RESUMEN
Solitary parathyroid adenoma is the most common cause of primary hyperparathyroidism; however, multiple parathyroid adenomas are an uncommon phenomenon. In this case report, we discuss a patient presenting with two concurrent ipsilateral parathyroid adenomas, and we review the literature. A 61-year-old African American female with a history of hypertension and kidney stones presented for the evaluation of hypercalcemia. Elevated serum calcium of 11 mg/dL was found on routine laboratory tests and low25 hydroxyvitamin-D level. Parathyroid hormone (PTH) was elevated at 172.5 pg/mL and increased to 443 pg/mL after correction of vitamin D deficiency. Renal function tests and thyroid function tests revealed normal findings. Imaging studies with 99mTc-Sestamibi scintigraphy raised concern for the possibility of either a parathyroid adenoma or hyperplasia. Minimally invasive parathyroidectomy with intraoperative PTH monitoring was planned. During surgery, the right superior parathyroid gland was found to be enlarged and was excised. However, intraoperative PTH monitoring showed an initial decrease to 203 pg/mL from a baseline of 443 pg/mL and a subsequent increase to 293 pg/mL suggesting the persistence of hyperparathyroidism. Further exploration of the neck revealed an enlarged right inferior parathyroid gland and two normal left parathyroid glands. Intraoperative PTH monitoring then revealed an appropriate decrease in PTH level to 56 pg/mL 10 minutes after excision of the right inferior parathyroid gland. More than a 50% decrease in PTH was achieved, and further exploration of the opposite side revealed no evidence of four-gland hyperplasia. Pathology reported two concurrent right superior and inferior parathyroid adenomas. Successful and curative parathyroidectomy for primary hyperparathyroidism was achieved. Although rare, multiple parathyroid adenomas occur in a significant minority of cases. Intraoperative PTH monitoring along with preoperative imaging provides guidance for curative parathyroidectomy. Additionally, more sensitive imaging such as four-dimensional computed tomography scans could lead to better localization, visualization, and identification of the second parathyroid adenoma.
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Elastofibroma dorsi (ED) is a rare tumor that most often occurs in the subscapular and infrascapular region between the thoracic wall, serratus anterior, and latissimus dorsi muscle. Based on a review of the literature, ED has been deemed an extremely rare entity. However, the incidence may be greater and is difficult to determine as the majority of ED being asymptomatic and therefore undiagnosed. Surgical excision is commonly performed when patients present with pain associated with ED. This being the case, it is important to evaluate the factors contributing to the pain seen in these patients and to evaluate the risks vs benefits of intervening in symptomatic ED patients who present for possible surgical intervention. We herein report a case of bilateral ED, situated in the upper back with only the right side being symptomatic in a 56-year-old male laborer. Due to pain in the right upper back, the patient underwent surgical removal of the ED. The postoperative course was uneventful and the patient had an excellent recovery. A review of the literature showed no correlation between pain on presentation and tumor size or location. Major complications of treating these patients include seroma or hematoma formation which according to the literature can be avoided using postoperative tube drainage and compressing bandages.
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Port-a-Cath also known as a subcutaneous implantable catheter is a common device used in patients undergoing drug infusions. Port-a-Cath placements are widely used among cancer patients who need multiple intravenous infusions with chemotherapeutic agents. The surgical approach to implanting a Port-a-Cath is associated with risks and benefits; however, it may also be associated with serious complications. We describe a rare case of a large right-sided hemothorax following right internal jugular vein cannulation after Port-a-Cath placement. We discuss possible causes of hemothorax in this patient and describe possible factors such as abnormal anatomy of vessels and body habitus contributing to this complication. We also highlight the use of imaging such as ultrasound-guided techniques and the importance of postoperative chest radiographs to screen for possible complications.
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Primary splenic epidermal cysts, a type I splenic lesion, are very uncommon and usually found coincidentally. In this report, we present a primary splenic epidermal cyst that presented as a mass in the left upper quadrant associated with sharp pain, early satiety, and constipation. We review the classification of splenic cysts with a detailed look into the causes and types of type I cysts. We discuss the different treatment options, how current and past surgical options are controversial, and indications for splenectomy in spleen cysts. We explore how percutaneous drainage as a bridge to splenectomy may have been beneficial in a splenic cyst of great size. This splenic cyst was attempted laparoscopically but converted to an open splenectomy after complications. The patient recovered with no difficulties postoperatively.
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Colon cancer is one of the most common diagnoses of cancer and a leading cause of death in America. Large cell neuroendocrine tumors are a very uncommon type of colon cancer that tends to have a poor prognosis. Usually, these tumors are only found at the time of metastasis making them even more difficult to treat. A 65-year-old female presented with worsened generalized abdominal pain associated with abdominal distention. She had not had a bowel movement in over a week and did not have any flatulence. She had a colonoscopy four years prior that was normal. Physical examination was significant for abdominal distention and a large right-sided palpable mass in her abdomen with generalized tenderness. A CT scan showed a large irregular mass at least 9.8 x 10.5 cm at the mid to distal ascending colon resulting in significant colonic narrowing significant for a large bowel obstruction. The CT also demonstrated suspicious nodules in the lung, lesions in the liver, and lymphadenopathy. She had an exploratory laparotomy with an extended hemicolectomy to remove the mass. Pathology revealed the mass was neuroendocrine carcinoma, a large cell subtype, that was poorly differentiated with involvement of at least 32 of 34 lymph nodes. This tumor was positive for AE1/AE3, CEA, CK20, and synaptophysin. Ki-67 showed 70% positivity. TTF1 was negative and ruled out a primary lung tumor. Microsatellite immunostains were positive for MLH-1, MSH-2, MSH-6, and PMS2. The patient was started on Carboplatin AUC6 and Etoposide 100mg/m2 in three-week intervals. Pegfilgrastim was also added to her treatment plan every 21 days. This is a review of a female who presented with colonic obstruction that was found to be poorly differentiated large cell neuroendocrine carcinoma after a previous negative colonoscopy.
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Linfoma de Células T Asociado a Enteropatía/complicaciones , Divertículo Ileal/complicaciones , Anciano , Linfoma de Células T Asociado a Enteropatía/diagnóstico , Humanos , Laparoscopía/métodos , Masculino , Divertículo Ileal/diagnóstico , Divertículo Ileal/cirugía , Tomografía Computarizada por Rayos XAsunto(s)
Enfermedades de las Arterias Carótidas/diagnóstico , Complicaciones Posoperatorias/diagnóstico , Fístula del Sistema Respiratorio/diagnóstico , Enfermedades de la Tráquea/diagnóstico , Traqueostomía/efectos adversos , Fístula Vascular/diagnóstico , Enfermedades de las Arterias Carótidas/etiología , Femenino , Humanos , Fístula del Sistema Respiratorio/etiología , Enfermedades de la Tráquea/etiología , Fístula Vascular/etiología , Adulto JovenAsunto(s)
Carcinoma Mucoepidermoide/diagnóstico , Neoplasias Orofaríngeas/diagnóstico , Tonsila Palatina , Adulto , Carcinoma Mucoepidermoide/cirugía , Humanos , Masculino , Neoplasias Orofaríngeas/cirugía , Tonsila Palatina/diagnóstico por imagen , Tonsila Palatina/patología , Tonsila Palatina/cirugía , LenguaRESUMEN
BACKGROUND: Parathyroid carcinoma is a rare neoplasm representing <1% of primary hyperparathyroidism cases. It is often not diagnosed until surgical exploration as a preoperative diagnosis is often not possible. Thus, preoperative staging for most patients is not feasible and this may compromise the treatment strategy. METHODS AND RESULTS: We report a case of a 29-year-old man presenting with avulsion fracture of the right elbow after a trivial fall. Neck exploration revealed an enlarged left lobe focally adherent to the larynx and trachea. Final pathology revealed parathyroid carcinoma with focally positive margin at the site of tracheal invasion. CONCLUSION: Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. The etiology of parathyroid carcinoma is usually obscured, and the initial operation offers the best chance for cure.
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Lesiones de Codo , Fracturas Espontáneas/etiología , Neoplasias de las Paratiroides/complicaciones , Neoplasias de las Paratiroides/diagnóstico , Accidentes por Caídas , Adulto , Biopsia con Aguja , Diagnóstico Diferencial , Estudios de Seguimiento , Fracturas Espontáneas/diagnóstico , Fracturas Espontáneas/cirugía , Humanos , Inmunohistoquímica , Imagen por Resonancia Magnética/métodos , Masculino , Neoplasias de las Paratiroides/cirugía , Paratiroidectomía/métodos , Resultado del TratamientoRESUMEN
Necrotizing fasciitis is an uncommon but a potentially fatal condition and can affect any part of the body. Most patients have pre-existing conditions that render them susceptible to infection, although etiology is unclear. Diagnosis is primarily clinical and is often delayed because of the unfamiliarity of the condition among clinicians. Management consists of immediate resuscitation, early surgical debridement, and administration of broad spectrum intravenous antibiotics. We report a case of a 70 year old woman who presented with a painful erythematous rash, was admitted as a case of cellulitis, later developed worsening of symptoms and septic shock, and was diagnosed as necrotizing fasciitis.
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OBJECTIVES: To understand baseline inequities in appendiceal perforation rates and the impact of hurricane destruction on the healthcare system with respect to perforation rates and racial disparities. METHODS: We used claims data extracted from Medicaid Analytic Extract files to identify appendicitis diagnoses in children and adolescents based on International Classification of Diseases-9 codes and appendectomy procedures based on Current Procedural Terminology codes in the hurricane-affected states of Mississippi and Louisiana. County-level summary data obtained from 2005 Area Resource Files were used to determine high and low hurricane-affected areas. We estimated logistic regression models, mutually adjusting for race, sex, and age, to examine disparities and mixed logistic regression models to determine whether county-level effects contributed to perforation rates. RESULTS: There were nine counties in the high-impact area and 133 counties in the low-impact area. Living in the high- or low-impact area was not associated with a statistically different rate of perforation before or after Hurricane Katrina; however, living in the high-impact area was associated with a change from a lower risk (odds ratio [OR] 0.62) of perforation prehurricane to a higher risk (OR 1.14) posthurricane compared with those living in the low-impact areas. African Americans had statistically higher perforation rates than whites in the high-impact areas both before (OR 1.46) and after (OR 1.71) Hurricane Katrina. CONCLUSIONS: Health professionals and hospital systems were able to maintain effective levels of care before and after Hurricane Katrina; however, perforation rates in African Americans suggest ongoing racial disparities during disasters.
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Apendicectomía/estadística & datos numéricos , Apendicitis/etnología , Negro o Afroamericano , Planificación en Desastres , Accesibilidad a los Servicios de Salud , Disparidades en Atención de Salud , Adolescente , Negro o Afroamericano/estadística & datos numéricos , Apendicitis/epidemiología , Apendicitis/cirugía , Niño , Preescolar , Tormentas Ciclónicas , Desastres , Femenino , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Louisiana/epidemiología , Masculino , Medicaid/estadística & datos numéricos , Mississippi/epidemiología , Análisis Multivariante , Características de la Residencia , Estudios Retrospectivos , Estados Unidos/epidemiología , Población Blanca/estadística & datos numéricosRESUMEN
Background. Acral lentiginous melanoma (ALM) is a less-common form of melanoma in US, and it accounts for about 5% of all diagnosed melanomas in US. ALM is often overlooked until it is well advanced because of the lesion's location and its atypical appearance in the early stages. We present a case of ALM initially presented as a diabetic foot ulcer. Case Report. An 81-year-old man initially presented to the primary care clinic with a right foot diabetic ulcer. There was a large plantar, dark-colored ulcer that bled easy. Initial excision biopsy revealed Clark's Level IV ALM. Subsequent definitive wide excision and sentinel node biopsy confirmed ALM with metastasis to inguinal lymph nodes (stage IIIb). The treatment included wide margin excision of the lesion with en bloc amputations of 4th and 5th toes, followed by adjuvant chemotherapy. Discussion. The development of ALM may potentially relate to diabetes as a reported higher prevalence of diabetes with ALM patients. Conclusion. The difficulty in early diagnosing of ALM remains as a formidable challenge particularly in diabetic patients who commonly develop plantar foot ulcers due to the diabetic neuropathy. This case reiterates the importance of a thorough foot exam in such patients.
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Neoplasias Óseas/cirugía , Lipoma/cirugía , Enfermedades del Sistema Nervioso Periférico/diagnóstico , Complicaciones Posoperatorias/diagnóstico , Escápula/cirugía , Diagnóstico Diferencial , Electromiografía , Humanos , Inflamación , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso Periférico/rehabilitación , Complicaciones Posoperatorias/rehabilitación , Tomografía Computarizada por Rayos XAsunto(s)
Adenocarcinoma/cirugía , Adenoma/cirugía , Colectomía/métodos , Neoplasias del Colon/cirugía , Laparoscopía/métodos , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Humanos , Tiempo de Internación/estadística & datos numéricos , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Radiation therapy to the head and neck for the treatment of benign diseases carries the potential for the late development of carcinoma. Low-dose radiation has been used as an adjunctive treatment for recurrent keloids, especially massive keloids, but the carcinogenic potential of ionizing radiation in this setting remains controversial. We report the case of a 37-year-old black woman with a history of severe earlobe keloids who had been first treated with resection and postoperative radiation at the age of 9 years. When she had reached the age of 36 years, she required reoperation for massive keloid scarring, after which she underwent a second course of postoperative radiation to the right side of her face and neck. Some 20 months after the second administration of radiation therapy, she developed a mucoepidermoid carcinoma in the right parotid gland. The tumor was successfully treated with surgery.