Hungarian Radiology

[Atypical breast cyst: problems of differential diagnosis]

PAPP László, KOVÁCS Zsolt, SZABÓ Éva, MINIK Károly, ANTALFI Bálint, BENDE Sándor

JUNE 20, 2006

Hungarian Radiology - 2006;80(03-04)

[INTRODUCTION - Cystic breast masses detected by ultrasound can be devided into several groups upon their morphology. One of them is the group of progressive atypical cysts. CASE REPORT - A young female patient presented multiple palpable nodules in the central part and in the upper-medial quadrant of the left breast. Ultrasound examination showed cystic lesions of middle size and with smooth walls. The cytological results of two consecutive punctures of the cyst was C2, consistent with acute inflammatory hemorrhagic cystic content. The patient was followed up by ultrasound, which 4-6 months later demonstrated considerable progression in size and morphological changes of the cysts. The presence of intracystic nodules and the pericystic solid lesions made the use of MRI examination justified but it couldn’t exclude the possibility of multicentric malignancy. The breast team decided the excision of the cystic lesions, at first. The biopsy revealed multiple intraductal and intracystic papilloma surrounded by normal breast tissue. CONCLUSION - Considering the problems of differential diagnosis which raised the suspicion of similar morphological histological entities (intracystic papillar carcinoma, adenoid cystic carcinoma, DCIS) surgery was justified. According to the authors’s suggestion, despite of the frightening morphological, radiological and clinical status, the less radical surgery should be performed.]



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Hungarian Radiology

[CT enteroclysis in small bowel Crohn’s disease]


[PURPOSE - The aim of this paper is to demonstrate morphological changes of Crohn’s disease observed by CT enteroclysis and also to evaluate the role of the method in the diagnosis and the follow up of patients with known or suspected Crohn’s disease. PATIENTS AND METHODS - We evaluated retrospectively 50 typical cases who were examined earlier. Crohns’s disease was diagnosed in 42 patients before CT enteroclysis. Histological confirmation was available in 36 cases after colonoscopy and in six cases after surgery. In eight patients had a high suspicion of the disease, histological examination was not performed. CT enteroclysis findings were read by two radiologist independently and results were compared. RESULTS - CT enteroclysis showed typical signs of Crohn’s disease in all patients. Different degree of wall thickening was seen in all cases, pathological enhancement of small bowel wall (in cases 35), multilayered appearance (n=29), fibrofatty proliferation (n=33), enlarged lymph nodes (n=37), entero-enteric fistula (n=6), entero-cutan fistula n (=5), mesenteric abscess (n=5) was found. CONCLUSION - CT enteroclysis is an accurate method to detect mural and extramural abnormalities in patients with Crohn’s disease. CT enteroclysis proved highly accurate in detecting small bowel involvement and it also provides an estimation of clinical activity of the disease. CT enetroclysis can be considered as the first imaging method in patients with clinical signs of Crohn’s diseases and also in the follow up of patients with known disease.]

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Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

Creutzfeldt-Jakob Disease: A single center experience and systemic analysis of cases in Turkey

USLU Ilgen Ferda, ELIF Gökçal, GÜRSOY Esra Azize, KOLUKISA Mehmet, YILDIZ Babacan Gulsen

We aimed to analyze the clinical, laboratory and neuroimaging findings in patients with sporadic Creutzfeldt-Jakob disease (CJD) in a single center as well as to review other published cases in Turkey. Between January 1st, 2014 and June 31st, 2017, all CJD cases were evaluated based on clinical findings, differential diagnosis, the previous misdiagnosis, electroencephalography (EEG), cerebrospinal fluid and cranial magnetic resonance imaging (MRI) findings in our center. All published cases in Turkey between 2005-2018 were also reviewed. In a total of 13 patients, progressive cognitive decline was the most common presenting symptom. Two patients had a diagnosis of Heidenhain variant, 1 patient had a diagnosis of Oppenheimer-Brownell variant. Seven patients (53.3%) had been misdiagnosed with depression, vascular dementia, normal pressure hydrocephalus or encephalitis. Eleven patients (87%) had typical MRI findings but only 5 of these were present at baseline. Asymmetrical high signal abnormalities on MRI were observed in 4 patients. Five patients (45.4%) had periodic spike wave complexes on EEG, all appeared during the follow-up. There were 74 published cases in Turkey bet­ween 2005 and 2018, with various clinical presentations. CJD has a variety of clinical features in our patient series as well as in cases reported in Turkey. Although progressive cognitive decline is the most common presenting symptom, unusual manifestations in early stages of the disease might cause misdiagnosis. Variant forms should be kept in mind in patients with isolated visual or cerebellar symptoms. MRI and EEG should be repeated during follow-up period if the clinical suspicion still exists.

Clinical Neuroscience

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

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