Giant intradiploic epidermoid cyst with large osteolytic lesions of the skull: a case report

<p>Abstract</p> <p>Introduction</p> <p>We report a case of tumor growth over a period of four decades, presenting with large multicentric lytic lesions of the skull and a profound mass effect, without neurological deficits. Clinical and radiological features of a patient with a giant intradiploic epidermoid and its impact on the choice of treatments are discussed.</p> <p>Case presentation</p> <p>An 81-year-old Caucasian man, who had first noticed a painless subcutaneous swelling over the left frontal scalp about 40 years ago, presented after a short episode of dizziness, which he experienced after treatment of focal retinal detachment. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations revealed an exceptionally large tumor involving major parts of the skull with extensive destruction of the bone and distinct deformation of the brain. Considering his age and the absence of neurological deficits or pain, the patient refused the option of tumor removal and cranioplasty, yet agreed to a biopsy, which confirmed the suspected diagnosis.</p> <p>Conclusions</p> <p>The course of the disease demonstrates that even patients with large tumors, inducing distinct pathomorphological changes, do not necessarily experience significant impairment of their quality of life without surgery. This is an impressive example of the chance to lead a long and satisfying life without specific medical treatment, avoiding the inherent risks of these procedures. Yet, there is a clear indication for surgery of intradiploic epidermoids in most cases described in the literature.</p

Why Pleiotropic Interventions are Needed for Alzheimer's Disease

Alzheimer's disease (AD) involves a complex pathological cascade thought to be initially triggered by the accumulation of β-amyloid (Aβ) peptide aggregates or aberrant amyloid precursor protein (APP) processing. Much is known of the factors initiating the disease process decades prior to the onset of cognitive deficits, but an unclear understanding of events immediately preceding and precipitating cognitive decline is a major factor limiting the rapid development of adequate prevention and treatment strategies. Multiple pathways are known to contribute to cognitive deficits by disruption of neuronal signal transduction pathways involved in memory. These pathways are altered by aberrant signaling, inflammation, oxidative damage, tau pathology, neuron loss, and synapse loss. We need to develop stage-specific interventions that not only block causal events in pathogenesis (aberrant tau phosphorylation, Aβ production and accumulation, and oxidative damage), but also address damage from these pathways that will not be reversed by targeting prodromal pathways. This approach would not only focus on blocking early events in pathogenesis, but also adequately correct for loss of synapses, substrates for neuroprotective pathways (e.g., docosahexaenoic acid), defects in energy metabolism, and adverse consequences of inappropriate compensatory responses (aberrant sprouting). Monotherapy targeting early single steps in this complicated cascade may explain disappointments in trials with agents inhibiting production, clearance, or aggregation of the initiating Aβ peptide or its aggregates. Both plaque and tangle pathogenesis have already reached AD levels in the more vulnerable brain regions during the “prodromal” period prior to conversion to “mild cognitive impairment (MCI).” Furthermore, many of the pathological events are no longer proceeding in series, but are going on in parallel. By the MCI stage, we stand a greater chance of success by considering pleiotropic drugs or cocktails that can independently limit the parallel steps of the AD cascade at all stages, but that do not completely inhibit the constitutive normal functions of these pathways. Based on this hypothesis, efforts in our laboratories have focused on the pleiotropic activities of omega-3 fatty acids and the anti-inflammatory, antioxidant, and anti-amyloid activity of curcumin in multiple models that cover many steps of the AD pathogenic cascade (Cole and Frautschy, Alzheimers Dement 2:284–286, 2006)

Images in Radiology - Complete Hydatidiform Mole With Live Pregnancy In A Twin Gestation

A 29-year-old primigravida, 22 weeks of gestation, complained of abdominal lump, pain in the abdomen, episodes of vasovagal attacks, headache and intermittent episodes of spotting. On physical examination she was normotensive and fundal height was 20 cm. Two big firm masses were palpable in the lumbar regions bilaterally. The foetal heartbeats were ausculated normally. Antenatal ultrasound examination revealed a live foetus, which had measurements consistent with 22 weeks of gestation. The placenta was anterior in location and showed grade I maturity, without any focal lesion. Another markedly enlarged mass, separate from the anterior normal placenta, with small cystic areas and increased echogenicity was seen along the posterior uterine wall, typically showing "snow storm" appearance. These changes were consistent with hydatidiform molar changes most probably in the second placenta (Figure 1). Two large extrauterine, predominantly cystic masses were also seen in the lumbar regions bilaterally near the fundus of the uterus. They were showing multiple cystic areas within it and measured approximately 15 X 15 cm in size. These were suggestive of theca lutein cysts in both enlarged ovaries in association with the hydatidiform mole (Figure 2). Serum titre of beta-HCG at 22 weeks was 1,20,000 mIU/ml. Chest x-ray, thyroid and liver function tests were normal. Repeat ultrasound at 24 weeks revealed exacerbation of placentomegaly and onset of polyhydramnios. The symptoms continued to increase and the patient underwent spontaneous delivery at 28 weeks of gestation and delivered a baby with weight of 1450 grams. The normal placenta was delivered within 15 minutes after birth and the abnormal posterior placenta was removed subsequently using surgical approach. The histopathology of the abnormal posterior placenta revealed hydatidiform (grapelike, cystic) degeneration of chorionic villi with inadequate vascularisation and abnormal, excessive proliferation of placental trophoblasts. Karyotype of the baby's white cells and mole revealed normal 46-XX chromosomal patterns. Mother's chest radiograph, abdomino-pelvic sonography and serum CA-125 marker study done post partum did not reveal any abnormality. She was not give any chemotherapy

Images in Radiology - Foetus in Fetu

A 2-year-old boy presented with gradual distension of the abdomen with an abdominal lump and 2-3 episodes of vomiting. There was history of low-grade intermittent fever. On examination the swelling was firm, ill-defined, globular, non-tender and moved with the respiration. Plain radiograph of the abdomen revealed a well defined mass of approximately 6 cm X 5 cm size, with a definite irregular hyperdense lesion in the right hypochondrium, displacing the bowel loops and the stomach. Ultrasonography (USG) of the abdomen showed a mixed echogenic predominantly cystic areas with large calcific foci causing posterior shadowing. Plain and contrast enhanced computed tomography (CT) scan of the abdomen revealed a 10 cm X 8 cm X 8cms sized mixed density mass with few well-defined cystic lesions within. The wall of the cyst measured 2 to 3 millimeters. There was a well-defined calcified structure within one of the cyst, which resembled the vertebral body (Figure 1). This hyperdense structure was surrounded by fat density (Figure 2). The mass lesion was displacing the bowel loops and was situated anterior to the dorso lumbar spine, extending from the level of upper pole of the kidneys upto the level of anterior superior iliac spine. Rest of the abdominal viscera was unremarkable

Images in Radiology - Intradiploic Epidermoid Cyst

A 35-year-old lady, presented with approximately 5 cm X 4 cm sized swelling in the left parietal region since childhood. There was history of progressive increase in the size of the swelling since childhood. There was no history of trauma. There was history of pain associated with swelling since last two months. On examination, the swelling was soft, non-tender and could be moved over the underlying bone. The skin over the swelling could not be retracted. Frontal and lateral radiograph of the skull showed an approximately 5 cm X 4 cm , well defined osteolytic lesion in the left posterior parietal bone (Figure 1). The inner table was scalloped and the outer table was everted (Figure 2). There was no evidence of calcification or periosteal reaction. Rest of the skull was unremarkable. For better delineation of the lesion, plain and contrast enhanced axial computed tomographic (CT) scan was performed. Plain CT scan revealed, a 5 cm sized soft tissue density lesion seen within the diploic space of the left posterior occipital bone with attenuation values ranging between 20 Hounsfield unit (HU) to +20 HU (Figure 3). This lesion was seen to protrude outside the margins of the skull and the dura matter was seen separately from the lesion. There was no calcification within the mass. On contrast there was no appreciable enhancement. Rest of the cerebral parenchyma was normal

Case Report - Giant Cell Tumour of Talar Body

Giant cell tumour (osteoclastoma) of talar bone is a rare entity and is seen more commonly in the third decade of life. We report this disease entity in a 17-year-old girl. The patient presented with painful swelling of the left ankle with an osteolytic lesion in the talus on conventional radiographs. Intralesional curettage and autologous bone grafting was performed following which patient's pain and swelling disappeared. Complete range of movement at the ankle joint was regained with minimal restriction at the subtalar joint. There is no evidence of relapse at six months follow up

Letter to the Editor - Percutaneous Conservative Management of Emphysematous Pyelonephritis

Sir, A 75-year-old lady presented with pain in left flank and fever. There was tenderness in left renal angle. On laboratory investigation, patient was found to be a diabetic and in renal failure. A plain film of abdomen showed unusual presence of air in the left renal fossa. Ultrasonography (USG) revealed non-visualisation of left kidney in left renal fossa with strong reflective echoes ('gassed out kidney'), which was consistent with emphysematous pyelonephritis. Plain computed tomographic (CT) scan revealed the presence of air collections in the left renal and perirenal space with fluid collections. The opposite kidney was unremarkable. Blood culture growed E. coli. Because of high risk for anaesthesia the decision of immediate nephrectomy was deferred. It was decided to manage the patient conservatively with immediate nephrostomy. A percutaneous nephrostomy was performed with Mallecot catheter under ultrasound guidance and the patient was kept on antibiotics and insulin. The patient showed immediate improvement in clinical status within 24 hours. Follow up CT scan demonstrated resolution of perinephric collection

Case Report - Iatrogenic Gastric Fistula Due to Inappropriate Placement of Intercostal Drainage Tube in a Case of Traumatic Diaphragmatic Hernia

A 26-year-old, 30 weeks primigravida presented with a gastric fistula through a left intercostal drain, which was inserted for drainage of suspected haemopneumothorax following minor trauma. It was confirmed to be a diaphragmatic hernia, with stomach and omentum as its contents. On exploratory laparotomy, disconnection of the tube and fistulous tract, with reduction of herniated contents and primary suturing of stomach was carried out. Diaphragmatic reconstruction with polypropylene mesh was also carried out. Post-operative recovery was uneventful with full lung expansion by 3rd postoperative day. Patient was asymptomatic at follow-up 6 months