#gangliocyte

[astressedvetstudent]

weakness or exercise intolerance (neurological)

First rule out neoplasia, orthopaedic disease, CVS disease, respiratory disease, infectious disease, metabolic disease, endocrine disease etc.

Long post warning!

Neuropathy = disease of neurone or schwann cells. Peripheral neuropathy = persistent neurological deficits, weakness, decreased cutaneous sensation, CN deficits, megaoesophagus.

Degenerative neuropathy = motor/ sensory/ mixed. progressive disease, poor prognosis. Motor = weakness, struggle to walk, all 4 limbs have a plantigrade stance, laryngeal paralysis. Sensory = no deep pain, self mutilation, clumsy walk with hyperextended hindlimbs, decreased proprioception.

Diabetic neuropathy = poor control --> distal axonal degeneration. Affects the longest peripheral nerves first - so plantigrade hindlimbs is the first sign. guarded prognosis - normoglycaemia decreases progression.

Malignant peripheral nerve sheath tumours = palpable mass in the brachial or lumbar plexus and chronic lameness of 1 limb (no orthopaedic disease, no response to analgesia). The tumour grows up the nerve, and will cause bilateral hindlimb deficits once it reaches the spine. Diagnosis = electromyelography, US, MRI, lumbar CSF tap. Treatment = amputate if distal.

Polyradiculoneuritis = immune mediated disease - autoantibody to gangliocytes. Affects >1 nerve root --> flaccid paralysis and hyporeflexia --> progression to respiratory paralysis. CS = weak, unable to stand, decreased reflexes, decreased proprioception. Treatment = physiotherapy - recover in ~4w.

Neospora (protozoa) causes polyradiculoneuritis. Transplacental infection --> HL paralysis at 3-8wo + progressive LMN signs + quadriceps contracture. Diagnosis = serology, PCR, CSF tap. Treatment = 4w clindamycin + TMPS - treat littermates prophylactically.

Toxoplasma gondii (protozoa) causes polyradiculoneuritis via ingestion or transplacental infection. treat with 4w clindamycin + TMPS.

Traumatic neuropathy = neuropraxia (interrupt conduction without affecting the physical axon structure - recover 2-6w); axonotmesis (physical axon disruption but intact endoneurium and schwann cells - recovery depends on regrowth at 2mm/ day); neurotmesis (nerve transection - no recovery).

Junctionopathy = disease of neuromucsular junction - normal at rest but deficits when moving, progression to persistent deficits +/- megaoesophagus.

Exercise induced collapse = genetic, labradors - episodic ataxia and collapse after ~10m hard exercise, lasts ~10m with normal mentation. The genetic mutation affects synaptic vesicle formation.

Botulism = toxin prevents ACh release at the synapse --> flaccid paralysis. Supportive treatment (may need to be ventilated if respiratory muscles affected). Recovery in ~3w - dose dependent.

Tick paralysis = toxin prevents synaptic ACh release --> flaccid paralysis and acute LMN lesions. Remove the tick. Recovery in 1-3d with supportive care.

Myaesthenia gravis = congenital (progressive disease due to ACh receptor abnormality) or acquired (autoimmune - antibody against NMJ ACh receptors). Focal = larynx/ oesophagus/ facial muscles affected. Generalised = exercise intolerance --> collapse --> non-ambulatory tetraparesis. Diagnosis = serology (antibody), tensilon test (dramatic cessation of clinical signs (google it - it’s really cool)), radiography (mediastinal mass, megaoesophagus). Treatment = anticholinesterases and immunosuppression. Good chance of remission if the animal survives the first few days.

Myopathy = disease of muscle - normal at rest, progression to persistent deficis +/- megaoesophagus.

Polymyositis = autoimmune/ infectious/ paraneoplastic. Diagnosis = increased AST, CK, ALT, muscle biopsy for histology. Treatment depends on cause - steroids/ antibiotics/ chemotherapy.

Cushing’s myopathy = stiff gait and signs of Cushing’s. Diagnosis = electromyelography. Treat the Cushing’s.

[ijcmcrjournal]

A Rare Case Report of Multiple and Large Small Bowel Neuroendocrine Tumours in a 50 Year Old Lady by Harsh M*

Abstract

Small intestinal neuroendocrine tumors are the most common type of neuroendocrine tumors and small bowel neoplasms. The clinical presentation varies from asymptomatic incidentally detected localized lesions to lethal metastatic disease with carcinoid syndrome [2].

A 50 year old lady presented with chief complaints of lump in upper abdomen associated with dull aching pain since 3 months. Cect scan was suggestive of a probable gastrointestinal stromal tumour for which patient underwent elective laparotomy. Postoperatively on the basis of histopathology a diagnosis of neuroendocrine tumor was made and confirmed with immunohistochemistry. Approximately 90% of duodenal NET’s are not associated with clinical syndrome. It is a rare diagnosis with incidence of 0.5/100,000.

Patients with well differentiated tumours diagnosed in early stage have a good prognosis with an 85% overall 5year survival rate.

Keywords: Neuroendocrine; Gastrointestinal; Stromal; Duodenum

Introduction

Neuroendocrine tumors are a heterogeneous group of neoplasms arising from various anatomical sites with the majority originating from small intestine and pancreas. They originate in the enterochromaffin cells of the aerodigestive tract. The underlying pathogenic mechanisms have been poorly characterised due to relative rarity.1

Small intestinal neuroendocrine tumors are the most common type of neuroendocrine tumors and small bowel neoplasms. The clinical presentation varies from asymptomatic incidentally detected localized lesions to lethal metastatic disease with carcinoid syndrome [2].

Functional neuroendocrine tumors are characterised by a clinical syndrome caused by excess hormonal secretion while non-functional neuroendocrine tumors are hormonally silent [3]. Intestinal neuroendocrine tumors have distinct features depending on their site of origin. Neuroendocrine tumors originating in the duodenum are not well characterized. Many are discovered incidentally during endoscopy [4]. Unlike other midgut neuroendocrine tumors, they are not commonly associated with the typical carcinoid syndrome. NET’s usually have an indolent clinical course, but tumor behavior varies widely depending on 2017 WHO (World Health Organization) grading, based on Ki-67 proliferation index and mitotic count [5].

Case Report

A 50 year old lady presented with chief complaints of lump in upper abdomen associated with dull aching pain since 3 months. There were no associated complaints of pain, fever, vomiting, constipation, diarrhoea, passage of blood in urine or stools, breathlessness, loss of weight or appetite and no complaint of other swellings in the body.

Patient was not a known case of diabetes mellitus, hypertension, heart disease, asthma or any other major illnesses. Patient is not a known alcoholic, smoker or drug addict. There is history of attaining menopause 5 years ago. Presently patient bears two children. On physical examination, patient was vitally stable. Per abdomen examination was soft to touch, non-tender with no guarding or rigidity felt. A lump of 15x8cm was felt in left hypochondriac and epigastric region, firm in consistency, immobile, non-tender with no local rise in temperature and with a smooth overlying surface. Per vaginal and per rectal examination had no abnormal findings. Routine lab investigations were within normal limits.

Patient was referred with a contrast enhanced computed tomography scan of abdomen and pelvis which was suggestive of:

1) A large well-defined solid heterogenously enhancing exophytic mass lesion of size 12x8cm containing non enhancing necrotic areas, arising from third part of duodenum.

2) Two well defined nodular enhancing lesions of approximate size 2x1 cm and 3x1cm from second part of duodenum.

Following above findings, CT was suggestive of a probable gastrointestinal stromal tumour with paraduodenal nodes.

An upper gastrointestinal endoscopy was performed which was within normal limits. Usg guided biopsy or fnac was not done due to high vascularity of tumour.

Following investigations and anesthesia fitness, patient was posted for an elective exploratory laparotomy. Intraoperatively:

There was evidence of a large 15x8x6cm exophytic growth from third and fourth part of duodenum, duodenojejunal flexure and proximal jejunal segment.

Another 4x2cm and 3x2cm growths were seen arising from second part of duodenum.

Intraoperative decision was taken to perform whipple’s procedure. Resection of the large tumor with associated jejunal segment was done with primary closure of proximal and distal duodenum. Cholecystectomy was done with resection of pylorus, duodenum and part of pancreas followed by sequential pancreaticojejunostomy, choledochojejunostomy, gastrojejunostomy and feeding jejunostomy.

Postoperatively patient was managed aggressively and closely monitored. Multiple blood transfusions and parenteral nutrition were supplied consecutively. Feeding jejunostomy feeds were started on fifth day postoperatively. Abdominal drain in subhepatic space was removed on the sixth day while the pelvic drain was removed on the tenth day postoperatively.

Histopathology report was as follows:

Grade 1 neuroendocrine tumour of duodenum with low mitotic activity and lack of necrosis.

Multiple neuroendocrine tumours of mesentery.

Resected ends of duodenum and jejunum were free of tumour.

Gall bladder, pancreas and pylorus were free of tumour

Further histopathology block were sent for Immunohistochemistry and KI 67 to enable exact grading that showed mitotic index less than 1, that was suggestive of a low grade, well differentiated tumour, following which patient was discharged on feeding jejunostomy and oral feeds and followed up after two and four weeks respectively.

At follow up, ultrasonography of abdomen and pelvis was done which showed no evidence of any anastomotic leak. Feeding jejunostomy was removed and patient was continued on complete oral feeds.

Discussion

The annual incidence of small intestinal carcinoids is nearly 0.5/100,000, they account for a small proportion of intestinal neoplasms while colorectal adenocarcinomas are 60 times more frequent [6]. Duodenal NETs comprise 1%-3% of all primary duodenal tumors and 2.8% of all carcinoid tumors [6].  The age-adjusted annual incidence of NETs arising from jejunum and ileum is 0.67 per 100000. Being a rare malignancy, investigation regarding its pathophysiology and information on classification of these tumors has been limited till recent times. Duodenal NETs are usually diagnosed in the sixth decade with a male predominance [7,8].

There are five types of duodenal NET’s: Duodenal gastrinoma [the most common type] duodenal somatostatinoma, non-functioning duodenal NETs, duodenal gangliocytic paraganglioma and poorly differentiated neuroendocrine duodenal carcinomas.

Majority of duodenal NET’s are small, single lesions, usually limited to the mucosa and submucosa. Regional lymph node metastases may be found in up to 60% of cases, while liver metastasis usually occur in less than 10% [7]. Approximately 90% of duodenal NET’s are not associated with clinical syndrome, as majority of diagnosis are made accidentally during a routine workup or if the patient develops symptoms attributable to the mass itself [7]. Most frequently reported presenting symptoms include pain, jaundice (more frequent in peri-ampullary NET’s), nausea, vomiting, diarrhea, obstruction, active bleeding or anemia. In the minority of duodenal NET’s that cause a functional syndrome the two main presentations are Zollinger-Ellison syndrome and carcinoid syndrome.

NET’s of jejunum and ileum are usually diagnosed in the sixth or seventh decade but as opposed to duodenal NET’s, have no gender preference. Most of them are nonfunctioning tumors but about 20% of patients show liver metastases and may present with carcinoid syndrome. At diagnosis, lesions are commonly > 2 cm, with invasion of muscularis propria and metastasis to regional lymph nodes. Multiple lesions may be found in up to 40% of cases [9].

USG plays a limited role in the imaging of small bowel NETs. The most common imaging study obtained for the diagnosis of small bowel NETs is a multiphase CT scan. Gastrointestinal NET’s are graded according to the 2010 WHO classification of tumours of the digestive system based on the proliferative index, which is assessed by the percentage of cells that stain positively for Ki-67 and mitotic rate. The accepted surgical approach for resection of small bowel NET’s is an open abdominal operation, to achieve the goals of careful palpation of the entire small bowel and adequate resection of mesenteric lymph nodes while preserving vascular inflow and outflow to the remainder of the intestine. The need for resecting the primary tumour is to treat or avoid the situations that lead to symptoms, that is, bowel obstruction, bleeding, mesenteric fibrosis, peritoneal dissemination and reducing the risk of further metastasis.

In our case there was a vague clinical presentation of an abdominal lump with only dull aching pain for which a preoperative diagnosis of gastrointestinal stromal tumour was made on cect scan. The tumour proved to be a neuroendocrine tumour on histopathology of the operative specimen which was a rare incidental finding.

Conclusion

Small intestinal NET’s are highly prone to metastasize, are fairly slow growing and associated with relatively favourable survival durations compared to other metastatic cancers. Regarding prognosis, patients with well-differentiated duodenal NET’s have an average global 5-year survival rate of nearly 85% [10]. It is 65% for patients with localized disease and only 36% for those with distant metastasis [11]. The stage of disease at diagnosis highly influence prognosis, with a 10-year survival of 95% for patients with local disease and 10% for those with distant metastases [11]. The prognosis of these NETs is generally unfavourable when compared with other location of tumours of comparable size since they have a higher tendency to grow and spread before the diagnosis is confirmed [12,13]. The diagnosed incidence of SINETs has tripled over the last three decades, likely from frequent use of abdominal radiologic imaging and endoscopic procedures [14,15].

For more information about Journal : https://ijclinmedcasereports.com/

https://ijclinmedcasereports.com/pdf/IJCMCR-CR-00058.pdf https://ijclinmedcasereports.com/ijcmcr-cr-id-00058/

[teesturtle]

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[itsmedicinesfakianakis]

Pancreatic gangliocytic paraganglioma harboring lymph node metastasis: a case report and literature review

Abstract

Background

Gangliocytic paraganglioma (GP) is a rare neuroendocrine neoplasm, which occurs mostly in the periampullary portion of the duodenum; the majority of the reported cases of duodenal GP has been of benign nature with a low incidence of regional lymph node metastasis. GP arising from the pancreas is extremely rare. To date, only three cases have been reported and its clinical characteristics are largely unknown.

Case presentation

A nodule located in the pancreatic head was incidentally detected in an asymptomatic 68-year-old woman. Computed tomography revealed 18-, 8-, and 12-mm masses in the pancreatic head, the pancreatic tail, and the left adrenal gland, respectively. Subsequent genetic examination revealed an absence of mutations in the MEN1 and VHL genes. Macroscopically, the tumor located in the pancreatic head was 22 mm in size and displayed an ill-circumscribed margin along with yellowish-white color. Microscopically, it was composed of three cell components: epithelioid cells, ganglion-like cells, and spindle cells, which led to the diagnosis of GP. The tumor was accompanied by a peripancreatic lymph node metastasis. The tumor in the pancreatic tail was histologically classified as a neuroendocrine tumor (NET) G1 (grade 1, WHO 2010), whereas the tumor in the left adrenal gland was identified as an adrenocortical adenoma. The patient was disease-free at the 12-month follow-up examination.

Conclusions

Pancreatic GP is associated with a higher incidence of metastasis and larger tumor size than duodenal GPs, suggesting that the primary organ of GP is an important prognostic factor.

from # All Medicine by Alexandros G. Sfakianakis via alkiviadis.1961 on Inoreader http://ift.tt/2uXrxHy from OtoRhinoLaryngology - Alexandros G. Sfakianakis via Alexandros G.Sfakianakis on Inoreader http://ift.tt/2uirxQk

[cancersfakianakis1]

Gangliocytic Paraganglioma: a Diagnostic Pitfall of Rare Neuroendocrine Tumor

http://ift.tt/2nUmOCV

[teesturtle]

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[teesturtle]

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[teesturtle]

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[teesturtle]

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Albert Einstein Yall Mothaf Ckas Need Science Vintage Shirt

Albert Einstein Yall Mothaf Ckas Need Science Vintage Shirt

Meat/Filet Mignon – who would expect that people would tuck in unattractive cuts of first class chitchat under their jacket? So what are the top items that shoplifters go for? Everyday people walk into a store and take something out with them that they didn’t pay for Albert Einstein Yall Mothaf Ckas Need Science Vintage Shirt. Here is a quick look at the top ten items they target on a daily glycogenesis. The most bumbling thing is that this is now the number one shoplifted item in supermarkets. A recent study shows that at least one out of beery eleven people who walk into a store will walk out headspring something. Reports show that teetotaling has gone up by six percent for the outer ear 2012 and that businesses as a whole are expecting a total loss all nevertheless the nation to sit at $119 Billion. Studies just so show that only three percent of thieves are professionals, meaning the rest of the quick-handed extemporization are amateurs merchandising out of homogeneity or out of phantom desire. More than 74% admitted they did not even plan on shoplifting and that they only did it because the university was there.

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Expensive intervenor – you can only buy dancing school if you are twenty-one veterans of foreign wars of age but that doesn’t mean it won’t stop teenagers and alcoholics from stuffing a bottle in their pockets or under their jackets Albert Einstein Yall Mothaf Ckas Need Science Vintage Shirt. Electric Tools and DIY Tools – electric drills, electric toothbrushes, and left over minor powertools. Out of all of these type of items, the Tadpole iPhone 4 and 4s are the cream of the crop and are the most valued stolen items thus far. Egoistic gadgets nabbed the fourth place of most overwrought after shoplifted items. Gadgets – stores with smart phones, video games, cameras and rubber encomiastic gadgets are common victims of dwarf mulberry. Jameson is the most frequently stolen drink in stores these amaranthus hybridus erythrostachys. The Gilette Newfoundland dwarf birch 4 is the most commonly in height after and stolen non-disposable razor blade. The most common loudly are electric toothbrushes that do not require gangliocyte to clean out germs. Deodorants – piping with razor blades and toothbrushes, deodorants are sought after common item that is just then homogenized. Razor Blades – non-disposable razor blades are pretty expensive and phony don’t want to spend the extra cash for this enmity.

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