Submandibular gland abscess in a kidney transplant recipient: a diagnostic and therapeutic enigma

A renal allograft transplant recipient presented to our emergency department with pus discharging right-sided cheek swelling. She had the same presentation 1 year after kidney transplant surgery. The abscess was incised and drained, and a sample was sent for culture and sensitivity. The culture initially grew Aspergillus fumigatus for which she was started on itraconazole. While the patient was on antifungal therapy, immunohistochemistry revealed diffuse large B-cell lymphoma to be the primary disease, and rituximab chemotherapy was initiated. The patient is being followed up and is currently in remission.We are reporting this rare case to raise awareness so that clinicians consider the possibility of post-transplant lymphoproliferative disorder when they see a similar presentation.

Modified Nasoseptal Flap Technique to Prevent the Recurrence of Rathke's Cleft Cyst

Background

Rathke's cleft cysts (RCCs) are benign epithelial lesions arising from the Rathke's pouch remnants that fail to regress during embryogenesis. Some RCCs become symptomatic and require treatment. Cyst fenestration and drainage of its contents is the preferred procedure to treat symptomatic cases but carries a risk of recurrence. We propose the use of a novel modified nasoseptal flap technique to partially line the cyst wall to avoid recurrence.

Methods

This was a prospective, observational study that included all RCC patients admitted to the Department of Neurosurgery, Aster Medcity, from April 2015 to May 2018. The modified nasoseptal flap technique was performed in all patients. They underwent preoperative and postoperative ophthalmological, endocrine, endoscopic, and MRI evaluations to look for recurrence.

Results

Ten patients underwent the modified nasoseptal flap technique. The median follow-up was 36 months. Postoperatively, all patients were relieved from headaches. Moreover, their visual fields and pituitary functions normalized. None of the patients developed recurrence of RCC on follow-up brain MRI. On endoscopic examination, all patients had retained patency of the fenestra. The longest follow-up was 72 months.

Conclusions

The modified nasoseptal flap technique maintains patency and avoids recurrence of RCCs on long-term follow-up.

A Trigeminal Neuropathy From an Inactive Hepatocellular Carcinoma

Breast, lung, prostate, thyroid, and kidney carcinomas are the primary tumors that are known to have bony metastasis. Hepatocellular carcinoma (HCC) frequently involves the lung and lymph nodes and less commonly the osseous system. Numbness/persistent pain in the distribution of the trigeminal nerve is more likely a neuropathy. The causes are idiopathic(common), unintentional injury to the trigeminal nerve during surgery or trauma, blood vessel pressing the trigeminal nerve, tumor infiltration, multiple sclerosis, and stroke. Unresolved facial pains after conventional treatment should prompt additional investigation to rule out other causes. In this case, we report a trigeminal neuropathy of rare cause, which is a solitary metastasis from an inactive HCC involving the osseous structures.

A Case of Diphtheria and Infectious Mononucleosis Co-Infection in a Partially Vaccinated Boy

We report the case of an eight-year-old partially immunized boy who presented with presumed bacterial tonsillitis. He was initially prescribed amoxicillin-clavulanic acid which resulted in the development of an erythematous maculopapular over the face which spread to the trunk and extremities including palms and soles and resolved over the next three days. He was diagnosed to have diphtheria and infectious mononucleosis (IMN) co-infection. He made an uneventful recovery and an extensive review of the literature showed that the incidence of diphtheria and IMN co-infection is a relatively rare clinical entity. We wish to highlight the possibility of such co-infections which often mimic one another.

Mucormycosis of Neck a Rare Presentation

Mucormycosis is a dreaded clinical entity caused by filamentous fungi of the order Mucorales mainly affecting immunocompromised individuals. Usually seen involving paranasal sinuses, orbit, lungs and gastrointestinal system, it is extremely rare in other areas. Herein we report a rare presentation of Mucormycosis affecting the ear and neck where early detection, timely intervention, multidisciplinary involvement and judicious use of local antibiotics apart from the mainstay treatment regimen like surgical debridement and intravenous Amphotericin B has saved the patient and given him a reasonably good quality of life devoid of morbidity.

Persisting Embryonal Infundibular Recess Masquerading as a Nasal Mass

Persisting embryonal infundibular recess (PEIR) is a rare anomaly of the development of the posterior pituitary wherein there is a defect in the third ventricular floor. Earlier reports have found PEIR descending only up to the sella. However, this is the first case of PEIR presenting as a pulsatile nasal mass. A 35-year-old female presented to the otorhinolaryngologist with hyposmia. Diagnostic nasal endoscopy revealed a pulsatile nasal mass. Magnetic resonance imaging revealed a cystic lesion extending from the third ventricular floor to the nasal cavity. There was no associated hydrocephalus or empty sella. The case was successfully managed by the endoscopic endonasal transsphenoidal approach.