A Rare Case of Primary Hepatic Adenosquamous Carcinoma Mimicking Liver Abscess

A 61-year-old woman with a 3-week history of chills, fevers to 39°C, anorexia, weight loss, and fatigue was referred to our hospital due to the progressive discomforts over the last week. Her documented medical history was notable for well-controlled type 2 diabetes. Physical examination was unremarkable. Notable laboratory tests of the blood revealed a hemoglobin level of 90 g/L, a white blood cell count of 11.7×109/L with neutrophil 90.7%, albumin 31.6 g/L, gamma glutamyl transferase 331 IU/L, alkaline phosphatase 748 IU/L. Direct microbiologic detection and cultures were negative for hepatitis B and C virus, bacterial and fungal pathogens, and human immunodeficiency virus. A computed tomography scan of the chest was unremarkable. Abdominal contrast-enhanced computed tomography discovered an ill-defined and sub-circular lowdensity region measuring 7.6×6.1cm with patchy enhancement in the right lobe of liver (Figure A), which implied a liver abscess. Empiric antibiotics were changed to meropenem combined with metronidazole on day three of hospitalisation. However, the fever did not alleviate with poorly therapeutic effect. Ultrasound-guided biopsy was performed and purulent fluid was collected to make a definitive diagnosis of the liver mass. Surprisingly, The histopathological detection of a needle biopsy sample confirmed neoplastic necrosis with negative bacterial and fungal culture of the purulent fluid. The patient then underwent right hemihepatectomy and histopathologic examination further revealed that the lesion included a mixture of a poorly differentiated adenocarcinoma with mucin production and squamous cell carcinoma with keratinization, as well as large patchy necrosis (Figure B). On immunostaining, the lesion stained strongly with CK5/6, P63, and P40, and was also partially positive for CK7, CK8/18, and Cam5.2 with negative staining for hepatocyte and alpha-fetoprotein, which were consistent with adenosquamous carcinoma of the liver. Primary hepatic adenosquamous carcinoma is a rare variant of intrahepatic cholangiocarcinoma with approximately 10 cases reported within 5 years.1,2 The pathogenesis of adenosquamous carcinoma of the liver is largely unknown owing to limited data in the literature. Fever, jaundice, weight loss, anorexia, and abdominal pain are the most frequently reported clinical manifestations.3 Adenosquamous carcinoma of the liver usually presents atypical imaging characteristics, which is difficult to distinguish it from liver abscess, hepatocellular carcinoma, and liver metastasis. Adenosquamous carcinoma of the liver is a highly aggressive neoplasm and the median survival time is 6 months after surgery.4 Therefore, preoperative diagnosis is of vital importance to predict a poor prognosis. Despite postoperative chemoradiation, the patient passed away 7 months after surgery.

952 When A Surgeon Was Called to The Obstetric Unit: A Rare Case of Gonococcal Peritonitis in A 12-Week Pregnancy

Background Primary bacterial peritonitis presenting as septic shock is infrequently seen in clinical practice. This is a case of gonococcal peritonitis presenting as septic shock in a pregnant lady needing emergency laparotomy, drainage of purulent fluid and abdominal lavage. Case Presentation A 35-year-old woman presented with severe generalised abdominal pain. No history of fever, vomiting, urinary or bowel complaints. She was in her 4th pregnancy, at 12-weeks gestation. She was afebrile but tachycardic and hypotensive. Abdomen was tender and there was no vaginal bleeding. Ultrasound scan showed minimal fluid in hepatorenal area and a viable intrauterine pregnancy. Differential diagnosis were ruptured appendix, ectopic pregnancy, acute abdomen and shock. Exploratory laparotomy was done. Moderate amount of purulent fluid was noted within the abdominal cavity and no bleeding was seen. General surgeon was called for assistance by the Obstetrician as no foci of infection was found. The uterus, fallopian tubes, ovaries, appendix, bowel and upper abdominal organs were found to be intact. Peritoneal fluid culture was taken. Drainage of purulent fluid and peritoneal wash was done. She was nursed in ICU because of peritonitis with septic shock and AKI. Peritoneal fluid culture showed Neisseria gonorrhoea and IV ceftriaxone was given for 7 days. Postoperatively she recovered well but needed evacuation of uterus for a missed miscarriage. She was screened for other STIs and were negative. Discussion Gonorrhoea is the second most common reported STI. It can present as acute peritonitis when the infection has spread beyond upper reproductive tract organs.

Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma

A 75-year-old man with a history of epithelioid mesothelioma and a right-sided indwelling pleural catheter (IPC) presented with a history of a purulent fluid drainage via the IPC. The pleural fluid cultured Klebsiella oxytoca and Enterococcus faecalis. He was treated with a course of oral fluoroquinolone followed by uneventful IPC replacement. One and half hours postprocedure, the patient had a witnessed drop in conscious level accompanied by seizure like activity. Acute stroke was suspected and a CT head was performed. CT head revealed multiple serpiginous pockets of air along the cerebral fissure, with features that were highly suggestive of cerebral air embolism and multiple wedge-shaped areas of infarction involving the cerebral hemispheres. Further imaging revealed satisfactory position of the replaced IPC. The patient was admitted to the intensive care unit for high flow oxygen therapy and head down ventilation. However, his condition deteriorated and he died later.

Necrotizing fasciitis in a 5-week-old infant: An unusual presentation

Necrotizing fasciitis is a rare and life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. These children should be managed promptly with broad-spectrum antibiotics and possible surgical debridement. Here, we present a 5-week-old female infant who presented with fever and ulcer on right lower jaw. She had a sudden onset of darkening of the right lower jaw, which progressed to reddish discoloration, and then an ulcer developed in the middle of this area of discoloration. She had a tender swelling extending from the right pre-auricular area to the right upper neck, crossing the right jaw and extending toward the right cheek and maxillary area. Swelling had areas of hyperpigmentation with an ulcer measuring 2 by 3 cm at the center of the lesion, oozing purulent fluid, and Staphylococcus aureus was cultured. The surgeons conducted incision and debridement in theater after suspecting necrotizing fasciitis of the jaw and the baby was kept on intravenous antibiotics, antiretroviral therapy and was dressed daily. The child fared well thereafter.

Recurrent Multifocal Mycoplasma orale Infection in an Immunocompromised Patient: A Case Report and Review

A young woman with mixed connective tissue disease complicated by erosive arthritis, secondary hypogammaglobulinemia due to rituximab, and a history of many infectious complications developed multiple nonhealing wounds, polyarticular joint pain, and leukocytosis. Radiographic studies demonstrated multiple scattered areas of osteomyelitis and complex abscesses. Purulent fluid drained from multiple sites did not yield a microbiologic diagnosis by standard culture technique, but Mycoplasma orale was ultimately identified using 16 S ribosomal RNA gene amplification and sequencing. We describe this unique case and review the literature.

Neisseira meningitidis Serogroup W causing primary meningococcal septic arthritis in a toddler and review of the literature

Since 2009, there has been a serious increase in the number of meningococcal infections in Europe caused by the serotype W meningococcus (MenW:cc11). Invasive meningococcal disease is typically known to cause severe sepsis or meningitiswith high overall mortality rates of 10% despite adequate antimicrobial treatment. Focal infections such as arthritis incidentally occur as a complication of systemic disease. Method We describe a rare case of primary meningococcal W135 arthritis in a 2-year-old patient. Results Arthrocentesis of the right Ankle while patient was under anesthesia, yielded grossly purulent fluid, so we made arthrotomy and drainage. The culture from synovial fluid revealed N. meningitidis.The status of the patient improved after surgical drainage and intravenous antibiotic therapy. She recovered completely after 1 month. Discussion.Atypical clinical presentation is associated with higher case fatality rates and can lead to misdiagnoses.an unusual presentation of invasive meningococcal infection and the early identification of the bacteria, combined with the correct treatment, prevent the complications and even death.

Fusobacterium Nucleatum Empyema: An Atypical Presentation

A 40-year-old man presented to the emergency room and was evaluated in the internal medicine department for unexplained weight loss, asthenia, anorexia and night sweats over the previous 2 months. After a loculated pleural effusion was identified on thoracic computed tomography, purulent fluid was drained from the lung and Fusobacterium nucleatum was isolated. The patient was successfully treated for 27 days with amoxicillin-clavulanic acid. This was an atypical presentation of a common micro-organism implicated in lung infections.

A Case of Valentino's Syndrome Presenting as Possible Appendicitis

Introduction We present a case of a 24-year-old female who presented with the signs and symptoms of acute appendicitis. Case report When computed tomography and ultrasound were not definitive for the diagnosis, the decision was made to perform a laparoscopic appendectomy. The appendix showed no gross signs of inflammation, so intraoperative esophagogastroduodenoscopy was used to examine for a perforated peptic ulcer. When no perforations were found, exploratory laparotomy was performed and revealed purulent fluid in the right colic gutter and a pinhole perforation in the first part of the duodenum. The defect was repaired and the abdominal space was washed thoroughly and closed. The patient recovered well and was discharged from the hospital in good health. Conclusion Valentino's syndrome is an uncommon cause of right lower quadrant pain and symptoms mimicking acute appendicitis.