   macroscopic specimen was appendicular mucocele [see photo]..

 Wait for microscopic result.


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