Browsing by Author "Schultz, Steven"
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Item Aggressive Fibromatosis of the Quadratus Lumborum in A 28-Year-Old-Female: A Case Report(2023) Gattu, Tejashwini; Ngo, Wayne; Martinez, Maria; Schultz, StevenBackground: Desmoid tumors (aggressive fibromatosis/desmoid-like tumors) are rare neoplasms that consist of proliferations of clonal fibroblastic proliferation that are aggressive and locally invasive. While the exact cause of desmoid tumors is unknown, they are associated with hereditary conditions such as Gardner’s syndrome and familial adenomatous polyposis both of which arise due to inactivating mutations of the APC gene. On the other hand, fibromatosis that arise sporadically generally has an activating mutation of the CTNNB1 gene which encodes beta-catenin. A history of trauma such as injuries and previous surgeries has also been associated with the development of desmoid tumors. Desmoid tumors are rare with an estimated incidence of 2-4 per million people per year and make up 0.03% of all neoplasms. Early diagnosis and treatment of desmoid tumors are crucial in minimizing morbidity and mortality. Fibromatosis primarily arise in the extra-abdominal setting which comprises approximately 58% of all cases. Among this, most arise in the shoulder or pelvic girdle region. Here, we report an uncommon site of origin for desmoid tumors. Case Presentation: A 28-year-old female with no previous history of trauma presented with lower back pain with radiculopathy radiating to her right hip. An MRI of the lumbar spine revealed a mass in the right iliac fossa and an abdominal and pelvic MRI showed a large circumscribed posterolateral right intra-abdominal wall mass extending up from the right iliac fossa with low signal bands on T1W and T2W imaging. There were intermediate signal areas elsewhere with islands of enhancement. Subsequent abdominal and pelvis CT showed a right posterior pelvic mass measuring 19x13x10 cm concerning for a neoplasm with fibrotic components. The mass originated from the right quadratus lumborum muscle. It involved the posterior distal transversus abdominis and internal oblique abdominal muscle anteriorly. Distally, it involved the iliacus muscle. Differential diagnoses were abdominal wall aggressive fibromatosis/desmoid tumor, solitary fibroid tumor, sarcoma, unusual GIST tumor, neuroectodermal tumor versus nerve sheath tumor, metastasis, lymphoma. A biopsy was performed and results were consistent with aggressive fibromatosis. Conclusion: Desmoid tumors are rare tumors with a locally aggressive and variable course and high risk of local recurrence. The diagnostic workup often includes imaging with MRI and CT and which allows for determining the origin and involvement of adjacent structures to guide possible interventions. Diagnosis can only be confirmed through biopsy which will reveal a monoclonal proliferation of fibroblasts. Treatment ranges from observation, radiotherapy, surgery, and various medications. Because this case presents a desmoid tumor originating from an uncommon site of origin in the quadratus lumborum region, we hope to provide a better clinical picture for the screening and diagnosis of similar aggressive fibromatosis.Item Presentation of a Rare Isolated Soft Tissue Nontuberculous Mycobacterial Infection with MRI Characterization(2022) Timmer, Benjamin; Ali, Arkoon; Schultz, StevenBackground: Nontuberculous mycobacteria (NTM), also known as atypical or environmental mycobacteria, was first described in the early 20th century. Although these bacteria are related to Mycobacterium tuberculosis, they are a distinct group of mycobacteria. Like Mycobacterium tuberculosis, NTM most commonly affects the lungs, however extra-pulmonary infections involving soft tissue, skin, and lymph nodes can also occur. These extra-pulmonary infections are rare and are primarily acquired secondary to skin breaks following trauma, minor surgeries and cosmetic procedures. Due to the rarity of NTM soft tissue infections the diagnosis is challenging and often delayed. Patients who develop NTM infections are typically immunocompromised, as the rate of clinical infection is significantly low. The incidence of skin and soft tissue infections (SSTI) by NTM however has increased threefold over a thirty-year period, which has attracted attention in the medical community. Case Presentation: A 78-year-old male pecan farmer presented with a left lateral knee mass that progressively worsened over a four-year period. He described the initial lesion as a small knot and denied any trauma or skin abrasions to the affected area prior to developing the nodule. The patient had no history of immunodeficiency and he denied pain, redness, or drainage of the nodule. He also denied fevers, chills, night sweats, chronic cough, or unintentional weight-loss. A T2 weighted axial MRI demonstrated a 5.3 x 7.4 cm well circumscribed, sharply marginated, and encapsulated perifascial soft tissue collection with mixed high and low signal that was mildly heterogeneous along the iliotibial fascial band. These imaging manifestations suggested either a soft tissue tumor or an infectious process. After failing conservative treatment with antibiotics, the patient was referred to an orthopedic surgeon for excision of the mass. An encapsulated cyst-like mass was excised circumferentially around the IT band and was sent to pathology. The gross specimen was described as a 3-cm diameter smooth walled cyst that was partially filled with soft material. Cut sections revealed caseating granulomatous inflammation. Special stain was positive for acid-fast bacilli consistent with mycobacteria. The specimen was negative for atypia, neoplasm, fungi, or polarizable crystals. Cultures did not grow any organisms and the TB gold assay and T spot test were negative for tuberculosis. This left a nontuberculous mycobacterial soft tissue infection as the diagnosis of exclusion. Treatment for SSTI NTM includes a multi-drug antibiotic regimen for at least 6 months based on susceptibility testing. Surgical intervention is indicated if antibiotic treatment is not effective. For this patient, surgical resection was the definitive treatment. Conclusion: This case illustrates a unique presentation of a rare isolated chronic NTM soft tissue infection of the lateral knee in a patient with no known history of trauma or immunodeficiency. Knowledge and clinical suspicion of this pathogen along with MRI findings can aid in the accurate and timely diagnosis of NTM soft tissue infections.