No abstract

Abdominal MRI allows the noninvasive diagnosis of bowel necrosis. This may aid the timing of surgical intervention in preterm infants with a clinical diagnosis of NEC.gangrene, ischemia, MRI, necrotizing enterocolitis.

A 40-year-old male agricultural laborer presented to our clinic with asymptomatic swellings on his left hand and left leg of 2 years' duration. A pea-sized swelling was first noticed on the back of the left hand, which was gradual in onset and slowly progressed to its present size. The patient later noticed multiple swellings over his left leg and thigh, with a similar progression. There was no history suggestive of inflammatory changes or discharge from the lesions. There was no previous history of trauma. The patient was an asthmatic and was on long-term oral steroid therapy (10-20 mg/day prednisolone). None of his family members had similar complaints. On physical examination, the patient was febrile. Cutaneous examination showed multiple, circumscribed, lobulated, non-tender, mobile, cystic swellings of various sizes, ranging from less than 2 cm over the left shin to more than 8 cm over the dorsum of the left hand and ankle (Fig. 1a,b). The surface over these swellings was shiny, smooth, and intact. The skin over the swellings was pliable and normal in color. There was no regional lymphadenopathy. The rest of the clinical examination was normal, except for decreased breath sounds over the left mid and lower pulmonary lobes. Routine laboratory tests, including complete blood count and liver and renal function tests, were within normal limits. Random blood glucose was greater than 400 mg%. Histopathologic examination of one of the cysts (from the hand) showed pheohyphomycotic cysts lined by dense fibrous tissue with chronic inflammatory infiltrate admixed with scattered giant cells in the dermis (Fig. 2). No fungal elements were visualized in the hematoxylin and eosin-stained sections. The fungal elements were found within the cystic cavity on special staining with Gomori's methenamine silver (GMS) and Masson-Fontana stains. The hyphae had irregularly placed branches and showed constrictions around their septae, thus resembling pseudohyphae and yeast forms (Fig. 3). Fine needle aspiration cytology from one of the swellings showed the presence of filamentous fungi on KOH examination and brown-pigmented distorted filaments and yeast-like cells on Masson-Fontana staining (Fig. 4a,b). The positive Masson-Fontana stain was indicative of the presence of melanin in the fungal hyphae, even when the fungal hyphae were not pigmented in the hematoxylin and eosin-stained section. Periodic acid-Schiff reagent also stained the fungal elements, thus confirming our diagnosis of pheohyphomycosis and ruling out the possibility of hyalohyphomycosis. The culture for fungus from the swelling aspirate grew contaminants. The chest X-ray showed dense nodular shadows in the left lower and mid pulmonary lobes. Sputum for acid-fast bacilli and Mantoux test were negative. During the hospital stay, the patient developed high fever and showed altered behavior, for which a computed tomography scan of the brain was performed; this showed evidence of multiple ring enhancing lesions in both frontal lobes. Ultrasound of the abdomen was normal. O...

The main cause of death in traumas is hypovolemic shock. Physical examination is limited to detect hemopericardium, hemoperitoneum, and hemopneumothorax. Computed tomography (CT) is the gold standard for traumatic injury evaluation. However, CT is not always available, is more expensive, and there are transportation issues, especially in hemodynamically unstable patients. In this scenario, a rapid, reproducible, portable, and noninvasive method such as ultrasound emerged, directed for detecting hemopericardium, hemoperitoneum, and hemopneumothorax, in a “point of care” modality, known as the focused assessment with sonography for trauma (FAST) protocol. With decades of experience, spread worldwide, and recommended by the most prestigious trauma care guidelines, FAST is a bedside ultrasound to be performed when accessing circulation issues of trauma patients. It is indicated to hemodynamically unstable patients with blunt abdominal trauma, with penetrating trauma of the thoracoabdominal transition (where there is doubt of penetrating the abdominal cavity) and for any patient with the cause of the instability unknown. There are four regions to be examined in the traditional FAST protocol: pericardium (to detect cardiac tamponade), right upper abdominal quadrant, left upper abdominal quadrant, and pelvis (to detect hemoperitoneum). The called extended FAST (e-FAST) protocol also searches the pleural spaces for hemothorax and pneumothorax. It is important to know the false positives and false negatives of the protocol, as well as its limitations. FAST/e-FAST protocol is designed to provide a simple “yes or no” answer regarding the presence of bleeding. It is not intended to quantify the bleeding nor evaluate organ lesions due to its limited accuracy for these purposes. Moreover, the amount of bleeding and/or the identification of organ lesions will not change patient’s management: Hemodynamically unstable patients with positive FAST must go to the operating room without delay. CT should be considered for hemodynamically stable patients.