Acta Medica Lituanica最新文献

Background: A rare but serious complication of heart valve replacement, prosthetic valve thrombosis carries significant risks of morbidity and mortality. Effective management depends on prompt diagnosis and the appropriate treatment, often involving fibrinolytic agents. Protocols using slower infusion rates and lower doses of these agents have led to improved therapy outcomes.

Clinical case: We report a case of a 56-year-old man admitted to the Lithuanian University of Health Sciences Kaunas Clinics due to mechanical mitral valve prosthesis thrombosis complicated by a respiratory failure and atrial fibrillation. The patient was treated with ultraslow thrombolysis with alteplase. The function of the mechanical valve prosthesis became normal, and the patient was discharged from the hospital.

Discussion and conclusions: Managing prosthetic valve thrombosis is challenging due to overlapping clinical features with other diagnoses and the lack of consensus on the treatment methods. Slow-infusion, low-dose thrombolytic therapy with alteplase can be a life-saving intervention with a high success rate.

IgG4-related disease (IgG4-RD) is a rare autoimmune disease which can affect almost any organ. We present a case of IgG4-RD, which manifested as chronic autoimmune pancreatitis with pancreatic insufficiency, severe malnutrition, autoimmune sialadenitis, and cholangitis. After the administration of prednisolone and mycophenolate mofetil, the patient's condition improved significantly.

Heavy chain diseases (HCDs) are rare B-cell/plasma cell disorders characterized by secretion of truncated immunoglobulin heavy chains without light chains. Pulmonary involvement has been described but is typically limited to interstitial or infiltrative patterns; whereas, cystic lung disease is exceptionally rare. We report a 23-year-old previously healthy male who presented with recurrent spontaneous pneumothoraces over a two-year period. High-resolution computed tomography revealed numerous bilateral thin-walled cysts with upper-lobe predominance, with several of these abutting the pleural surface. Laboratory evaluation demonstrated a discrete monoclonal spike on serum protein electrophoresis, and immunofixation confirmed an isolated IgG heavy chain without light chains, consistent with γ-heavy chain disease (γ-HCD). Bone marrow biopsy showed a mild increase in plasma cells (5-10%) without overt malignancy, and alternative causes of cystic lung disease, including Birt-Hogg-Dubé syndrome, autoimmune disease, α1-antitrypsin deficiency, and HIV, were excluded. This case highlights γ-HCD as a rare cause of diffuse cystic lung disease with recurrent pneumothorax, expanding the pulmonary spectrum of heavy-chain dyscrasias. The radiographic overlap with light-chain deposition disease emphasizes the need to include monoclonal gammopathies in the differential diagnosis of unexplained cystic lung disease. Recognition of γ-HCD in this context is clinically important, as it may precede lymphoproliferative malignancy and mandates careful longitudinal surveillance.

We hereby report a 40-year-old woman presenting with chest pain and recurrent pericardial effusion. Cardiac MRI revealed diffuse sheath-like mass involving predominantly the right heart chambers. She also had bony and perirenal involvement. Additionally, she had a pineal gland tumor, a biopsy from which revealed xanthogranulomatous infiltration with foamy histiocytes which were CD 68 positive and CD1a negative, diagnostic of Erdheim Chester disease. Erdheim Chester disease is a rare form of non-Langerhans cell histiocytosis. We highlight the importance of multimodality imaging for comprehensive assessment of all the organ systems to enable prompt diagnosis of this rare condition.

Hepatic oligometastasis (hOMC) incidence varies from 10-40% in the literature. While the old standard for local treatment was surgical resection, options like TACE, TARE, SBRT with photons and off late protons have come to the fore. The proton beam therapy (PBT) use has gradually started to get adopted in all regions worldwide with increasingly better availability and ever-reducing costs. The role of PBT in hOMC has been studied in many retrospective cohort studies. Although there is a plethora of evidence on photon-SBRT, there are very few analyses on the role of PBT in hOMC. The author intends to analyse the efficacy in terms of the local control (LC) and the overall survival (OS) for PBT and its toxicity profile in this systematic review. LC remains persistently high (76-89% at 1-2 years) across breast, colo-rectum, stomach, and esophagus. Sites like colo-rectum and breast show relatively better survival outcomes, with progression free survival (35-52% at 1-2 years) and OS (33-78% at 1-2 years) than other sites, likely due to disease biology. Breast primary derived hOMCs had the best 3-year OS of 67.6%. Toxicities remain remarkably low with grade 3 plus toxicities ranging from 0-3%, which reflects the ability of proton therapy to deliver beams with precision.

Background: An anomalous right coronary artery (RCA) originating from the left anterior descending artery (LAD) is a rare subtype of single coronary artery ostium. Revascularization in such cases is challenging due to the large feeding territory or the potential for compression by an adjacent vessel.

Case description: We report the case of a 57-year-old woman who presented to our hospital with exertional chest pain and dyspnea. An anomalous RCA was identified, originating from the mid-portion of the LAD. Coronary angiography and coronary multi-detector computed tomography revealed a significant stenosis at the LAD just proximal to the RCA bifurcation. A successful percutaneous coronary intervention was performed to revascularize the LAD stenosis. The patient was discharged in good general condition two days later.

Conclusions: Despite the rarity of coronary anomalies, future studies could be undertaken to assess the potential benefits of screening, particularly in specific populations such as professional athletes.

Background: Accessory bones of the foot are common anatomical variants, with Os Vesalianum Pedis (OVP) representing a rare example located near the base of the fifth metatarsal within the peroneus brevis tendon. Although typically asymptomatic, OVP can become painful following trauma and may be misdiagnosed as a fracture, leading to inappropriate management.

Case presentation: We present two cases of symptomatic OVP in patients who reported lateral foot pain after acute ankle inversion injuries. Following radiological evaluation at a regional polyclinic, both patients were initially diagnosed with fractures of the fifth metatarsal base and referred to a traumatologist. However, further physical examination and detailed review of previous radiographs, revealing well-corticated, smoothly contoured ossicles, led to the correct diagnosis of OVP. Both patients were treated conservatively with rest, ice, elevation, physiotherapy, and NSAIDs, achieving complete functional recovery within three weeks.

Conclusions: These cases highlight the importance of recognizing OVP as a potential cause of lateral foot pain after trauma. Accurate diagnosis based on imaging characteristics can prevent mismanagement. Conservative treatment remains highly effective, and awareness of OVP is essential for appropriate clinical decision-making.

Background: Deaths resulting from car-pedestrian collisions are frequently encountered in forensic practice. Such accidents often cause extensive, multi-system injuries, many of which are concealed beneath minimally damaged soft tissues and may not be immediately visible externally. Common external injuries include extensive skin abrasions, subcutaneous hematomas, and lacerations. Internally, these incidents typically result in multiple bone fractures and severe organ ruptures. A less frequent but noteworthy injury is the evisceration of abdominal organs through ruptures in the diaphragm, rectum, or abdominal wall. This report presents a unique case of small intestine evisceration through damaged skin on the wrist.

Materials and methods: The literature search was conducted in the PubMed and Google Scholar databases using keywords. The analysis focused on scientific literature that was published in last 10 years but also referred to older scientific papers with strong arguments. To the best of our knowledge, there are no reported cases of evisceration of abdominal contents through the damaged skin of the lower arm (wrist). A clinical case examination from the Lithuanian State Forensic Medicine Service data was performed.

Case presentation: A 70-year-old woman was injured in the run-over accident by a truck. The victim died at the scene. External examination revealed multiple injuries, including significant soft tissue deformities in the left arm. During the internal examination of the corpse, multiple fractures with ruptures of internal organs were found. Only isolated fragments of intestinal loops were present in the abdominal cavity. Evisceration of the small intestines through the left upper arm and forearm was found.

Conclusions: Run-over accidents involving heavy vehicles are a common cause of fatal injuries. These incidents often result in extensive lacerations, multiple comminated fractures, and severe damage to internal organs. In rare cases, evisceration of internal organs can occur through various anatomical sites. This case demonstrates that evisceration can occur not only through common locations such as the diaphragm, abdominal wall, rectum, or vagina but also through atypical sites, such as the skin of the wrist. In such cases, it is particularly important for a forensic pathologist to assess the damage of clothing and to evaluate the macromorphological appearance of the injuries to determine the mechanism of injury.

Background: Computed tomography is a highly informative diagnostic tool, but its use poses the challenge of managing potentially high radiation exposure to patients. Children are particularly vulnerable to the harmful effects of ionizing radiation, and the growing use of paediatric Computed Tomography (CT) scans has been linked to an elevated lifetime risk of cancer and an increased mortality. The aim of this study was to evaluate local radiation exposure doses in paediatric thoracic and abdominal-pelvic CT exams, to establish Diagnostic Reference Level (DRL) curves, propose local diagnostic reference levels, and compare them with the existing literature and the European Guidelines on Diagnostic Reference Levels for Paediatric Imaging (PiDRL).

Materials and methods: A dataset of thoracic and abdominal-pelvic CT exams performed on children was analysed. Scan data entries were grouped according to the patient weight in the following intervals: 5 to 14 kg, 15 to 29 kg, 30 to 49 kg, and 50 to 79 kg. In each weight group, the minimum, first quartile, median, third quartile, and the maximum values of Volumetric Computed Tomography Dose Index (CTDI_vol) and the Dose Length Product (DLP) were calculated. The relationship between CTDI_vol, DLP, and the patient body weight was assessed by using exponential curves.

Results: The local DRLs were established for thoracic CT exams, while, for abdominal-pelvic CT exams, the DRL curve was set as a substitute due to limited data. The proposed local DRL values for thoracic computed tomography examinations are 2.0, 2.4, 3.6, and 5.0 mGy for CTDI_vol and 40, 60, 116, and 156 mGy•cm for DLP in the corresponding weight groups of 5 to 14 kg, 15 to 29 kg, 30 to 49 kg, and 50 to 79 kg. The median values of CTDI_vol for paediatric abdominal-pelvic computed tomography were 2.8 mGy in the 5-to-14 kg weight group, 3.6 mGy in the 15-to-29 kg group, 4.8 mGy in the 30-to-49 kg group, and 7.9 in the 50-to-79 kg group. The median DLP values were 81, 127, 203, and 304 mGy•cm, respectively.

Conclusions: The set local DRLs for thoracic and the median dose values in abdominal-pelvic CT exams are generally lower than the European DRLs. The derived DRL curves fulfil the same purpose as weight-group DRLs, serving as benchmarks for dose optimization.

Background: Phyllodes tumors are highly uncommon fibroepithelial neoplasms of the breast, accounting for less than 1% of all breast tumors. Differential diagnosis between phyllodes tumors and fibroadenomas by using imaging techniques such as ultrasound or mammography, as well as histological methods, can be challenging due to overlapping features. Phyllodes tumors are categorized into benign, borderline, and malignant types, each posing a different risk of recurrence and metastasis. Despite many advances in the imaging and biopsy techniques, diagnosing phyllodes tumors remains challenging. The purpose of this study is to review the existing literature on this topic and describe two cases of misdiagnosed phyllodes tumors.

Materials and methods: A literature review was conducted by using the Medline (PubMed) database over 10 years. Information concerning the patients was sourced from the Uster Hospital database. After analyzing the cases of women with breast lumps from 2020 to 2023 in the Uster Hospital database, two cases of misdiagnosed phyllodes tumors were identified. These two cases were analyzed retrospectively.

Results: A retrospective study of two cases confirms that phyllodes tumors are a rare phenomenon. A 51-year-old premenopausal woman presented with an 8 × 4 × 5 cm mass, initially diagnosed as a fibroadenoma. The final histopathology after surgical excision revealed a borderline phyllodes tumor with features overlapping those of a fibroadenoma. The second case involved a 59-year-old postmenopausal woman with a rapidly growing mass, which reached 11.9 × 11.3 cm and was initially diagnosed as a fibroadenoma but later confirmed as a borderline malignant phyllodes tumor with focal malignant components. Both cases highlight the limitations of imaging and core biopsy in accurately diagnosing phyllodes tumors and emphasize the need for comprehensive histopathological evaluation. The described clinical cases corresponded to the characteristics of phyllodes tumors indicated in the literature: they appeared in women older than 35 years, were hard to distinguish from fibroadenomas, and required surgical treatment.

Conclusions: Phyllodes tumors are challenging to distinguish from fibroadenomas based on imaging and the initial biopsy results alone. Accurate diagnosis requires thorough histopathological examination following surgical excision. A multidisciplinary approach is essential for optimal management. Our cases show the complexity of phyllodes tumor diagnosis and the importance of considering phyllodes tumors in the differential diagnosis of breast masses, especially when clinical and imaging findings suggest a more aggressive pathology.