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Differential diagnoses of pigmented lesions of the nipple include melanocytic nevus, melanosis of the nipple, seborrheic keratosis, pigmented basal cell carcinoma, melanoma and Paget disease. The histologic exam with appropriate immunohistochemistry is a fundamental tool to achieve a correct diagnosis. We present a patient with a pigmented lesion of her right nipple revealing mammary Paget disease and elucidate diagnostic obstacles and prognostic importance of early breast cancer detection.

Objective: Urogenital tuberculosis and disseminated tuberculosis affecting urogenital system are more frequent in developing countries but are often overlooked in developed ones. We aimed to compare clinical characteristics and outcomes of urogenital tuberculosis and disseminated tuberculosis affecting the urogenital system. Material and methods: We retrospectively reviewed data from patients with tuberculosis in the urogenital system, diagnosed in a tertiary center in a European country, from 2008 to 2018. Cases were divided into urogenital tuberculosis and disseminated tuberculosis affecting the urogenital system and compared. Results: We included 172 patients, 31 with urogenital tuberculosis and 141 with disseminated tuberculosis affecting urogenital system. Patients with disseminated tuberculosis affecting the urogenital system were younger (median 45 vs. 64 years, P = .001), more likely to be male (80 vs. 55%, P = .005), or having risk factors for the disease (84 vs. 23%, P = .005) than patients with urogenital tuberculosis. Patients with urogenital tuberculosis presented most commonly with symptoms related to the urinary tract, with 52% complaining of lower urinary tract symptoms attributed to urinary tract infections and 48% of dysuria, while patients with disseminated tuberculosis affecting the urogenital system presented mainly with systemic symptoms, with 89% complaining of malaise, 62% of fever, and 57% of anorexia. Patients with urogenital tuberculosis were more likely to need urological surgery as part of their treatment (71 vs. 5%, P < .001) and patients with disseminated tuberculosis affecting the urogenital system were more likely to die due to tuberculosis (10 vs. 21%, P < .001). Conclusion: Tuberculosis of the urogenital system can have multiple clinical presentations, and a simple diagnostic algorithm does not exist. In the presence of urogenital tuberculosis in injected drug users, immunosuppressed individuals, or patients with systemic symptoms, we should think of disseminated tuberculosis affecting the urogenital system and remember these patients less frequently need surgery but entail a worst outcome. [ABSTRACT FROM AUTHOR]

Azathioprine (AZA) is used in a wide array of autoimmune diseases, still corresponding to the mainstay maintenance therapy in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides. Although generally well-tolerated, several side effects are recognized. We report the case of a 50-yearold Caucasian man with kidney-limited ANCA myeloperoxidase (MPO) vasculitis who presented with general malaise, fever, worsening renal function, and elevated inflammatory markers 2 weeks after the initiation of therapy with oral AZA. Although a disease relapse was suspected, renal biopsy revealed an eosinophilic infiltrate, suggestive of acute interstitial nephritis. After suspension of AZA, a sustained improvement of renal function and normalization of inflammatory markers was observed. A diagnosis of allergic interstitial nephritis secondary to AZA was established, corresponding to the first biopsy-proven case described in an ANCA MPO vasculitis patient. Although rare, renal toxicity of AZA must be present in the clinician's mind, avoiding the straightforward assumption of disease relapse in the case of worsening renal function. [ABSTRACT FROM AUTHOR]

Objectives: Multinodular goiter (MNG) and well-differentiated thyroid carcinoma (WDTC) are emerging phenotypes of DICER1 syndrome.Methods: Histologic and molecular findings of botryoid-type embryonal rhabdomyosarcoma (bERMS) and thyroid nodules from a 12-year-old DICER1 mutation carrier (p.Arg1060Ilefs*7) were investigated, providing interesting clues for understanding thyroid carcinogenesis.Results: The patient had bERMS at age 7 years. The thyroid was enlarged and multinodular (61 g). Histologically, some nodules were classified as adenomatous and others as tumors with "intermediate" nuclei. One displayed vascular invasion and was classified as WDTC not otherwise specified (NOS). Somatic DICER1 mutations were identified in bERMS, two tumors with "intermediate" nuclei and WDTC. No somatic DICER1 mutations were found in adenomatous nodules. No molecular alterations were detected in BRAF600, NRAS61, HRAS12/61, KRAS12/61, TERT promoter, RET/PTC1, RET/PTC3, and PAX8/PPARγ.Conclusions: The findings obtained from this single case support the assumption that DICER1 syndrome-related WDTC NOS may develop on a background of MNG, via a stepwise process, involving DICER1 somatic mutations and additional molecular events, distinct from the classic pathways of papillary/follicular carcinoma. [ABSTRACT FROM AUTHOR]

Background: The mechanism(s) responsible for breast capsular contracture (CC) remain unknown, but inflammatory pathways play a role. Various molecules have been attached to implant shells in the hope of modifying or preventing CC. The intrinsic antibacterial and antifungal activities of chitosan and related oligochitosan molecules lend themselves well to the study of the infectious hypothesis; chitosan's ability to bind to growth factors, its hemostatic action, and its ability to activate macrophages, cause cytokine stimulation, and increase the production of transforming growth factor (TGF)-β1 allow study of the hypertrophic scar hypothesis. Objective: The authors perform a comprehensive evaluation, in a rabbit model, of the relationship between CC and histological, microbiological, and immunological characteristics in the presence of a chitooligosaccharide (COS) mixture and a low molecular weight chitosan (LMWC). Methods: Eleven adult New Zealand rabbits were each implanted with three silicone implants: a control implant, one impregnated with COS, and one impregnated with LMWC. At four-week sacrifice, microdialysates were obtained in the capsule-implant interfaces for tumor necrosis factor alpha (TNF-α) and interleukin-8 (IL-8) level assessment. Histological and microbiological analyses were performed. Results: Baker grade III/IV contractures were observed in the LMWC group, with thick capsules, dense connective tissue, and decreased IL-8 levels (p < .05) compared to control and COS groups. Capsule tissue bacterial types and microdialysate TNF-α levels were similar among all groups. Conclusions: Chitosan-associated silicone implantation in a rabbit model resulted in Baker grade III/IV CC. This preclinical study may provide a model to test various mechanistic hypotheses of breast capsule formation and subsequent CC. [ABSTRACT FROM AUTHOR]

Background: Immunoglobulin G4-related disease (IgG4-RD) is now recognized as a systemic fibro-inflammatory disorder of unknown origin. Renal involvement occurs in approximately 15% of patients, mainly tubulointerstitial nephritis. Although IgG4-RD and AAV have different clinical and pathological features, it is sometimes difficult to distinguish between them. Case Report: A 70-year-old man presented with a 5-month history of asthenia, recurrent fever, anorexia, nauseas and weight loss. He had a previous diagnosis of AAV with renal involvement, 9 years ago, being in remission since then. His laboratory tests revealed normocytic normocromic anemia, hypereosinophilia (27,1%), hypoalbuminemia, ESR 102 mmh, C-RP 82.8 mg/L, renal function impairment (urea 70 mg/dl/creatinin 1.63 mg/dl) and active urinary sediment with markedly increased but intermittent erytrocituria (3914/ul), although red cell casts or dysmorphic erythrocytes were absent and with 0,25 g/l proteins in 24hurine sample. MPO-ANCA antibody was in normal range at this time. Nevertheless, he had polyclonal increase of gammaglobulins, particularly of IgG4 subclass (1940 mg/dl; normal range 8-140). Abdominal and renal scan were normal and abdomino-pelvic CT revealed mild and diffuse parenchymal heterogeneity of the kidneys and bilateral pyelectasis with thickening and hypercaptation of the urothelium in a probable relation with inflammatory manifestations, but with no evidence of abscesses or urolithiasis. PET and biopsy of minor salivary glands were unremarkable and fine needle biopsy of subcutaneous fat tissue was also negative for amyloide protein. Due to significant worsening of general condition with progressive weight loss, asthenia and anorexia, marked aggravation of anemia and renal function, associated with intermittent fever peaks, marked microscopic haematuria, sustained hypereosinophilia, increased IgG4 levels in blood samples and increased acute-phase reactants, renal biopsy was repeated. Histopathological analysis revealed presence of necrosis and tubular atrophy, interstitium with fibrosis and inflammatory infiltrate consisting of lymphocytes, plasmocytes and numerous eosinophils. Moreover, IgG4 immunoreactivity was observed in the plasma cells. The aspects described were compatible with the diagnosis of IgG4-related renal disease. The patient received 3 pulses of endovenous metylprednisolone 1g in consecutive days and then started oral prednisolone 30 mg/day (0,4 mg/Kg/day). He improved quickly after these treatment and at a 9-month follow-up he remained in sustained remission, apyretic and with progressive weight gain, maintaining progressive withdraw of prednisolone (15 mg/day). His laboratory tests further improved with hemoglobin 16.2 g/dL, hematocrit 45.2%, without hypereosinophilia, improvement of renal function and low acute phase reactants. Furthermore, serum IgG4 levels substantiatly decreased (153 mg/dl). Conclusion: Our case represents a description of an IgG4-related tubulointerstitial nephritis with concomitant positivity of cytoplasmic MPO-ANCA, mimicking AAV. The possibility that they have common immunopathogenetic mechanisms should be considered since it seems that they both are Th-2 mediated diseases, which may account for the enhanced IgG4 response observed for both syndromes. Nevertheless, distinction between these 2 conditions is crucial for treatment and prognostic purposes in order to be able to anticipate potential disease complications. [ABSTRACT FROM AUTHOR]

Objectives: The main objective of this study is to analyze factors associated with nodal yield in level II-IV selective neck dissections (NDs) and the secondary objective is to assess its impact on overall and disease-free survival., Methods: Observational retrospective study including adult patients submitted to level II-IV ND from January 2015 to December 2021 in the otorhinolaryngology department of a tertiary hospital center., Results: A total of 44 patients and 78 level II-IV NDs (34 bilateral and 10 unilateral) were included. The median age at diagnosis was 60 (22-74) years, and 93.2% of the patients were male. A lower nodal yield was significantly associated with previous radiotherapy (p = 0.042) and extranodal invasion (p < 0.001) and was non-significantly associated with older age (p = 0.065). Furthermore, on a Cox analysis adjusted to the cN status and age, the nodal yield was not associated with five-year disease-free survival (HR = 0.986; 95% CI = 0.922-1.054; p = 0.681) nor with five-year overall survival (HR = 1.006; 95% CI = 0.925-1.095; p = 0.888)., Conclusion: A reduced nodal yield in level II-IV NDs was significantly associated with previous radiotherapy and extranodal extension and non-significantly associated with age. There was no association between the nodal yield and five-year overall survival or disease-free survival., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics Committee of Hospital de São João, Porto, Portugal issued approval 27/2022. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. 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, Pinto et al.)

Background: Metastatic tumors of the heart are 20 to 40 times more common than primary tumors. Metastases originate mainly in carcinomas and melanomas, the latter having the greatest propensity for cardiac involvement. On rare occasions this type of tumor may first manifest itself as a cardiac metastasis., Methods: The authors present clinical, laboratory and imaging data from a patient with a cardiac mass that was the first manifestation of a melanoma. No other tumor location was detected by imaging studies., Results: The patient presented with exertional dyspnea and tachycardia and was found to have a large mass in the right atrium. He underwent surgical removal of the tumor, but curative excision was not possible. A diagnosis of cardiac metastasis from malignant melanoma was made. The patient died soon afterwards from disseminated metastatic disease., Conclusions: This case represents a rare manifestation of melanoma located in the right atrium, with unknown origin of the primary tumor. Although surgery may be useful to palliate symptoms and improve survival in certain patients, it may also be associated with dissemination of the disease.