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A 69-year-old man was initially referred to urology outpatient clinic for investigation of frank haematuria. His medical history included transurethral resection of prostate in 2008, autoimmune hepatitis, hyperlipidaemia and hypertension. He was an active smoker with a 52 pack-year history and drinks 12 units of alcohol per week. He worked as a librarian with no history of chemical or asbestos exposure. His regular prescription included azathioprine and ursodeoxycholic acid, amlodipine, alfuzosin and finasteride. He underwent a cystoscopy which was normal. Subsequently, a CT urogram was performed which demonstrated a 48 mm mass within the left adrenal gland, suspected of malignancy; however, no primary site had been identified. A subsequent CT of the thorax and abdomen displayed a 6.5 cm diameter mass within the base of the right upper lobe on the background of emphysema, with precarinal and right hilar lymph nodes, and multiple nodules in the middle lobe and left lower lobe (figure 1A). A large left adrenal mass was again identified. On further questioning, the patient described symptoms of breathlessness and lethargy but denied any chest pain or cough. There was no history of sputum production or haemoptysis. He did, however, report loss of appetite and had lost 3 kg of weight over the previous 4 weeks. Figure 1 (A) Initial CT thorax demonstrating a 6.5 cm diameter mass within the base of the right upper lobe, small precarinal and right hilar nodes and evidence of multiple intrapulmonary nodules; (B) PET CT demonstrating large necrotic mass at right upper lobe; (C) FDG avid intrapulmonary metastasis; (D) histopathological features of lymphomatoid granulomatosis under high power microscopy (40× objective, NIKON eclipse 80i). With the symptoms of breathlessness and unintentional weight loss, in combination with a significant smoking history and suspicious radiological findings, metastatic bronchogenic carcinoma with a left adrenal metastasis was the most …

Kaposi’s sarcoma (KS) is an AIDS-defining condition. Typically, KS affects the skin with or without visceral involvement. The extensive use of antiretroviral therapy (ART) has decreased the incidence of KS amongst the HIV-positive population. We report a case of a 40-year-old man with HIV-1 infection with CD4 count of 551 cells/mm3 and an undetectable viral load who presented with two skin-coloured KS lesions on the prepuce of the penis. Diagnosis was confirmed by histopathology. He had been commenced on ART three years earlier with a nadir CD4 count of 255 cells/mm3. He had achieved and maintained viral suppression since commencing ART. The patient was initially treated with cryotherapy and 5% imiquimod as the lesions were presumed to be warts. The lack of response to treatment prompted further investigation. We carried out a literature search of published cases of penile KS over the past 10 years. The majority of articles regarding penile KS were published in the pre-ART era and involved patients with AIDS. Over the past 10 years, published cases of penile KS have almost exclusively been in HIV-negative men. We found 10 published cases of penile KS in HIV-negative men and only one other published case of penile KS in a HIV-positive man, who had severe immune suppression with CD4 count below 200 cells/mm3. This is the first case report to describe a HIV-positive patient stable on ART with a CD4 count above 200 cells/mm3 and suppressed HIV-1 viral load, to develop two KS lesions on the penis. Clinicians have to remain suspicious of penile lesions and appreciate the crucial role a biopsy with histopathological analysis plays in confirming a diagnosis. In addition, this case illustrates that unusual presentations of KS can still occur in treated HIV-positive patients with sustained immune recovery.

Epithelioid haemangioendothelioma (EHE) is a rare, welldifferentiated vascular tumour of bone, accounting for only 0.5–1% of malignant primary bone tumours [1]. Weiss and Enzinger first described it in 1982 in soft tissues [2]. EHE is the most common epithelioid vascular neoplasm of bone. EHE can present in locations other than bone, such as skin, soft tissue, liver, lungs, heart, intestine, nervous system, retroperitoneum and other body sites. However, it is most common in liver, soft tissues and bone [3]. EHE in bone typically affects adults in the second or third decade, though all age groups can be affected. Sixty percent of EHE cases occur in the long bones with tibia (23%), femur (18%) and humerus (13%) being the commonest sites [4]. Metaphysis and diaphysis are usually involved. EHE presents as synchronous or metachronous disease in 20–50% of patients [4]. Multicentric presentation has been described in 50–62%, with a predilection for bones of the lower extremities in one anatomic region [5]. Nearby or distant soft tissues and skin (Fig. 4) can be involved, and metastases to the lung have also been reported. Conventional radiography of EHE shows an expansile, lytic and often poorly demarcated lesion. A coarse trabecular or honeycombing pattern is commonly seen, with a distinctive ‘soap bubble’ matrix. A well-defined sclerotic rim is seen in most lesions [6]. Calcification is rare, and periosteal reaction is not seen unless complicated by pathologic fracture [7]. Lesions with ill-defined borders are considered more aggressive (Fig. 1). On MR imaging, the lesions are of intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Homogenous enhancement is seen after administration of gadolinium. Flow voids due to vascular channels are not typically seen on MRI of EHE, and if present, should suggest an alternative diagnosis [4]. This could be due to the small size of the vascular channels [7] (Fig. 3). Bone scintigraphy is often undertaken to identify the multicentric involvement of EHE. Increased uptake is seen at sites of involvement (Fig. 2). Doughnut-shaped lesions have been described at the site of involvement [8]. This appearance on bone scan can also be seen in benign or malignant lesions, but multiple lesions should raise the suspicion of a vascular lesion, such as haemangioendothelioma. The case presentation can be found at doi:10.1007/s00256-011-1127-1.

Mucormycosis (zygomycosis) is a rare fungal infection seen most commonly in association with immunosuppression. Intestinal mucormycosis is extremely rare and difficult to diagnose. Early medical and surgical treatment is known to improve survival. This report describes a fatal case of ileal mucormycosis following repair of an abdominal aortic aneurysm in an otherwise healthy elderly man.