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  #1  
Old 04-17-2012
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Question Necrotic Sternal Mass!

A 30-year-old Filipino woman presented for evaluation of sternal pain associated with a palpable mass that she had noticed 8 months earlier. She had no history of significant medical illness. She had recently immigrated to El Paso, TX, from the Philippines. She reported no hemoptysis, fevers, or night sweats, but she said she had unintentionally lost 15 lb over the last 8 months. She reported no coughing and dyspnea. Her vital signs were normal. A skin examination revealed mild sternal erythema and a tender, nonmobile 1.5-cm mass at the lower left sternal border. There was no palpable cervical, axillary, or supraclavicular lymphadenopathy. Results of chest radiography, a complete blood count, and a chemistry panel were within normal limits. Computed tomography of chest revealed a necrotic mass and bony destruction of the inferior sternum, but no pulmonary parenchymal lesions. Open surgical biopsy of the sternal lesion was performed and revealed revealed necrotizing granulomatous inflammation. what is the most likely cause of the woman's problem.

  • A Plasmacytoma
  • B Chondrosarcoma
  • C Extrapulmonary tuberculosis
  • D Lymphoma
  • E Metastatic breast cancer
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Old 04-17-2012
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Default A) Plasmacytoma

The patient doesnt have fever or night sweats, so C) Extrapulmonary tuberculosis can be ruled out. Breast cancer is usually in the upper lateral breast since thats where most of the breast tissue is present so I guess E) Metastatic breast cancer can be ruled out; also because it metastasizes through the lymphnodes and there is no lymphadenopath. This also rules out D) Lymphoma.

I am thinking its either A) Plasmacytoma or B) Chrondosarcoma but I would go with Plasmacytoma since there are destructive bone lesions (inferior sternum).

Is that correct?
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Old 04-17-2012
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B) chondrosarcoma
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Old 04-17-2012
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It's C.

I'm Filipino -- I think I should know. LOL!!!

I'm betting one bucket of beer!

**If I'm wrong... Ooopps!!
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Old 04-17-2012
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Quote:
Originally Posted by d_wiqed View Post
It's C.

I'm Filipino -- I think I should know. LOL!!!

I'm betting one bucket of beer!

**If I'm wrong... Ooopps!!

Unfortunately I am under age and i don't take beer. .....lol
can you please change the offer!!
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Old 04-17-2012
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Just a thought - if its saying there is bony destruction of the inferior sternum .. is that referring to xiphoid process of the sternum ? Xiphoid process is made of cartilage so that would be B) Chondrosarcoma .. but if its bony destruction then A) Plasmacytoma ?

Good question. I am confused
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Quote:
Originally Posted by Desos View Post
Unfortunately I am under age and i don't take beer. .....lol
can you please change the offer!!
Desos - you're underage and you already have Step 1 and CS bagged ?! That's awesome
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Old 04-17-2012
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Quote:
Originally Posted by Desos View Post
Unfortunately I am under age and i don't take beer. .....lol
can you please change the offer!!
Oh no.... Looks like I'm wrong! Oh, the embarrassment!

But the biopsy says necrotizing granulomatous inflammation.

I just assumed that in the biopsy of the other diseases:
A Plasmacytoma - contains plasma cells
B Chondrosarcoma -contains cartilage cells (chondroid cells)
C Extrapulmonary tuberculosis - granulomatous inflamm.
D Lymphoma - contains lymphocytes
E Metastatic breast cancer - contains ducts, etc.

In addition, TB in itself is hard to detect clinically. There can be only chronic cough and nothing else in a pulmonary TB. In an extra-pulmonary TB, you don't have chronic cough. Fever and night sweats are not necessarily present too. When you think about it, in all of the choices, fever should have been somehow present (i.e. carcinomas).

Furthermore, the demographics point to C. LOL!

I might be wrong, but oh well... That's just how I thought about it. Ooooppss.

@Desos: It's ok. If you're underaged and you win the alcohol, DocSikorski and me are here to drink it for you. Hahaha!!

Last edited by d_wiqed; 04-17-2012 at 12:08 PM.
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Old 04-17-2012
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Correct Answer Extra pulmonary TB

The correct answer is C. Extra pulmonary TB.

Guy beware of classical findings " necrotizing granulomatous inflammation". There are only 2 causes of a granuloma with central necrosis which I can think of TB and Fungi.
That is my secret when I don't understand a question or when the stem is very long and I think it will take a lot of my time. generally I have noted thaT the buzz word is usually towards the last few sentences of the question stem. try to apply this, you won't go wrong most of the time (you may go wrong in <5% of the time but its not statistically significant).


Our Fillipino friend (d_wiqed) is very right! I guess I owe you a bucket of beer instead or lets make it 2 buckets then so we can share with DocSirkori and Hope2Pass......lol
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Good job dwiqed! And great question Desos ... quite tricky.

PS. After failing so hard at answering this question, Beer sounds good! lol
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@Hope2Pass: Thanks! It just so happens I'm in the same demographic. It's very rare to see my ethnicity mentioned in a question stem. Knowing the prevalence of that disease in my country, it was a dead give-away. Yep, a break sounds good for us... We've been seriously studying these past few weeks. LOL!

@Desos: Thanks for the test-taking tip! These are great questions from you! Made me think and look for the presenting signs and symptoms of the other diseases. Without the biopsy, the choices would have been hard to differentiate, since the question stem provided mostly normal findings.
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Old 04-18-2012
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Quote:
Originally Posted by Desos View Post
The correct answer is C. Extra pulmonary TB.

Guy beware of classical findings " necrotizing granulomatous inflammation". There are only 2 causes of a granuloma with central necrosis which I can think of TB and Fungi
I'm sorry, but I'm a little confused. Sarcoidosis and company won't be necrotising?
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Old 04-18-2012
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Quote:
Originally Posted by d_wiqed View Post
In addition, TB in itself is hard to detect clinically. There can be only chronic cough and nothing else in a pulmonary TB. In an extra-pulmonary TB, you don't have chronic cough. Fever and night sweats are not necessarily present too. When you think about it, in all of the choices, fever should have been somehow present (i.e. carcinomas).
I know what you mean. In my part of the world, it is TB unless proven otherwise. And, 90% of the time, you'd be correct.
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Old 04-22-2012
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Default Necrotic granulomas

Quote:
Originally Posted by Valkoff View Post
I'm sorry, but I'm a little confused. Sarcoidosis and company won't be necrotising?
There are only two causes for caseous granulomas, which are TB and fungal infection, but necrotic granuloma is more general term and it can also include sarcoidosis.
The biopsy reselats point to infammation and there is only one aswer that fits: extrapulmonary TB
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