Dilemma of seronegative lupus nephritis: A case report of diffuse proliferative glomerulonephritis with thrombotic microangiopathyYuxuan Wu1, Qiaoyu Wang1, Haiyan Zhang2, Jianhua Qin1*, Weihua Wu1*1Department of Nephrology,Affiliated Hospital of Southwest Medical University; Sichuan Clinical Research Center for Nephropathy; Metabolic Vascular Disease Key Laboratory, Luzhou, Sichuan, China
Ectopic duodenal mucosa with adenomatous hyperplasia in the stomach: a case reportXiaowei Cai1, Lin Li1, Yanxia Yang2, Kang Lu1, Peng Wang1*1The 985th Hospital of the Joint Logistics Support Force;2The 986th Hospital of the Joint Logistics Support Force;*Corresponding Author: Peng Wang, Master Degree of Pathology, Department of Pathology, the 985th Hospital of the Joint Logistics Support Force, Qiaodong Road No.30, Taiyuan 030001, China. Email:[email protected].[Abstract] Introduction: Space-occupying lesions in the stomach are common diseases in gastroenterology. The diagnosis often needs the support of pathological results, and the prognosis of different masses is very different. Patient concerns: A 49-year-old man presented with abdominal distension and loss of appetite for one month as the main symptoms. Gastroscopy revealed a space occupying lesion in the pylorus of the antrum. Interventions:The mass was removed by gastroscopy resection with high-frequency electrocautery. Diagnosis: After electroresection, pathological and immunohistochemical examination showed that it was “ectopic duodenal mucosa with adenomatous hyperplasia in the stomach”. This disease has not been reported. Outcomes: After short-term follow-up and endoscopic review of this patient, we concluded that this disease is an extremely rare gastric tumor with benign growth and good prognosis. Conclusion: This case helps us to recognize the pathology and treatment of this disease, which is helpful for the differential diagnosis of other gastric space-occupying diseases.Keywords: ectopic duodenal mucosa, adenomatous hyperplasia,stomach,tumor
Fusion of a maxillary third molar with a supernumerary fourth molar: a case reportCase ImageA 20-year-old Caucasian male consulted the Department of Dentoalveolar Surgery, School of Dentistry in February 2023 due to intermittent pain in the left side of maxilla and face. Intraoral examination revealed probing pocket depth distally to left maxillary second molar 7mm and bleeding on probing. No health problem arises from medical history. Panoramic radiograph revealed impacted mandibular third molar, mesially angulated, with medium impaction depth, abnormal shape and size in close proximity with maxillary sinus floor (Figure 1).Preoperatively 2gr of Amoxicillin were prescribed. Surgical extraction took place under local anesthesia. Infiltration anesthesia with Lidocaine 2% with 1:80000 epinephrine. A full thickness mucoperiosteal flap was prepared and raised, and then ostectomy was performed using surgical handpiece and sterile saline irrigation. Tooth extraction was performed using straight and Warwick-James elevators. Valsalva maneuver was negative. Extraction socket was flushed with saline and flap was repositioned and sutured. Niflumic acid 250mg was prescribed for 3-5 days. Ex vivo examination of the tooth confirmed “double” tooth diagnosis. In order to obtain as much information as possible regarding dental anatomy, photos of all aspects of the tooth were taken and ex vivo CBCT of the tooth was carried out (Figure 2, Figure 3). Additionally, tooth was submerged in epoxy resin. After setting, three sections of the tooth were cut with a low-speed precision sectioning machine (Isomet 11-1180 Buehler, Lake Bluff, IL, USA) with water cooling. The cut surface of each tooth specimen was ground on a polishing machine (Jean Wirtz TG 250, Dusseldorf, Germany) with 200 rpm under water cooling (50 mL/min) using gradually 600-, 800-, and 1000-grit silicon carbide abrasive papers (Apex S system, Buehler, Lake Bluff, IL, USA) for 20s each. Final tooth sections were <1mm. Tooth specimen was placed between two liner polarization filters. Afterwards flash (Speedlight SB-700, Nikon, Japan) with softbox (Godox, China) was held from one side and DSLR camera (D7200, Nikon, Japan) with macro lens (Micro Nikkor 105mm, Nikon, Japan) from the other side. Filters were crossed in different directions until intended result was obtained (Figure 4, 5, 6). Sutures were removed after one week, healing was unproblematic. Oral examination after six months revealed complete healing of soft tissues.Differential diagnosis between different subcategories of “double” tooth is difficult. The supposition that gemination displays a single root canal and fusion displays several root canals is controversial. Fusion of a normal tooth with supernumeraries will still result in a normal tooth count. Given the presence of features suggestive of both diagnoses, this case, actually, presented a diagnostic dilemma.Fusion of two impacted teeth apparently results in a larger dental structure that makes extraction more invasive and inevitably raises the possibility of complications. Close proximity of maxillary third molar with maxillary sinus floor has to be appreciated. Fracture of maxillary tuberosity may occur in cases with extensive ostectomy.Alterations in tooth size and shape during initial radiographic examination may be a primary sign of dental abnormalities. Utilizing contemporary imaging techniques, including CBCT and dental photography, may showcase such special dental anatomies and complement dentists’ education in this field. Dentists’ awareness will result in a meticulous treatment planning and ensure a successful outcome.Figure legendsFigure 1: Initial panoramic radiograph. White arrow shows impacted third molar with small changes in size and shapeFigure 2: Images of the extracted “double” tooth from different aspectsFigure 3: Images exported from ex vivo CBCT of extracted “double tooth”. Shared pulp canal system is noticed.Figure 4: Image of the first tooth section, using polarization filters, DSLR, macro lens and flashFigure 5: Image of the second tooth section, using polarization filters, DSLR, macro lens and flashFigure 6: Image of the third tooth section, using polarization filters, DSLR, macro lens and flash
A Rare Case Report of Marjolin Ulcer of the Lower Limb Managed with AmputationDr Suraj KC1*, Dr Rakesh Kumar Gupta1, Dr Abhijeet Kumar1, Dr Bhawani Khanal1, Dr Samiksha Lamichhane2 ,Dr Sanjok Bartaulla1 , Dr Raghav jindal1, Dr Injmamul Haque Raki1* Corresponding Author: Dr Suraj KCDepartment of General Surgery, BPKIHS, [email protected] Rakesh Kumar Gupta:Department of General Surgery, BPKIHS, [email protected] Abhijet Kumar:Department of General Surgery, BPKIHS, [email protected] Bhawani Khanal:Department of General Surgery, BPKIHS, [email protected] Samiksha Lamichhane:Department of Radiodiagnosis and imaging, BPKIHS, [email protected]. Rahul Shrestha:Department of General Surgery, BPKIHS, [email protected]. Sanjok Bartaulla:Department of General Surgery, BPKIHS, [email protected] Injmamul Haque Raki:Department of General Surgery, BPKIHS, [email protected] Raghav JindalDepartment of General Surgery, BPKIHS, [email protected]:Marjolin ulcers are known to develop on chronic wounds and ulcers. Biopsy is indicated for chronically suspicious ulcers with no signs of healing. Metastatic workup is necessary before considering any type of surgery. Amputation, as in our case, is indicated when wide local excision or Mohs surgery cannot be performed. Chemotherapy and radiotherapy are reserved for advanced disease and patients who are not fit for surgery. Introduction: Post-burn wounds or scars have the potential to become chronic and may progress into Marjolin ulcers. While rare, it is important to be vigilant with suspicious wounds that do not show signs of healing. We present a case of a 55-year-old woman who developed a non-healing ulcer on the back of her right foot, covering the Achilles tendon, which ultimately required below knee amputation.Case Report:A 55-year-old woman with a history of hypertension and a flame burn on her right foot two years ago presented to the General Surgery Outpatient Department with a non-healing ulcer and foul-smelling discharge. The ulcer had grown from the size of a coin to 5cm x 5cm, located on the posterior aspect of her right ankle. The ulcer was painless with minimal bleeding, and she had intact distal neurovascular function. She denied any respiratory symptoms, chest pain, cough, or similar ulcers elsewhere on her body. Physical examination and vitals were stable. Upon local examination there was 5 x 5cm ulcer over the lateral malleolus and mass on the posterior aspect of the right Achilles tendon ( figure 1). Routine tests were normal, and a biopsy revealed squamous cell carcinoma. Imaging showed no signs of metastasis. The patient underwent a right below knee amputation, and the postoperative period was uneventful (figure2). She was discharged on the 4th post-operative day. The margins were negative for squamous cell carcinoma. On a follow up, stump was healthy, and she was referred for a prosthesis and rehabilitation. Regular follow-ups were advised under the General Surgery Department.\sout
IntroductionLemierre’s syndrome is a systemic septic embolism caused by thrombophlebitis of the internal jugular vein and presenting with various distantly infected abscesses. Various diagnostic criteria exist, but there is no standardized definition. Lemierre’s syndrome is generally believed to be caused by infection with anaerobic bacteria around the oropharynx. Delayed diagnosis can lead to dyspnea and deep neck infections due to acute airway constriction, which can lead to fatal outcomes. Ophthalmologic complications of Lemierre’s syndrome are relatively rare. In this study, we report our experience with a patient with Lemierre’s syndrome who lost her sight.
A case of Berry syndrome: a rare congenital cardiac structural abnormality with one-stage surgical repair Shanshan Ma1, Bi Wen1, Qi An2, Xin Zhang1*1Department of Cardiology, West China Hospital, Sichuan University, Guoxuexiang 37th, 610041 Chengdu, Sichuan, P.R. China2Department of Cardiovascular Surgery, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, Sichuan 610041, China*Corresponding Author: Dr. Xin Zhang, MBE-mail: [email protected]
Coarctation of the aorta in an adult with a concurrent large-size aortic arch aneurysmPing Zhang1, Dou Yuan2*1Department of Cardiology, West China Hospital, Sichuan University, Guoxuexiang 37th, 610041 Chengdu, Sichuan, P.R. China2Department of Cardiovascular Surgery, Cheng Du Shang Jin Nan Fu Hospital, West China Hospital of Sichuan University, Chengdu, Sichuan, China.* corresponding author：Dou Yuan
Prurigo nodularis (PN) is a chronic condition of unknown etiology that presents with pruritic, excoriated dome-shaped lesions on the extremities. It is challenging to treat using topical therapies alone. Newer options include monoclonal antibodies, as well as excimer UVB and psoralen UVA phototherapies. While these have shown clinical efficacy, they may
Accidental Finding Prior to Rhinoplasty: Rhinolith- A Rare Case ReportKey Clinical MessageThrough this case report, we review a rare radiopacity finding within the nasal cavity and its histopathological findings in order to emphasize the importance of familiarizing oneself with all radiographic findings, regardless of their rarity.Keywords: Rhinoplasty; Nasal Cavity; Nasal Obstruction; RhinolithIntroductionA rhinolith, also known as a nasal calculus, is a densely calcified mass, possibly formed around either external substances such as stones, batteries and plastic, or internal materials including dental epithelium and dried blood clots, within the nasal cavity (1-4). However, its exact etiology remains unknown (2). Typically, it is found either between the maxillary sinus wall and the inferior turbinate or between the nasal septum and inferior turbinate (1). Rhinoliths are generally single, unilateral and have an irregular shape (5). Various sizes and internal structures have been reported based on the nature of the rhinolith’s core, including homogeneous or heterogeneous radiopacities (6). The occurrence of rhinoliths in the oral and maxillofacial structures is rare (1). However, they are more commonly observed in young adults, females, and individuals with a low socioeconomic status (2). Symptoms such as headache, anosmia, nasal obstruction, discharge, swelling, unpleasant nasal odor, halitosis, epistaxis, localized pain, and fever have been reported in approximately 1 out of 10,000 patients visiting ear, nose, and throat (ENT) specialists in relation to rhinoliths, which may persist for months or even years (4, 6). Although rhinoliths are often asymptomatic (7) and may be detected incidentally through routine radiographic imaging (5). Conventional radiographs are useful in differentiating rhinoliths from other lesions and detecting their location, especially in cases where the foreign body has high radiodensity (5, 7). However, computed tomography (CT) is more effective in localizing rhinoliths with lower radiodensity in the core (3).In this case report, we present the incidental detection of a rhinolith through radiographic imaging in a 20-year-old patient who was a candidate for aesthetic rhinoplasty.Case presentationA 20-year-old female came to the outpatient department as a candidate for rhinoplasty. The patient’s general medical history and the head and neck examinations were unremarkable. There were no complaints of nasal obstruction or discharge. On extraoral examination, there was no sensory disturbance and the face was symmetrical except for the nasal septum deviation. Cone beam computed tomography (CBCT) was prescribed to the septum deviation. The CBCT revealed an s-type deviation of the nasal septum, open ostia, and clear maxillary sinus cavity. Additionally, a solitary, densely heterogenic calcified mass measuring 9.3 mm in width, 14.4 mm in height, and 8.7 mm in anteroposterior size was noted in the right nasal fossa between inferior turbinate and nasal septum. The mass was attached to the septum and the superomedial portion of inferior nasal concha and the inferomedial part of the middle nasal concha. The mass was well defined with mix, mostly opaque, and laminated internal view. (fig. 1)Based on the radiographic findings, three differential diagnoses were rhinoliths, paranasal osteoma, and nasal foreign body.The procedure entailed the removal of the lesion under general anesthesia. The lesion, which was attached to the perichondrium, was successfully excised using a nostril approach. Unilateral perforations on the mucosa of the septum and inferior and middle conchae, resulting from the lesion removal, were left unsutured due to their size, allowing them to heal through secondary intention. The excised lesion was sent for histopathological evaluation, and a routine septorhinoplasty was performed. For this purpose, a septal graft was harvested. However, the preserved L-strut proved inadequate in supporting the septal mucosa perforation due to its location and the amount of cartilage graft required. Turbinate outfracture or cauterization were not carried out, although turbinectomy was performed. An internal splint was applied as a routine measure, and follow-up sessions were scheduled for 1 week, 1 month, 3 months, and 6 months after the operation.The histological examination revealed the presence of vascular respiratory epithelium, with subepithelial glands displaying a bland appearance and mild chronic inflammation. Calcified foreign body fragments were also identified. No atypical cells or conclusive evidence of malignancy were detected. The histological findings were consistent with a diagnosis of rhinolith. (fig.2)The patient expressed satisfaction with the results and reported no nasal obstruction. Additionally, the patient noted improved breathing, despite having had no difficulties in breathing prior to the operation. No asymmetry was detected.A CBCT scan was ordered 3 months post-surgery to validate the histopathologic outcomes and confirm the complete removal of the lesion. The CBCT evaluation confirmed the successful and complete excision of the lesion, thus supporting the rhinolith diagnosis. Synechia was found to be limited. (fig.3)DiscussionRhinoliths are uncommon findings, likely caused by the deposition of mineral salts around a nidus, such as a foreign body (8). A high level of suspicion is necessary, and differential causative factors, including osteoma, calcified nasal polyps, and ossifying fibroma should be considered to choose the best treatment approach (9). A variety of symptoms may be reported, depending on the localization and size of the lesion, such as unilateral nasal obstruction, epistaxis, headache, anosmia, epiphora, and purulent rhinorrhea (2, 9). However, rhinoliths can also be asymptomatic (6). Therefore, in cases with no symptoms, radiographic scans can lead to a diagnosis of rhinolith (4). A radiopaque lesion with lesser radiopacity in the center, located in either the nasal cavity or maxillary sinus, is a good predictor for rhinolith (5). However, rhinoliths may also appear as a homogeneous radiopaque view due to the presence of a radiopaque nidus (2).In the present case, CBCT evaluations revealed a mixture of radiopaque and radiolucent radiographic findings. Furthermore, in the absence of any symptoms, a histopathological examination was conducted to establish a definitive diagnosis.In cases where there is a coexistence of septal deviation and rhinoliths, the septum is typically deviated towards the opposite side of the rhinolith (2). This is likely due to the influence of the rhinolith on the cartilaginous septum during mass growth (2). This finding is consistent with our case.Although previous studies have reported the concurrent performance of septoplasty or septorhinoplasty and removing rhinolith (2), the specific details of the septoplasty procedures used are unclear. In this case presentation, we have provided a detailed description of the septorhinoplasty procedure to assist surgeons in surgical planning.The defects in the intranasal mucosal lining may be asymptomatic and do not require additional treatment procedures (10). However, the intranasal exposure of the spreader grafts may occur due to the presence of a defect in the mucosa. Therefore, large defects may require covering the grafts using various techniques to protect them from intranasal exposure (11).A variety of surgical interventions have been introduced to manage perforations of the septal mucosa in cases where the underlying septum is also perforated. These procedures are categorized into local flaps only or incorporation of interposition grafts (10). The local flap may be used unilaterally or bilaterally, unipedicled or bipedicled, and with an anterior or posterior base (12). The interposition graft can also be harvested from various sites including temporalis fascia, conchal cartilage, and tragal cartilage (10). In the present case, despite the absence of supporting septal cartilage, the unilateral perforation of septal mucoperichondrial tissue was left unsutured because of the intact contralateral mucoperichondrial tissue of the septum. Moreover, the internasal splint was used to prevent synechia following the unsutured perforation of the mucosa of the septum and inferior and middle conchae. Favorable outcomes revealed the secondary intention was successfully performed.However, there is insufficient evidence regarding the critical limit of septal mucosa perforation that prevents synechiae and ensures secondary intention. This may also be influenced by many other factors, including the cite of the perforation. Therefore, further researches should be conducted in this matter.Based on the favorable outcomes and absence of complications, the introduced procedure may be useful for assisting surgeons in carrying out septorhinoplasty and successfully removing the rhinolith without concerns about synechia.Conflict of interest statementThe authors have no conflict of interest to declare.ConsentWritten informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.References1. Orhan K, Kocyigit D, Kisnisci R, Paksoy CS. Rhinolithiasis: an uncommon entity of the nasal cavity. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2006;101(2):e28-e32.2. Aksakal C. Rhinolith: Examining the clinical, radiological and surgical features of 23 cases. Auris Nasus Larynx. 2019;46(4):542-7.3. Hsiao J-C, Tai C-F, Lee K-W, Ho K-Y, Kou W-R, Wang L-F. Giant rhinolith: a case report. The Kaohsiung journal of medical sciences. 2005;21(12):582-5.4. Ersözlü T, Gültekin E. Rhinolith in the concha bullosa as a rare location: a case report. Journal of International Medical Research. 2020;48(8):0300060520951019.5. Barros CA, Martins RR, Silva JB, Souza JB, Ribeiro-Rotta RF, Batista AC, et al. Rhinolith: a radiographic finding in a dental clinic. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2005;100(4):486-90.6. Maheshwari N, Etikaala B, Syed AZ. Rhinolith: An incidental radiographic finding. Imaging Sci Dent. 2021;51(3):333-6.7. Manzi FR, Peyneau PD, Piassi FP, Machado VdC, Lopes AC. Radiographic and imaging diagnosis of rhinolith in dental clinics: A case report. Revista Odonto Ciência. 2012;27:170-3.8. Seyhun N, Toprak E, Kaya KS, Dizdar SK, Turgut S. Rhinolithiasis, a rare entity: Analysis of 31 cases and literature review. North Clin Istanb. 2021;8(2):172-7.9. Vedasalam S, Sipaul F, Hill A, Porter G. Nasendoscopy for unusual nasal symptoms. BMJ Case Rep. 2010;2010.10. Goh A, Hussain S. Different surgical treatments for nasal septal perforation and their outcomes. The Journal of Laryngology & Otology. 2007;121(5):419-26.11. Toriumi DM. Structure rhinoplasty: lessons learned in 30 years: DMT Solutions; 2019.12. Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngologic clinics of North America. 2009;42(3):483-93.Figure legends:Fig.1: pre-operative CBCT. (a) sagittal view; (b) coronal aspect; (c) axial section.Fig.2: histopathological micrograph. Note the fragments of calcified foreign bodies.Fig.3: post-operative CBCT. (a) sagittal aspect; (b) coronal view; (c) axial section. Note the limited synechiae in comparison with pre-operative CBCT.