Complete progressive ophthalmoplegia and numb chin syndrome, the first clinical manifestations of a lethal abdominal Burkitt lymphoma

A 57-year-old patient was admitted to the Neurology Clinic for hypoesthesia, intense pain in the right chin and double vision. During the hospitalization, the patient developed progressive complete bilateral ophthalmoplegia and numbness of both sides of the chin. Brain CT and MRI scans with gadolinium were normal. Standard laboratory tests on admission were normal. The cerebral spinal fluid examination and the infectious and autoimmune workup were also normal. A thoracic-abdominal and pelvic CT scan revealed two hypodense lesions in the liver, irregular thickening of the gastric and ileal wall, and multiple abdominal adenopathies. Meanwhile, the patient developed marked fatigue, fever, sweats, nausea, vomiting and abdominal pain. An exploratory laparotomy was performed that showed multiple tumours of the small intestinal wall, stomach wall, multiple liver masses in both lobes and appendicular tumour. Histopathological findings of the liver biopsy and appendicular walls revealed Burkitt lymphoma. The patient died two days after surgery by cardiopulmonary arrest. This case underscores the importance of keeping BL in the differential diagnosis of patients with rapidly progressive ophthalmoplegia and numb chin syndrome, with normal brain MRI and CSF examinations

Cerebral lesions of multiple sclerosis: is gadolinium always irreplaceable in assessing lesion activity?

PURPOSEWe aimed to identify imaging characteristics on conventional magnetic resonance imaging that could predict multiple sclerosis (MS) brain lesion activity without contrast media administration. MATERIALS AND METHODSMagnetic resonance data sets of forty-two patients with relapsing-remitting MS who presented symptoms or signs suggestive of new disease activity were retrospectively reviewed. We classified the MS lesions into three types according to different patterns present on T2-weighted images and evaluated their relationship with the contrast uptake. Evolving aspects of each type of lesion were observed in 18 patients during a follow-up period ranging from nine to 36 months. RESULTSOn T2-weighted images, only the pattern consisting of a thin border of decreased intensity compared with the lesion’s center and perifocal edema (Type II) reached diagnostic accuracy in terms of its relationship with gadolinium enhancement (P = 0.006). The sensitivity was 0.461, and the specificity was 0.698. In contrast, enhancement was not significantly related to the pattern consisting of a lesion center that was homogeneously brighter than its periphery (Type I) or less-hyperintense T2 focal lesions with either homogeneous or inhomogeneous center (Type III) (P > 0.05 for both). CONCLUSIONThe assessment of MS lesion activity should include a careful evaluation of T2-weighted images in addition to contrast enhancement assessment. The presence of an accompanying peripheral thin rim of hypointensity on T2-weighted images related best with contrast enhancement and subsequent lesion activity and may represent an additional pattern for disease activity assessment when gadolinium examination is contraindicated or influenced by prior therapy

A Rare Case of Double-System With Ectopic Ureteral Openings Into Vagina

The presence of an ectopic ureter may be indicated by continuous wetting, despite a normal voiding pattern, especially in girls. In most cases, an ectopic ureter is associated with a duplex collecting system and complete ureteral duplication. A 5-year-old girl presented with urinary incontinence regardless of the successful toilet training and a suspicion of left duplex kidney on a previous ultrasound. Contrast-enhanced computed tomography revealed a double left kidney with double ureters, both inserting together into the vagina. The surgical treatment consisted in the “en block” reimplantation of the ectopic ureters into the bladder, with complete resolution of the symptoms. The reported case does not represent just a typical presentation of a single ectopic ureter, as the duplex kidney system had ectopic both ipsilateral ureters (with insertion into the vagina). This case reminds us that congenital abnormalities of the genito-urinary tract should be considered in case of urinary incontinence and recurrent urinary tract infections

Acute Pulmonary Embolism in a Teenage Female – A Case Report

Thrombophilia represents a tendency towards excessive blood clotting and the subsequent development of venous thromboembolism (VTE). VTE is a rare condition in children that comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE). This paper reports the case of a 16-year-old girl, admitted to the Pediatrics Clinic No. 1, Tîrgu Mureș, Romania, for dyspnea, chest pain and loss of consciousness. Her personal history showed that she had had two orthopedic surgical interventions in infancy, two pregnancies, one spontaneous miscarriage and a recent caesarian section at 20 weeks of gestation for premature detachment of a normally positioned placenta associated with a deceased fetus. Laboratory tests showed increased levels of D-dimers. Angio-Computed Tomography (Angio-CT) showed multiple filling defects in both pulmonary arteries, establishing the diagnosis of PE. The laboratory tests were undertaken to assist in the diagnoses of a possible thrombophilia underlined a low level of antithrombin III. Antiphospholipid syndrome was ruled out and genetic tests revealed no specific mutation. Anticoagulant therapy was initiated with unfractionated heparin and afterwards subcutaneously low molecular heparin was prescribed for three months. Later it has been changed to oral therapy with acenocoumarol. The patient was discharged in good general status with the recommendation of life-long anticoagulation therapy. Thrombophilia is a significant risk factor for PE, and it must be ruled out in all cases of repeated miscarriage

Synchronous Colorectal Cancer: Improving Accuracy of Detection and Analyzing Molecular Heterogeneity—The Main Keys for Optimal Approach

Background: In patients with synchronous colorectal cancer (SCRC), understanding the underlying molecular behavior of such cases is mandatory for designing individualized therapy. The aim of this paper is to highlight the importance of transdisciplinary evaluation of the pre- and post-operative assessment of patients with SCRCs, from imaging to molecular investigations. Methods: Six patients with SCRCs presented with two carcinomas each. In addition to the microsatellite status (MSS), the epithelial mesenchymal transition was checked in each tumor using the biomarkers β-catenin and E-cadherin, same as KRAS and BRAF mutations. Results: In two of the patients, the second tumor was missed at endoscopy, but diagnosed by a subsequent computed-tomography-scan (CT-scan). From the six patients, a total of 11 adenocarcinomas (ADKs) and one squamous cell carcinoma (SCC) were analyzed. All the examined carcinomas were BRAF-wildtype microsatellite stable tumors with an epithelial histological subtype. In two of the six cases, KRAS gene status showed discordance between the two synchronous tumors, with mutations in the index tumors and wildtype status in the companion ones. Conclusions: Preoperative CT-scans can be useful for detection of synchronous tumors which may be missed by colonoscopy. Where synchronous tumors are identified, therapy should be based on the molecular profile of the indexed tumors

Lethal Subarachnoid and Intracerebral Haemorrhage Associated with Temporal Arteritis. A Case Report

Giant cell arteritis is a systemic inflammatory vasculitis, typically involving the superficial temporal arteries, but with possible ischemic and hemorrhagic cerebrovascular complications

Pediatric COVID-19: Low Incidence, but Possible Fatality—A Case Report and a Review of the Literature

Background: Pediatric COVID-19 is a current health burden mostly due to the lack of knowledge in terms of symptoms, clinical course and management. COVID-19-associated coagulopathy is one of the most recently described complications among adults, along with acquired thrombophilia resulting in an increased risk for venous, arterial and microvascular thrombosis. Case presentation: We report the case of a 4-year-old male child, admitted to our clinic for generalized seizures being intubated and mechanically ventilated before admission, with a personal history of ureterovesical junction obstruction, mild hydronephrosis, and an episode of generalized seizures. The laboratory tests revealed anemia, an increased number of monocytes, and a mildly increased C-reactive protein. A real-time polymerase chain reaction (RT-PCR) of the oropharyngeal swab was performed and it tested positive for SARS-CoV-2 in the child and both of his parents. The thoracic CT showed consolidation in the lower lobe of the left lung associated with an opacity in the right apex, suggesting possible atelectasis. We initiated antibiotic, antiviral, corticosteroids, as well as anticoagulants and antipyretics, continuing the chronic anticonvulsant therapy. The patient’s condition deteriorated progressively, and, after 72 h of hospitalization, he developed desaturation and bradycardia. The laboratory parameters on the third day showed leucopenia, neutropenia, increased creatine kinase, a high ferritin level, hypoalbuminemia, a prolonged prothrombin time and an increased international normalized ration. The patient died on the fourth day of admission. Conclusion: In spite of its low incidence and frequent benign clinical course, COVID-19 complications such as coagulopathy might represent a leading cause of death, even in pediatric patients