Category Archives: Case Report

Histopathological Diagnostic Criteria for Non-invasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features Highlighted by Six Illustrative Cases

Adela Nechifor-Boilă1,2, Edit Dee2, Angela Borda1,3

1. Department of Histology, University of Medicine and Pharmacy of Tîrgu-Mureș, Romania
2. Department of Pathology, Tîrgu-Mureș County Hospital, Romania
3. Department of Pathology, Tîrgu-Mureș Emergency County Hospital, Romania

DOI: 10.2478/amma-2018-0015

Introduction. The encapsulated, non-invasive subtype of follicular variant of papillary thyroid carcinoma (FVPTC) represents approximately 10% to 20% of all thyroid cancers. Many studies over the past decade have shown that these tumors carry an indolent clinical course, with no recurrence, even in patients treated by lobectomy. Their reclassification as neoplasms with “very low malignant potential” has recently been suggested by an international group of experts and a new terminology was proposed: “non-invasive follicular thyroid neoplasm with papillary-like nuclear features” (NIFTP). However, a diagnosis of NIFTP is still challenging for many pathologists in daily practice.
Presentation of case series. By presenting six illustrative cases of NIFTP, this article aims to highlight the diagnostic criteria and the burden difficulties when dealing with NIFTP cases. Characteristic histological features, inclusion and exclusion criteria for NIFTP, as well as sampling guidelines and differential diagnosis challenges are all discussed.
Conclusions. The diagnosis of NIFTP is not straightforward and requires meeting strict inclusion and exclusion criteria. Total sampling of the tumor capsule in these cases is mandatory in order to exclude invasion (capsular and/or vascular). A diagnosis of NIFTP promotes a less-aggressive patient management that is, no need for completion thyroidectomy or radioactive iodine therapy.

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Glomus Tumor of the Kidney: Case report

Edith Dee1,2, Andrada Loghin1, Tamas Toth1, Adrian Năznean3, Angela Borda1,2

1. Department of Histology, University of Medicine and Pharmacy of Tîrgu Mureș, Romania
2. Department of Pathology, Tîrgu-Mureș Emergency County Hospital, Romania
3. Department of Foreign Languages, University of Medicine and Pharmacy of Tîrgu Mureș, Romania

DOI: 10.2478/amma-2018-0018

Introduction: Glomus tumors are rare benign mesenchymal neoplasms accounting for only 2% of all types of soft tissue tumors. Commonly located in the peripheral soft tissues, they are most frequently encountered in the subungual areas of fingers and toes, and very rarely in visceral organs due to the absence of glomus bodies. To date, 22 cases of primary renal glomus tumors have been described in the literature, of which 17 benign, with no evidence of recurrence or metastasis, three cases of malignant glomus tumor, and two cases with uncertain malignant potential.
Case report: We report the 18th case of a benign glomus tumor of the kidney in a 49-year-old female patient, presenting the microscopic appearance (round, uniform cells with indistinct borders, scant finely granular eosinophilic cytoplasm, round nuclei lacking prominent nucleoli, arranged in solid sheets, accompanied by slit-like vascular spaces), the immunohistochemical profile (tumor cells showed immunoreactivity for smooth muscle actin, vimentin, as well as for CD34; they were negative for AE1/AE3, desmin, HMB-45, S-100 protein, renin, and chromogranin), and the differential diagnosis of this rare entity (juxtaglomerular tumor, angiomyolipoma, hemangioma, epithelioid leyomioma, solitary fibrous tumor, carcinoid tumor, and paraganglioma).
Conclusion: Primary renal glomus tumors are rare tumors that radiologically can mimic other mesenchymal renal neoplasm. Accurate diagnosis is based on the microscopic appearance and especially the characteristic immunophenotype.

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Late Onset Tay-Sachs Disease in a Non-Jewish Patient: Case Report

Smaranda Maier1, Zoltan Bajko1, Anca Moţăţăianu1, Adina Stoian2, Bianca Şchiopu3, Rodica Bălaşa1

1. University of Medicine and Pharmacy Targu Mures, Department of Neurology
2. University of Medicine and Pharmacy Targu Mures, Department of Patophysiology
3. Mureş County Clinical Emergency Hospital, Târgu Mureş

DOI: 10.1515/amma-2017-0034

Tay-Sachs disease (TSD) is a rare, inherited, autosomal rececessive lysosomal storage disease. The late-onset form is an uncommon condition among non-Jewish population.
We present the case of a 32 years old male patient without Jewish origins, in whom the disease began in adolescence and was initially diagnosed with spinal muscular atrophy. He developed progressively protean neurological symptomatology, including tetraparesis, cerebellar and extrapyramidal syndromes. The diagnosis was based on the cerebral MRI, showing severe cerebellar atrophy and the determination of the Hexosaminidase A activity, revealing low level.
In patients showing signs of lower motor neuron involvement, cerebellar and pyramidal signs and marked cerebellar atrophy the late-onset TSD should be suspected, and the first step in establishing the diagnosis should be to determine the serum activity of Hexosaminidase A.

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Colorectal Carcinoma in a Patient with Situs Inversus Totalis

Iunius Paul Simu1, Janos Jung2, Tivadar Bara3, Patricia Maria Luminita Simu4, Alexandru Ghizdavat5

1. Department of Radiology and Imaging, University of Medicine and Pharmacy Tîrgu Mures, Romania
2. Department of Pathology, University of Medicine and Pharmacy Tirgu Mures, Romania
3. Department of Surgery, University of Medicine and Pharmacy Tirgu Mures, Romania
4. University of Medicine and Pharmacy Tirgu Mures, Romania
5. Department of Anatomy, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2017-0039

Introduction: Colorectal cancer is one of the most common types of malignant tumors worldwide. In patients with situs abnormalities such as situs inversus totalis or situs ambiguus, the presence of this tumor could be a challenge for the surgeon, especially in cases in which the laparoscopic approach is considered.
Case presentation: We report the case of a 69-year-old male patient with situs inversus totalis. This particular case of situs inversus totalis was not a classical type because the patient had bilateral bilobed lungs, polysplenia, preduodenal portal vein in association with midgut malrotation. The pathology report after surgery revealed moderately differentiated adenocarcinoma of the sigmoid colon, stage pT3 N1c M1a, liver metastases but without metastases in the eight resected lymph nodes. We compared this rare association of diseases of particular anatomic aspects with other reports in the specialty literature.
Conclusion: The identification of situs abnormalities or other malformations in patients with resectable colorectal cancer is essential, thus preoperative imaging studies are imperative for a proper surgical management. Colorectal cancer metastasizing patterns in patients with intestinal malrotation need to be further investigated.

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Simultaneous Extrahepatic Portal and Iliac Veins Thrombosis After Abdominal Surgery – A Case Report and Review of Literature

Ioan Tilea1, Anca Elena Negovan2, Cristina Maria Tatar2, Elena Ardeleanu3, Radu Mircea Neagoe4, Raluca Marginean5, Andreea Varga1

1. Family Medicine Discipline, University of Medicine and Pharmacy Tirgu Mures, Romania
2. Internal Medicine III Discipline, University of Medicine and Pharmacy Tirgu Mures, Romania
3. Victor Babes University of Medicine and Pharmacy Timisoara, Romania
4. Surgery II Discipline, University of Medicine and Pharmacy Tirgu Mures, Romania
5. University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2017-0038

Introduction: Extrahepatic portal vein thrombosis (EPVT) is the most frequent cause that leads to portal hypertension in non-cirrhotic patients. This condition is related to systemic and local risk factors (such as inflammatory lesions, injuries to portal venous system by surgery, vascular procedures).
Case presentation: A case of extended extrahepatic portal vein thrombosis and simultaneous thrombosis of left common iliac vein and inferior vena cava, appeared after abdominal surgery in a hypertensive, diabetic, 50 y.o. man is presented. An acute episode of abdominal pain was interpreted as an emergency and a surgical (initially laparoscopic and then open) procedure was planned in order to perform an appendectomy. Discharge diagnosis was hemoperitoneum secondary to iatrogenic rupture of sigmoid mesocolon provoked by trocar manipulation. Repeated imaging studies performed later revealed the thrombosis of portal vein with extension into right portal branch associated with superior mesenteric thrombosis and free-floating thrombus into left common iliac vein extended towards inferior vena cava. Surgical manoeuvres are considered as triggers of these thrombotic events. After 4 weeks of parenteral anticoagulation a partial recanalization of thrombi was identified, without bleedings.
Conclusions: Acute EPVT needs a carefully management. Case is linked to abdominal surgery and requires prolonged anticoagulation related to simultaneous portal and iliac vein thrombosis. Associated conditions (hypertension and diabetes mellitus) must have an appropriate approach. After our knowledge this is the first case published in literature.

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Heterozygous Deletion in Exons 4-5 of SHOX Gene in a Patient Diagnosed as Idiopathic Short Stature

Anna David1, Imre Zoltán Kun1, Gábor Nyírő2, Zsuzsánna Szántó1, Attila Patócs2,3

1 University of Medicine and Pharmacy, Tirgu Mures, Romania
2 Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
3 MTA-SE Molecular Medicine Research Group, Budapest, Hungary

DOI: 10.1515/amma-2017-0028

Introduction: Isolated Short Stature Homeobox (SHOX) gene haploinsufficiency can be found in 2-15% of individuals diagnosed with idiopathic short stature determining different skeletal phenotypes.
Case presentation: We present the history of an 11-year-old female patient diagnosed with idiopathic short stature. Clinically, she was moderately disproportionate, with cubitus valgus and palatum ogivale. Her breast development was in Tanner stage 1 at the time of diagnosis. The endocrine diagnostic tests did not reveal any abnormalities except a slightly elevated thyroid stimulating hormone. We have also assessed the bone radiological findings. Multiplex Ligation-dependent Probe Amplification technique used for the identification of SHOX gene haploinsufficiency showed a heterozygous deletion spanning exons 4-5 of SHOX gene.
Conclusions: This case is determined by deletions in exons 4-5 of SHOX gene and indicates the necessity of screening for SHOX deletions in patients diagnosed with idiopathic short stature, especially in children having increased sitting height-to-height ratio or decreased extremities-to-trunk ratio.

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Transthoracic 3D Echocardiographic Imaging of Type A Aortic Dissection – Case Presentation

István Adorján Szabó, Ildikó Kocsis, Zoltán Fogarasi, Boglárka Belényi, Attila Frigy

Clinical County Hospital Mures, Romania

DOI: 10.1515/amma-2017-0027

In type A aortic dissection (AoD) an early and accurate diagnosis is essential to improve survival, by applying urgent surgical repair. 3D transthoracic echocardiography (3D-TTE), an advanced noninvasive imaging technique, could offer a comprehensive evaluation of the ascending aorta and aortic arch in this regard. Both modalities of real-time 3D imaging – live 3D and full-volume aquisition – proved to be useful in evaluating the localization and extent of AoD. Our case illustrates the utility of 3D-TTE in the complex assessment AoD. By providing the proper anatomical dataset, 3D-TTE could facilitate considerably the diagnosis of type A AoD.

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Practical Advantages of CBCT in the Surgical Treatment of Impacted Lower Third Molar

Alina Ormenișan, Alina Iacob, Daniel Szava, Balint Bogozi, Adina Coșarcă

University of Medicine and Pharmacy Tirgu Mures, Romania

 

DOI: 10.1515/amma-2017-0006

Introduction: The imaging method of cone beam is an improved, extremely accurate computed tomography applicable in the whole field of dentistry. Due to its ability to locate the exact position of the impacted teeth, CBCT software has an important role in the management of difficult cases of impacted third molar. In some situations, the lower third molar is quite near to the inferior alveolar nerve that the surgical extraction can present a high risk of post-operative sensitive impairs of the skin and mucosa of the lower lip and chin on the same side.
Presentation of case series: Our study tried to assess the contribution of CBCT in the pre-operative evaluation and further treatment of patients with impacted third molars in mandibular bone with high risk of inferior alveolar nerve injury. The paper presents three clinical cases showing positive signs on standard OPG, which exhibit indicators of a potential contact between the inferior alveolar nerve and the impacted lower third molars. For an improved exploration Dental CT Scan, DICOM image acquisition program, and 3D reconstruction with a special software were used. Conclusions: The study showed that compared with panoramic radiography, CBCT improve the evaluation of the surgical risk and allow a more accurate planning of surgery.

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An Uncommon Severe Case of Pulmonary Hypertension – From Genetic Testing to Benefits of Home Anticoagulation Monitoring

Varga Andreea1, Țilea Ioan1*, Lazar Erzsebet1, Negovan Anca Elena2, Banescu Claudia3, Tatar Maria Cristina2

1 Family Medicine, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Internal Medicine III, University of Medicine and Pharmacy Tirgu Mures, Romania
3 Genetics, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0050

A 62 year-old caucasian male was admitted in our pulmonary hypertension expert center with initial diagnosis of pulmonary veno-occlusive disease for validation and specific treatment approach. Routine examinations revealed no apparent cause of pulmonary hypertension. Patient was referred for a thorax contrast enhanced multi-slice computed tomography which revealed extensive bilateral thrombi in pulmonary lower lobe arteries, pleading for chronic post embolic lesions. A right heart catheterization and pulmonary angiography confirmed the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). Following the local regulations, the patient underwent thrombophilia screening including molecular genetic testing, with positive findings for heterozygous for VCORK1 -1639G>A gene single nucleotide polymorphism, PAI-1 4G/5G and factor II G20210A gene. With heterozygous genetic profile of 3 mutations he has a genetic predisposition for developing a thrombophilic disease which could be involved in the etiology of CTEPH. Familial screening was extended to descendants; the unique son was tested with positive results for the same three genes. Supportive pulmonary hypertension drug therapy was initiated together with patient self-monitoring management of oral anticoagulation therapy. For optimal control of targeted anticoagulation due to a very high risk of thrombotic state the patient used a point-of-care device (CoaguChek®XS System, Roche Diagnostics) for coagulation self-monitoring.

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Case Report: Endoscopic Management of Sleeve Gastrectomy Fistula

Roşu Alexandra Floriana1*, Ferreira Carlos Noronha2, Ribeiro Luis Carrilho2, Velosa José2, Zlatian Ovidiu Mircea3

1 Gastroenterology Department, County Clinical Emergency Hospital, Craiova, Romania
2 Gastroenterology and Hepatology Department, University Hospital Santa Maria, Lisbon, Portugal
3 Microbiology department, University of Medicine and Pharmacy of Craiova, Romania

DOI: 10.1515/amma-2016-0049

Background. Morbid obesity is an important cause of morbidity and mortality. Bariatric surgery is the best option to manage obesity. Vertical gastrectomy is safe and effective but sometimes complicate with hemorrhage, fistulas and stenosis. Fistulas can be solved by conventional surgery or interventional endoscopy.
Case presentation. We describe a morbidly obese patient with vertical gastrectomy who developed complications after surgery. Immediately after surgery the patient developed sepsis. Upper gastrointestinal endoscopy excluded fistula. One month later a peri-gastric abscess developed due to a fistula orifice in the distal esophagus, treated with argon plasma and two double pigtail plastic stents placed endoscopically to drain the abscess. The stents were removed two weeks later and was placed a covered metallic stent in the distal esophagus. Six weeks later the metallic stent was removed and the orifice closed. Four months later the patient developed sepsis. Computer tomography revealed a subdiaphragmatic abscess and endoscopy revealed a 2 mm fistula orifice at the previous site, treated with argon plasma and two trough-the-scope clips that closed it. There were no further incidents after two years of follow-up.
Conclusions. Early diagnosis and endoscopic approach can resolve these complications without the morbidity and increased mortality risk of surgical re-interventions.

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