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GYN: Pelvic Mass & Urachal CystFrom: Terrence.Jones@ncal.kaiperm.orgMon Apr 6 18:25:51 1998
Gary, goin' back to Your initial impression on imaging studies, the TOA's just didn't appear to have that 'inflammatory' nature. Think there's somethin' to Your suggestion of the host immune response being altered. Makes ya' wonder if the ARDS is part of SIRS (sepsis) versus diffuse pulm alveolar hmrg due to APL (acute pro-myelocytic leukemia) - hard to distinguish on X-ray alone (Saka Intern Med (4/92) 31:457-8). APL is notorius for assoc DIC; and tho bleeding (ie: hemorrhagic CVA) would be more common, thrombotic events have been described in the MCA as well as the internal carotid. APL, with the highest levels of TAT (Thrombin-antithrombin III complex), and PIC (plasmin-alpha 2-plasmin inhibitor complex) dominates activation of fibrino- lysis. Sepsis has much less effect on PIC, and much greater effect on PAI (active plasminogen activator inhibitor), resulting in greater activation of coagulation. Interestingly, MOF (multiple organ failure) is more closely linked to elevated PAI and low PIC (sepsis), and the related inhibition of secondary fibrinolytic activation in the microcirculation (Asakura (10/94) Blood Coagul Fibrinolysis 5:829-32). This would explain the outlook shared by Calvin, had this presentation be due to sepsis, alone. As You mentioned, would've expected some neurologic s/s on preop had a lesion this size been present, arguing more for a recent infarct/thrombosis. First clinical rotation in Med School was Neuro, at a NYC Hosp specializing in Cancer research. Consideration at that time was to pre-Rx first course chemo with anticoagulation to avoid aggravation of bleeding diathesis. Think with the newer modalities (inducing differentiation with retinoic acid derivatives) rather than conventional Rx (Ara C/Daunorubicin), with assoc cell lysis and subsequent procoagulant release, this problem has been reduced, somewhat (Kawai (7/94) Am J Hematol 46:184-88). (Same Res. Cntr. released info last Sept. at the Int Soc Hematol Meeting in Stockholm, on 'Panretin' (9-cis retinoic acid) which might avoid problems with resistance noted in some Pts. on ATRA (all-trans retinoic acid)). 'Course, Mats'll wanna' mention, in Stockholm, You can get Tranexamic acid OTC - 'over-the counter' - (Sugawara "Successful treatment with tranexamic acid for severe bleeding in acute promyelocytic leukemia" , Acta Haematol (1992), 87:109.) Must agree with You, this case realms in the outer, both clinical and emotional, limits. OTOH, Your painstaking consideration of all clinical nuances, and subsequent management, is self-evident. Finally had a chance to view Terry Dubose's case of midline cystic structure/?urachal cyst. As no evidence of urethral or ureteral obstruction, would also include bladder diverticula(e). OTOH, these are more likely to occur as a consequence of long-standing obstruction in the adult, at sites of congenital weakness in the detrussor. As Terry alluded, would expect urachal cyst to be unilocular and smooth-walled, when seen on antenatal sono (might form walled-off abscesses following post-natal infection). For now, I'm gonna' guess this multiseptated cystic structure is a torsed adnexa. Have a look at Beryl Benacerraf's presentation in the Case Records from NEJM 1995 (332:522-27). She mentions checking Mom for glucose intol (theca-lutein stim from inc HCG by the enlarged placenta), and baby for hypothyroidism. Would have expected other GU anomalies if hydrometrocolpos, or megaloureter. Mesenteric/omental cysts might be on the list, tho of lesser stat. likelihood. She (Dr. Benacerraf) confirms Terry's skepticism with usual urachal cyst appearance ("...the echoes within it make the diagnosis of urachal cyst very unlikely.") GI obstructive lesions and volvulus would likely have assoc hydramnios; and lymphangiomas - ascites. The unusual location, as Terry mentioned, in the midline, may have been secondary to torsion, amputation, and mesenteric adherence. Please let us know the outcome! tj.
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