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Introduction Case Description Discussion Conclusion This case examines the sonographic and clinical challenge of diagnosing a Klebsiella pnumoniae pyogenic liver abscess with systemic metastatic infection.The patient in this case study is an 81‐year‐old man who presented with intermittent rigors. Following radiological and clinical assessments, a Klebsiella pnumoniae pyogenic liver abscess, with evidence of systemic metastatic infection, was diagnosed. Sonographic features of the liver abscess were atypical for a cystic lesion and instead appeared as a solid mass, raising the possibility of malignancy. Treatment of intravenous ceftriaxone infusions resulted in full resolution of the liver lesion.The discussion criticises the terminology when describing hepatic lesions, which result from a Klebsiella pnumoniae infection. The term hepatic phlegmon is appropriate when a liver lesion caused by bacterial infection demonstrates a solid appearance on radiologic imaging. The term hepatic abscess is appropriate in cases where liver lesions caused by bacterial infection demonstrate a fluid filled core on radiologic imaging. Differentiation of these terms is important when treating the underlying lesion as a phlegmon, in contrast to an abscess, cannot be drained because it contains no pus. The variable sonographic appearances of Klebsiella pnumoniae pyogenic abscesses were also examined. Despite reported sonographic appearances in the literature, none are sufficient to distinguish a pyogenic liver abscess from malignancy without further investigation.Ultrasound operators should be aware of the variable sonographic appearances of a Klebsiella pnumoniae liver abscess and how these features, combined with non‐homogenous terminology, can obfuscate the correct diagnosis. [ABSTRACT FROM AUTHOR]

Background: A prosthetic joint infection is a devasting diagnosis and challenging condition to treat. The aim of this study is to outline the investigations, management and outcomes in a series of patients who presented to our institution with an iliopsoas abscess (IPA) in the setting of an infected, metal-on-metal (MoM), hip arthroplasty. Case details: Six patients with an IPA associated with an ipsilateral MoM presented over four years. Medical history, serum markers, trimodal imaging, aspirations and surgical procedures performed were analysed The management algorithm employed is outlined.Five were diagnosed with culture positive prosthetic joint infections (PJI). Four patients had elevated Cobalt and Chromium levels and all patients had characteristic aseptic lymphocytic vasculitis (ALVAL) associated lesions on Magnetic Resonance Imaging. Four proceeded to two stage revision. One patient opted for lifelong antibiotic suppression therapy. Four patients who opted for revision surgery had an infection free survival at mean 6 years. Conclusions: Our case series describes a rare, but significant consideration in the practice of the modern arthroplasty surgeon and a successful management strategy to treat these cases. Surgeons should be mindful of the potential concurrent presence of a PJI in cases of an IPA in the context of a total hip replacement, but especially for MoM, where concomitant malignancy, ALVAL, and metallosis are frequently implicated.

Inflammatory pseudotumour of the testis is a rare but important clinical entity to be recognised by the surgical trainee. We present a case of a 30-year-old gentleman who presented with a hard painless testicular mass. Ultrasound scrotum revealed a diffuse paratesticular swelling arising from the tunica vaginalis with a normal-appearing testis. Germ cell tumour markers were normal. Exploration through an inguinal approach confirmed it to be arising from the tunica vaginalis. Wide excision of the tumour along with a cuff of adherent tunica albuginea was done. Final histopathology revealed a diffuse fibrous pseudotumour of the tunica vaginalis confirming its benign nature. [ABSTRACT FROM AUTHOR]

Introduction: Sternal pseudotumour is an important but rare entity thought to be an inflammatory, non‐neoplastic lesion that can mimic tumours. The purpose of this paper was to illustrate the imaging features of this lesion to avoid unnecessary investigations. Methods: The clinical notes and imaging features of four patients with a diagnosis of sternal pseudotumour were reviewed over a period from February 2016 to July 2019. Results: All patients were afebrile with no history of trauma. The median age at presentation was 12.5 months. The median length of symptoms prior to presentation was 3.5 days. One patient had a mildly elevated C‐reactive protein. Chest radiographs showed a pre‐sternal soft‐tissue mass, with or without osseous destruction of the subjacent sternum. Ultrasound showed a heterogeneous, hypoechoic pre‐sternal soft‐tissue mass with variable internal vascularity with extension between sternal ossification centres. CT and MRI showed an enhancing dumbbell‐shaped lesion with a pre‐sternal and retro‐sternal soft‐tissue component. The median time to complete resolution was 3 months. One patient had a biopsy that showed chronic inflammation and fibrosis. Discussion: These lesions present in young children typically with a 1‐ to 2‐week history of a focal 2‐ to 4‐cm swelling over the sternum. The aetiology is unknown but may be on the basis of a yet‐to‐be identified pathogen. Inflammatory markers and cultures are normal or mildly elevated. Important differential considerations include sternal osteomyelitis or neoplastic causes such as Ewing sarcoma, rhabdomyosarcoma, Langerhans cell histiocytosis and infantile fibrosarcoma. Conclusion: Sternal pseudotumor is a rare but important entity to be aware of to avoid unnecessary invasive biopsy or further investigations. Our suggestion is that this is a 'Don't touch' lesion that requires close short‐interval follow‐up at a surgical outpatient clinic and with ultrasound until resolution. [ABSTRACT FROM AUTHOR]

Introduction: Metal reaction and pseudotumor formation are very rare complications following ceramic on polyethylene total hip replacement. Pseudotumors have been described in the case of metal on polyethylene as well as in metal on ceramic interfaces. We report the largest pseudotumor formation to be observed after a thorough literature review following ceramic on polyethylene total hip replacement in a case of ankylosing spondylitis and chronic kidney disease. Case report: The patient had reported 7 years following the index surgery with an uncemented total hip arthroplasty and presented with osteolytic changes of the right proximal femur and later was lost to follow-up due to the COVID-19 pandemic. The patient returned again 2 years later presenting with the pseudotumor. Owing to the presence of extensive osteolysis with gross necrotic muscle mass around the proximal one-third of femur and since bone stock was available, reconstruction of the hip joint was not considered and hence a right side hind-quarter amputation was performed. Conclusion: This immune reaction was possibly exacerbated due to the underlying ankylosing spondylitis and chronic kidney disease requires more stringent follow up protocols and early intervention. It is, thereby, necessary to evaluate patients with serial radiography following total hip replacement, especially those with conditions which could accelerate the immune responses to the metal. This could potentially avoid an amputation and allow for reconstruction of the hip with appropriate immunomodulation. [ABSTRACT FROM AUTHOR]

Cyrus, a haemophilia nurse in Kenya, reflects on his experience of treating a patient with a rare complication of haemophilia in a setting with limited access to treatment. The patient developed a debilitating abdominal pseudotumor following an inadequately treated traumatic bleed. After consulting with experts in other countries, surgery was deemed too great a risk. Initiating FVIII prophylaxis with the aim of shrinking the pseudotumour was identified as the most appropriate approach to treatment, however supply issues made it difficult to maintain a prophylactic regimen. When the pseudotumour continued to grow, posing a risk to adjacent organs, an international partnership enabled the initiation of emicizumab prophylaxis through a clinical trial. It was hoped that emicizumab would prevent further bleeding into the pseudotumour and allow it to shrink over time. The patient continued to experience breakthrough bleeding and was withdrawn from the trial after 2.5 years. By this time the supply of FVIII to Kenya through the through the WFH Humanitarian Aid Program had increased and the patient was able to resume FVIII prophylaxis. The pseudotumour is now stable and he continues to be cared for by the same nursing team. Reflecting on this case, Cyrus highlights the value of sharing expertise across borders and working in partnership to try to ensure the best treatment outcome for a patient with a rare complication in a resource-constrained setting. He also reflects on being compassionate in his practice and the importance of a holistic approach to patient support.

Introduction: Benign vocal fold polyps and nodules are pseudotumours that are frequently diagnosed in clinical practice, along with other benign pseudotumour conditions like Reinke edema and vocal cord cysts. These lesions are primarily caused by vibratory trauma. The present study aims to explore the clinical and histological differences between benign vocal cord polyps and nodules. Aim: To compare the demographic and clinical profiles, as well as the basic histological changes, and evaluate the concordance between clinical and histopathological diagnoses in vocal fold polyps and nodules. Materials and Methods: This retrospective observational study was conducted in the Department of Pathology at Hamdard Institute of Medical Science and Research, New Delhi, India for a period of six months, from January 2022 to June 2022. Data from the past seven years, from June 2012 to May 2019, were retrieved from the department archives. Biopsies of all cases with vocal fold lesions were processed, and sections were examined under light microscopy. The lesions were comparatively studied based on age, gender, profession, predisposing factors, type of lesion, and presenting symptoms. Basic histological features defining the lesions and the agreement between clinical and histological diagnoses were also studied. Descriptive statistics were used to measure the data. Results: Out of 36 cases, 27 (75%) were diagnosed histopathologically as vocal fold polyps, while 9 (25%) were diagnosed as vocal fold nodules. Among the cases of vocal fold polyps, 14 (52%) were in the above 40-year age group, whereas only 4 (44%) cases of vocal nodules were in the above 40-year age group. Excessive voice abuse was the most common predisposing factor in 21 (58.3%) cases, and hoarseness was the most common clinical manifestation in 34 (94.4%) cases, observed in both types of lesions. There was an agreement of 85% (23/27) in clinical and histological diagnoses of vocal fold polyps and 100% (1/1) in vocal fold nodules. Conclusion: The present study found a higher prevalence of vocal fold polyps compared to vocal nodules. Excessive voice abuse and hoarseness were the most common predisposing factor and clinical manifestation, respectively, in both types of lesions. Thus, the present study highlights the importance of considering various clinical factors and histopathological changes in the accurate diagnosis and management of benign vocal fold polyps and nodules.

Background: Granulomatosis with polyangiitis (GPA) is characterised by granulomatous inflammation and small-to-medium vessel necrotising vasculitis, mainly affecting respiratory tract and kidneys. Renal involvement presenting as tumour-like lesions poses diagnostic and treatment challenges. Methods: Following the observation of a GPA patient presenting with multiple renal tumour-like lesions, we conducted a systematic literature review on MEDLINE/PubMed, EMBASE, and Cochrane databases. Data gathered from the literature were analysed to summarise the diagnostic approach, management, and outcome of renal GPA-related tumour-like lesions. Results: a 49-year-old female presented with persistent constitutional symptoms and multiple bilateral renal lesions. Renal biopsy showed chronic interstitial inflammation with necrotising granulomas. Laboratory tests disclosed positive anti-proteinase 3 (PR3) anti-neutrophil cytoplasmic antibody (ANCA) leading to a final diagnosis of GPA. She was effectively treated with high-dose glucocorticoids and rituximab. Literature search yielded 41 articles, concerning 42 GPA patients with renal masses, presenting bilaterally in 23.8% of the cases. Positive PR3-ANCA was observed in 86.5% of the cases. Half of 42 patients showed kidney abnormalities. Treatment with glucocorticoids (83.3%) and immunosuppressive agents (80.9%) resulted in an overall good remission rate and favourable prognosis. Conclusions: GPA should be considered in the differential diagnoses of kidney tumour-like lesions. The diagnosis is challenging, and histological examination greatly contributes to the diagnostic work-up. [ABSTRACT FROM AUTHOR]

Background: Granulomatosis with polyangiitis (GPA) is characterised by granulomatous inflammation and small-to-medium vessel necrotising vasculitis, mainly affecting respiratory tract and kidneys. Renal involvement presenting as tumour-like lesions poses diagnostic and treatment challenges. Methods: Following the observation of a GPA patient presenting with multiple renal tumour-like lesions, we conducted a systematic literature review on MEDLINE/PubMed, EMBASE, and Cochrane databases. Data gathered from the literature were analysed to summarise the diagnostic approach, management, and outcome of renal GPA-related tumour-like lesions. Results: a 49-year-old female presented with persistent constitutional symptoms and multiple bilateral renal lesions. Renal biopsy showed chronic interstitial inflammation with necrotising granulomas. Laboratory tests disclosed positive anti-proteinase 3 (PR3) anti-neutrophil cytoplasmic antibody (ANCA) leading to a final diagnosis of GPA. She was effectively treated with high-dose glucocorticoids and rituximab. Literature search yielded 41 articles, concerning 42 GPA patients with renal masses, presenting bilaterally in 23.8% of the cases. Positive PR3-ANCA was observed in 86.5% of the cases. Half of 42 patients showed kidney abnormalities. Treatment with glucocorticoids (83.3%) and immunosuppressive agents (80.9%) resulted in an overall good remission rate and favourable prognosis. Conclusions: GPA should be considered in the differential diagnoses of kidney tumour-like lesions. The diagnosis is challenging, and histological examination greatly contributes to the diagnostic work-up.

Pseudotumors are a rare complication of total hip arthroplasty (THA), arising from local soft tissue reactions. These reactions can lead to painful joint effusions and prosthetic loosening, often necessitating revision surgery. Metal-on-metal and metal-on-polyethylene prostheses are particularly prone to this complication due to the accumulation of metal debris from prosthetic wear, which represents a significant drawback. In contrast, ceramic-on-ceramic (CoC) prostheses are considered a superior alternative, offering lower wear rates and avoiding complications related to metal debris. This case report presents a rare instance of pseudotumor formation in a CoC THA. A 57-year-old patient underwent a cementless CoC THA in 2010. Despite developing a pulmonary embolism, the patient experienced no prosthetic-related complications until 2021, when they presented to the Royal Orthopaedic Hospital with concerns about a deep vein thrombosis. MRI and ultrasound scans of the hip revealed a complex collection involving the iliopsoas bursa and a small joint effusion, prompting a biopsy. Histopathology confirmed a pseudotumor with tissue necrosis, macrophages, neutrophils, and ceramic debris. In 2024, the patient underwent revision arthroplasty with excision of the pseudotumor. The original prosthesis was well-fixed, with minimal damage to the ceramic head and acetabular liner, and there were no signs of infection or metallosis. Following the revision, the patient's pain resolved, and they were satisfied with the outcome of the surgery., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Piper et al.)

Pseudotumours are uncommon complications of haemophilia, occurring in 1%-2% of patients with haemophilia. 1 , 2 It is a slowly expanding haematoma as a result of recurrent haemorrhage, surrounded by a fibrous capsule. It can occur in both bone and soft tissue, and progressive enlargement may result in bone destruction and/or muscle and skin necrosis. Pseudotumours by themselves are usually painless though its mass effect can result in nerve compression resulting in pain or neurologic symptoms. It may also predispose to pathologic fractures (as in our case) and superimposed infections. 2 , 3 ., Competing Interests: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology.)

• The median age of patients with relapsing TDLs is similar to that of typical MS. • Differences from MS include a lower female: male ratio and relative lack of OCBs. • More than half of those with relapsing TDL underwent a brain biopsy. • Screening for systemic malignancy in those with relapsing TDLs is recommended. • Outcomes in those with relapsing TDLs vary from minimal disability to death. Relapsing or recurrent tumefactive demyelination is rare and has not been studied beyond individual case reports. We examined the clinical course, neuroimaging, cerebrospinal fluid (CSF), treatment and outcomes of patients with recurrent tumefactive demyelinating lesions (TDLs). We used PubMed to identify reports of recurrent TDLs and included the details of an additional, unpublished patient. We identified 18 cases (11F, 7 M). The median age at onset of the index TDL was 37 years (range 12–72) and most were solitary lesions 72 % (13/18). CSF-restricted oligoclonal bands (OCBs) were detected in 25 % (4/16). Only one of those tested (n = 13) was positive for AQP4-IgG. A moderate-to-marked treatment response (high dose corticosteroid with or without additional plasmapheresis, IVIg or disease modifying therapies) was evident in 89 % of treated patients. Median EDSS at the median follow-up of 36 months (range 6–144) was 2 (range 1–10). Most remained ambulatory (EDSS < 4 in 13/18), but 1 patient died. The median age of patients with relapsing TDLs is similar to that of typical MS, but differences include a lower female:male sex ratio, larger lesions, and a comparative lack of CSF-restricted OCBs. Outcomes vary among this group of patients ranging from minimal disability through to death. [ABSTRACT FROM AUTHOR]