Category Archives: Case Report

T-cell/Histiocyte-rich B-cell Lymphoma

Turcu M.1, Horvath Emoke2, Chira Liliana3, Cotoi O.S.4

1 Department of Pathology, University of Medicine and Pharmacy, Department of Pathology, Emergency County Hospital, Targu-Mures
2 Department of Pathology, University of Medicine and Pharmacy, Department of Pathology, Emergency County Hospital, Targu-Mures
3 Department of Pathology, University of Medicine and Pharmacy, Department of Pathology, Emergency County Hospital, Targu-Mures
4 Department of Cellular and Molecular Biology, University of Medicine and Pharmacy, Department of Pathology, Emergency County Hospital, Targu-Mures

Background: T-cell/histiocyterich B-cell lymphoma (T/HRBCL) is an uncommon morphologic variant of diffuse large B-cell lymphoma (DLBCL), representing less than 10% of all DLBCL cases. T/HRBCL has attracted considerable attention as a result of the difficult task of distinguishing it from similar entities, such as nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL), classic Hodgkin lymphoma and peripheral T/cell lymphoma, nonspecific.
Case report: We present the case of a 70-year-old female patient addressing her primary care physician for headaches, nausea and a large, painful tumor in her left axilla. The paraclinical examinations revealed minimal deviations of hematological tests, but showed elevated LDH values. Surgery was performed and a specimen, composed of 13 lymph nodes, (the largest one having the surface diameter of 130 mm) was removed and examined histologically. On microscopic evaluation, the HE stain showed portions of lymph node completely effaced and replaced by a vaguely nodular lymphoid proliferation composed of scattered, large cells, with abundant cytoplasm, multilobated vesicular nuclei and proeminent nucleoli, consistent with lymphocytes and histiocytes. The immunohistochemical study proved the proliferative mass to be constituted of a limited number of large, CD20 positive B-cells, with proeminent nucleolus, in a background of CD3 positive T-cells, together with a variable number of histiocytes, highlighted with CD68. The large B-cells were scattered and did not form any clusters or strips. A diagnosis of T/HRBCL was made.
Conclusion: T/HRBCL is a rare variant of DLBCL, with an aggressive clinical outcome. In such cases immunohistochemical analyses are mandatory to reach correct diagnosis.

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Successful Treatment with Infliximab in a Case of Crohn’s Disease with Peripheral Arthropathyes

Hodut A, Sabau I, Simedrea I, Belei Oana, Militaru Andrea

First Pediatric Clinic, Faculty of Medicine, University of Medicine and Pharmacy “Victor Babes”, Timisoara, Romania

Introduction: Crohn disease is an inflammatory bowel disease that involves any region of the alimentary tract from the mouth to the anus and it is transmural. Children with early onset are more likely to have colonic involvement. Infliximab constitutes today one of major therapeutic approaches at cases of Crohn’s disease.
Material and methods: We present the case of a 15-year-old female who was admitted in our department presenting pain of the large joints (exacerbated by movement), abdominal pain (epigastric and hypogastric), vomiting, diarrhea. In order to induce remission of the disease, we chose the step-up therapy (the only one accepted in Romania for children with Crohn disease). The initial response to immunosupressant therapy was moderate: no digestive symptoms were present, but extradigestive (articular) symptoms were still present and remission was not obtained (inflammation markers were still present and PCDAI was still above 15). We decided to try to induce remission with Infliximab.
Results: We obtained only temporary improvement of symptoms with “classical” therapy. We had a good response to Infliximab (remission was obtained), but treatment discontinuation without medical advise led to relapse after 9 months.
Conclusions: Infliximab was effective as therapy in Crohn’s disease with peripheral arthropathy, but too soon discontinuation of treatment due to patient’s non compliance determined relapse of the disease.

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The von Meyenburg Complexes

Turdean S1, Turcu M3, Varga AF1, Unguraş Dana1, Moldovan C4, Sin Anca2

1 “Gheorghe Marinescu” Municipal Hospital, Târnăveni
2 University of Medicine and Pharmacy of Tîrgu Mureș, Department of Cellular and Molecular Biology
3 University of Medicine and Pharmacy of Tîrgu Mureș, Department of Pathology
4 University of Medicine and Pharmacy of Tîrgu Mureș, Department of Histology

Background: Biliary duct hamartomas (the von Meyenburg complexes) is a rare malformation of the hepatic ductal plates usually discovered incidentally during surgery or autopsy.
Case presentation: We present the case of a 66 year-old man who presented symptoms suggestive of a biliary colic. Following an open surgical biopsy from the liver, the sample obtained underwent classic Hematoxylin-Eosin, as well as histochemical and immunohistochemical stains, which allowed establishing the diagnosis of biliary duct hamartoma, using macro- and microscopical criteria (well-defined, subcapsular hepatic lesions and no nuclear atypia).
Conclusion: The recognition of this particular lesion is important due to its macroscopic and microscopic resemblance to multiple liver metastases and other types of multicentric subcapsular hepatic lesions. The mandatory technique in order to diagnose this rare type of hepato-biliary lesion remains the histopathological examination.

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Giant Abdominal and Penoscrotal Idiopathic Lymphedema

Hintea A1, Botan A2, Coros MF1, Nagy S1, Cozma D1, Kazay Z2

1 County Emergency Clinical Hospital Tîrgu Mureș, Surgical Clinic I
2 County Emergency Clinical Hospital Tîrgu Mureș, Department of Plastic and Reparatory Surgery

The lymphatic system produces and transports fluids, immune cells and fats throughout the body. Abnormal transport and accumulation of lymph fluid may cause swelling (lymphedema).
Lymphedema, occurring quite frequently in the medical practice, may appear in a variety of pathologies such as: allergic reactions, infectious diseases, localized infections, radiotherapy, insect bites, as post-surgery reaction, etc. In all cases, it represents a subsequent effect of the main illness [1].
There is very small number of cases where lymphedema occurs as sole affection, the so-called ”primary or idiopathic lymphedema”. It is considered a genetic disease resulting in agenesis or the insufficient development of the lymphatic system [2].
The FLT4 gene provides instructions for producing a protein called vascular endothelial growth factor receptor 3 (VEGFR-3), which regulates the development and maintenance of the lymphatic system. Mutations in the FLT4 gene interfere with the growth, movement, and survival of lymphatic cells. These mutations lead to the development of small or absent lymphatic vessels. If lymph fluid is not properly transported, it builds up in the body’s tissues and causes lymphedema. It is not known how mutations in the FLT4 gene lead to the other features of this disorder, but many of these patients do not have a FLT 4 gene mutation. In these cases the cause of the swelling is unknown [1,3].[More]

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Gastric Trichobezoar

Mureșan Simona1, Mureșan M2, Eșianu M2, Bara T2, Bancu Ș2, Dénes L3, Bara T jr2

1 Department of Physiology, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
2 Surgical Clinic II, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
3 Department of Anatomy, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Introduction: Trichobezoars arise from the aggregation of ingested hair with other indigestible organic fibers. Trichotillomania, the practice of habitually pulling hair out, in association with habitual ingestion of hair (trichophagia) can predispose to the formation of trichobezoars.
Material and method: We present the case of a 28 year-old woman who was admitted to our clinic for abdominal pains, nausea and weight loss. The clinical examination revealed an abdominal mass in the upper part. The laboratory parameters were normal excepting a mild anemia and hipoproteinemia. A CT Scan of her abdomen showed a markedly distended stomach with a centrally located soft tissue abnormality. The patient underwent exploratory laparotomy and gastrotomy. We found an intragastric mass made up by hair. The trichobezoar was removed intact as a firm black mass and it was confirmed by the microscopic examination.
Results: The patient’s post-operative course was uneventful and she was discharged after 7 days of hospitalisation. We suggested psychiatric counseling.
Conclusions: The trichobezoar appears in young people with psychiatric disorders. Due to its dimensions, the only treatment in this case was open surgery. The after surgery course is usually favorable and needs psychiatric counseling.

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Acute Infusion Reaction to Infliximab in a Case of Crohn’s Disease with Recto-Scrotal Fistula

Hoduț A, Simedrea I, Belei Oana, Militaru Andrea, Bojinescu Raluca, Brad Giorgiana

First Pediatric Clinic, Faculty of Medicine, University of Medicine and Pharmacy, Timișoara, Romania

Crohn disease is an inflammatory bowel disease that involves any region of the alimentary tract from the mouth to the anus and it is transmural. Children with early onset are more likely to have colonic involvement. Infliximab constitutes today one of major therapeutic approaches in severe and fistulising cases of Crohn disease. We present the case of a 16 year-old boy who was admitted to our department presenting recto-scrotal fistula, fever, tenesmus, red-bloody stools, pain during and after defecation. In order to induce remission of the disease, we administrated Infliximab. The initial response to therapy was good, but he developed an acute infusion reaction during the administration of the 3rd dose, which forced us to quit this therapy.

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Chronic Vulvar Pain

Guță Camelia-Daniela1, Roșu Lucica2, Cotarcea Smărăndița3, Gavrilă Alice3

1 Department of Laboratory Medicine, “Plus Medica” Diagnostic and Treatment Center, Craiova, Romania
2 Discipline of Bacteriology, Virusology and Parasitology, University of Medicine and Pharmacy, Craiova, Romania
3 Department of Obstetrics-Gynecology, Filantropia Hospital, Craiova, Romania

Background: Chronic vulvar discomfort due to paucity of clinical signs is often associated with the term “vulvodynia”, perceived as a psychiatric problem.
Case report: A 28-year-old female patient presented for a 2-year history of vulvodynia, without any pathologic vulvar aspects. We investigated this syndrome by means of vulvar cytology, vulvoscopy, histology and ViraPap, too.
Results: Our interdisciplinary consultation indicates that vulvar vestibulitis syndrome co-exists with micropapillomatosis labialis (MPL), due to certain types of HPV. A herpes simplex episode occured 4 months after therapy and recurrent vulvovaginal candidiasis, too. During a period of 8 months, clinical examination showed smooth and well-demarcated whitish shiny plaques, that affected the clitoral hood, labia minora, the posterior fourchette and perineum. The clinical picture suggested a vulvar dystrophy.
Discussions: In this case report we intend a multidisciplinary approach to give a physical support to certain cases of vulvodynia, often associated with an expression of a psychological discomfort.

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Routine Immunophenotyping in Acute Leukemia, the Importance of Lineage Assessment

Bacârea Anca1, Dorcioman Bogdana2, Bacârea V3, Tilincă Mariana4, Demian Smaranda5, Șchiopu A1, Băţagă Simona6

1 Department of Physiopathology, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
2 Department of Hematology, County Emergency Clinical Hospital, Tîrgu Mureş, Romania
3 Department of Medical Research Methodology, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
4 Department of Cell Biology, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
5 Department of Hematology, Medical Clinic I, County Emergency Clinical Hospital, Tîrgu Mureş, Romania
6 Department of Internal Medicine, University of Medicine and Pharmacy, Tîrgu Mureş, Romania

We present the case of an adult male patient, where the assessment of cell line could not be done without corroboration of the immunophenotype and cytological analysis. The correct lineage assessment is needed in order to treat the patient correctly. Morphology, cytochemistry, and immunophenotyping were used and the diagnosis we established was B acute lymphoblastic leukemia with aberrant myeloid markers (CD13, CD33). Periodic Schiff Acid stain was very useful to obtain an accurate diagnosis. Adult B acute lymphoblastic leukemia usually has an unfavorable prognosis because of certain cytogenetic abnormalities (Philadelphia chromosome) and different reactivity to treatment. This case strongly supports the continued use of immunophenotyping in the diagnosis and monitoring of acute leukemia and corroboration of different diagnostic techniques for the diagnosis.

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Acute Myeloblastic Leukemia: Difficulties of Treatment, Complications and Evolution

Tilinca Mariana¹, Benedek Lázár Erzsébet², Köpeczi Judith Beáta², Bacârea Anca³, Bănescu Claudia4, Benedek I², Bățagă Simona5

1 Department of Cellular and Molecular Biology, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
2 Department of Hematology, Bone Marrow Transplantation Compartment, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
3 Department of Physiopathology, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
4 Department of Genetics, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
5 Internal Medicine I, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Introduction: This paper presents a special case of an acute myeloblastic leukemia accidentally diagnosed on a 57 years old asymptomatic person without occupational exposure, without a medical history, with normal blood count, without thrombocytopenia, as a result of routine hematological tests that reveal the presence of more than 10% blasts on peripheral blood smear.
Material and method: Bone marrow aspirate revealed 80% blasts and flow cytometry confirmed the diagnosis of acute myeloblastic leukemia LAM0. Cytogenetic examination showed normal karyotype 46, XX. The treatment aims to induce, maintain and consolidate remission. Since the classical therapeutical approach with Idarubicine and Cytarabine 3+7 was not tolerated, adjustments were necessary to 2+5, four courses being administered. During the remission period Methotrexate and Purinetol maintenance treatment was administered, it was obtained a tolerable quality of life, the patient resumed his work. The first relapse occurred after approximately one year. Later medical courses were established after chemotherapy protocol with Clofarabine and Cytarabine, but after intolerance, neutropenia, sepsis and death occured.
Results: Because of the severe prognosis and infectious complications the treatment was difficult and dose ajustments were necessary according to patient’s tolerance. Bone marrow transplant was not possible due to the lack of a compatible family donor.
Conclusions: This case of acute myelogenous leukemia treatment reflects the difficulties and complications occurred during the disease evolution. However remission periods with a tolerable quality of life were obtained, duration of treatment was approximately three years until death.

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Multidisciplinary Approach of Breast Cancer. Case Reports

Podeanu Daniela1, Stolnicu Simona2, Georgescu R3, Treaba Andrada1, Șincu Nina-Ioana4, Copotoiu C5, Brînzaniuc Klara6

1 Department of Radiology and Medical Imaging, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
2 Department of Pathology, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
3 Surgery Clinic III, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
4 Clinic of Infectious Diseases I, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
5 Surgery Clinic I, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
6 Department of Anatomy, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Introduction: Breast cancer is still the world’s most common cancer in women. Multidisciplinary approach represents the gold standard in diagnosis.
Case presentation: In order to emphasize the importance of this issue, we present three of our cases. In these cases of invasive carcinoma, in women ranged from 42 to 54 years, the diagnosis tools were clinical examination, mammography, ultrasound and histopathology. Minimal invasive breast biopsy and preoperative localisation procedures, under ultrasound and stereotactic guidance contributed to preoperative planning.
Conclusions: Interdisciplinary approach in diagnosis provides optimal management of breast cancer.

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