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approach with appropriate broad spectrum antibiotics, and specific treatment initiated based on the culture report, followed by splenec--tomy after appropriate vaccinations. Since the functional residual splenic tissue in massive splenic infarction is minimal, splenectomy is not ex--pected to worsen the hyopsplenic state postoperatively. The recom--mended indications for splenecto--my in patients with massive splenic infarction are persistent upper ab--dominal pain, pressure symptoms of a large spleen, accidental rupture and the concern of potential risk of infection, or the presence of an ab--scess of the infarcted splenic tissue. Splenectomy could, however, pose special technical problems due to the size of the spleen and surround--ing perisplenic inflammation. Dense adhesions are usually seen between the spleen, diaphragm, stomach and perinephric region. This makes laparascopic splenctomy a relative contraindication.10 Dissection could be partly facilitated by decompress--ing the cystic mass intraoperatively by aspiration, while taking precau--tion to avoid spillage of splenic tis--sue into the peritoneal cavity, as we did in our second case.

In conclusion, massive splenic infarction is rare, and constituted approximately 3.8% of patients who required splenectomy for splenic se--questration in this large single insti--tution study. All our three patients with massive splenic infarction were adults with persistent splenomegaly well into adulthood, making them liable to this complication. An el--evated HbF is an important risk factor that is significantly associated with massive splenic infarction. A potential complication of a massive infarcted spleen is splenic abscess. A high index of clinical suspicion supported by radiological evidence on ultrasound and CT scan would help early, prompt and appropriate

management. Splenic aspiration may be warranted in some of these cases. These patients can be man--aged initially by conservative mea--sures followed by splenectomy. The predominant indication for splenec--tomy would be persistent pain, pres--sure effects and the risk of infection of the infarcted splenic tissue.

Salam Alkindi, Norman Machado, Pradeep Chopra, Mohammed Al-Huneini, Khalil AlFarsi, Anil Pathare

from the sultan Qaboos university hospital, muscat, Oman

Correspondence:salam alkindi, mDDepartment of haematologysultan Qaboos university hospital,P.o. Box 35, PC 123, al Khod,muscat 000123 omant: +96899353188f: +96824144887sskindi@yahoo.com

Doi: 10.5144/1658-3876.2011.144

REFERENCES

Uterine sarcoma: a rare cause of uterine inversion

To the Editor: We describe a case of uterine inversion associated with endometrial sarcoma. Initially, the patient was thought to have a cer--vical mass, as she developed severe bleeding and the mass protruded outside the vagina. A CT scan was done before examination under anesthesia, with findings of a large uterine mass. We performed a to--tal abdominal hysterectomy and bilateral salpingo-oophorectomy. A completely inverted uterus was found during surgery. Histology showed adenosarcoma of the en--dometrium. The tumor was limited to the endometrium. At the 5-year follow up, there was no clinical or radiological evidence of recurrent disease. Uterine sarcoma should be suspected in uterine inversion diag--nosed in a postmenopausal woman. Most cases of uterine inversion are obstetric related and encountered during the puerperium. Non-puer--peral uterine inversion is estimated to account for just 17% of all cases of uterine inversion.1 Benign uter--ine pathology may present as uter--ine inversion (submucosal myoma is a good example).2 Rarely, uterine inversion may complicate the pre--sentation of uterine sarcoma.6-12 The differential diagnosis of uter--ine inversion in a postmenopausal woman should include uterine pa--thology, particularly sarcoma.

A 76-year-old woman was ad--

1. al Jama aH, al Salem aH, al dabbous ia. mas--sive splenic infarction in Saudi patients with sickle cell anemia-a unique manifestation. am J Hema--tol 2002 ;69:205-9.2. Sears da, udden mm. Splenic infarction, splenic sequestration, and functional hyposplenism in hemo--globin S-C disease. am. J. Hematol 1985; 18: 261-8.3. al-Salem aH, indications and complications of splenectomy for children with sickle cell disease. J Pediatr Surg. 2006 ; 41: 1909-15.4. Wali Ya, al-lamki Z, Hussein SS, bererhi H, Kumar d, Wasiuddin S, Zachariah m, Ghosh K. Splenic function in Omani children with sickle cell disease: correlation with severity index, hemoglo--bin phenotype, iron status, and alpha-thalassemia trait. Pediatr Hematol Oncol 2002; 19:491-500.5. alkindi S, al Zadjali S, al madhani a, daar S, al-Haddabi H, al abri Q, Gravell d, berbar T, Pravin S, Pathare a, Krishnamoorthy r. forecasting hemo--globinopathy burden through neonatal screening in Omani neonates. Hemoglobin 2010; 34 :135-44.6. adekile ad, Owunwanne a, al-Zaabi K, Haider mZ, Tuli m, al-mohannadi S. Temporal sequence of splenic dysfunction in sickle cell disease. am J Hematol 2002; 69: 23-7.7. fishbone G, nunez d, leon r, Paz G, isturiz P, mclaughlin C. massive splenic infarction in sickle

cell-hemoglobin C disease: angiographic findings. am J roentgenol 1977; 129:927-928.8. adekile ad, Tuli m, Haider mZ, al-Zaabi K, mohanna--di S, Owunwanne a. influence of alpha thalassaemia trait on spleen function in sickle cell anemia patients with high Hbf. am J Hematol 1996 ; 53: 1-5.9. al-Salem aH, al-aithan S, bhamidipati P, al-Jama a, aldabbous i. Sonographic assessment of spleen size in Saudi patients with sickle cell dis--ease. ann Saudi med 1998; 18: 217-20.10. moores dC, mcKee ma, Wang H, fischer Jd, Smith JW, andrews HG. Pediatric laparoscopic splenectomy. J Pediatric Surg. 1995; 30: 1201-5.

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mitted through the emergency department with postmenopausal bleeding and lower abdominal pain for six weeks prior to her presenta--tion. She was obese with a BMI of 31. The patient was known to have high blood pressure and cardio--myopathy. A CT scan suggested a mass involving the upper vagina and surrounding the lower uterine segment and cervix with air also in the endometrial canal that may have represented endometritis, although extension from the endometrial ca--nal into the cervix could not be ex--cluded. The patient developed pro--fuse vaginal bleeding and a 10-cm mass protruded outside the vagina. The on-call team managed her by applying a suture ligature around the pedicle, which controlled the bleeding. Examination under an--esthesia was done and a huge mass in the vagina was found. The cervix could not be visualized and the uter--us was enlarged. A biopsy was taken of the mass and histological exami--nation indicated adenosarcoma of the endometrium. Total abdominal hysterectomy, a bilateral salpingo-oophorectomy and a bilateral pel--vic lymphadenectomy were done. During laparotomy, a completely inverted uterus was found with a fungating necrotic mass expand--ing the vagina. The inverted uterus demonstrated the characteristic uterine dimple at the uterine fundus (Figure 1). The final histopathology was adenosarcoma of the endome--trium with a clear margin (Figure 2). Postoperatively, the patient re--covered well and follow-up, both clinically and by CT scan, showed no evidence of recurrence. The last CT scan in October 2009 (5 years from the diagnosis) showed no evi--dence of local or distant recurrence.

Non-puerperal uterine inversion is an extremely rare disease, account--ing for only one sixth of all cases of inversion.2 Takeno et al. reported

that the frequency of nonpuerperal uterine inversion with endometrial carcinoma was 6.8% (71.6% were leiomyomas, 13.6% were sarcoma, and 8.0% were idiopathic).1 It is extremely difficult to preoperatively diagnose nonpuerperal uterine in--

Figure 1. uterine inversion at time of laparotomy with uterine dimple at the uterine fundus indicating the inversion.

version, and the diagnosis is often made at time of surgery. Particularly in postmenopausal women, uterine inversion with corpus malignancy can be misdiagnosed as a cervical malignancy.4 Furthermore, it has been described that the symptoms

Figure 2. Histopathology of endometrial adenosarcoma.

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associated with a nonpuerperal uterine inversion were vaginal bleed--ing, vaginal tumor, lower abdominal pain, menorrhagia and urinary dis--turbance. Including our cases, none of the reported cases were in shock, which is sometimes associated with puerperal uterine inversion.

Uterine inversion is suspected when a tumor is palpable in the va--gina, but the uterine fundus is not palpable by a pelvic examination.5 In the present case, extruded tumor was observed in the vagina, but a pelvic examination failed to identify uterine inversion. MRI has been shown to be a useful diagnostic tool since it can examine the char--acteristic image of the uterine cavity and a thickened and inverted uter--ine fundus on a sagital image and a ‘bulls eye’ configuration on an axial image are signs indicative of uterine inversion.12 Our case was diagnosed by CT scan, but inversion was not suspected by CT. The diagnosis of uterine inversion was made during the surgical procedure.

The etiological factors of this combination include (a) sudden ex--trusion of a tumor from the uterus, (b) thin uterine wall, (c) dilatation of the uterine cervix, (d) tumor size, (e) thickness of the tumor pedicle and (f ) tumor attachment site.3 In our case, as the tumor with its ped--icle attached to the uterine muscle became progressively relaxed at the point of pedicle attachment, the cer--vix dilated and the tumor extruded into the vagina, resulting in uterine inversion. When a rapidly growing tumor exhibits signs indicative of myoma delivery, patients should be treated as having not only uterine sarcoma, but also uterine inversion.

Ehrlich et al. reported that the abdominal approach is the best and least hazardous treatment for uterine inversion caused by uter--ine sarcoma.5 Since patients with this disease are less likely to suffer

shock, there is enough time to per--form tests such as MRI to deliver an accurate preoperative diagnosis. However, in our case the severe vaginal bleeding and mass protrud--ed outside the vulva, which made surgical intervention life saving. At present, surgery and/or chemo--therapy have been recommended for the treatment of uterine inver--sion caused by sarcoma, but the standard therapy has not yet been established. Therefore, treatment options for this combination should be studied in the future.

Ezzeldin Korshid,a Ismail A. Al-Badawib

from the aKing fahad medical City and the bKing faisal specialist hospital and research Centre, riyadh, saudi arabia

Correspondence: ismail a. al-Badawi, mDDepartment of obstetrics and GynecologyKing faisal specialist hospital and research CentremBC 52, P.o. Box 3354, riyadh 11211, saudi arabia t: +966-1-4427392f: +966-1-4427393i_albadawi@yahoo.com

Doi: 10.5144/1658-3876.2011.146

1. Takano K, ichikawa Y, Tsuboda H, nishida m. uter--ine inversion caused by uterine sarcoma: a case report. Jpn J Chin Oncol 2001 (Jan); 31(1):39-42.2. Kopal S, Seckin nC, Turhan nO. acute uterine inversion due to a growing submucous myoma in an elderly woman: case report. eur J Obstet Gyne--col reprod biol 2001 (nov); 99(1):118-20.3. das P. inversion of the uterus. J Gynaecol br emp 1940;47:525-48.4. Krenning ra. nonpuerperal uterine inver--sion. review of literature. Clin exp Obstet Gynecol 1982;9:12-5. medline5. lascarides e, Cohen m. Surgical management of nonpuerperal inversion of the uterus. Obstet Gy--necol 1968;32:376-81. medlineWed of Science6. mwinyoglee J, Simelela n, marivate m. non-puerperal uterine inversions. a tow case report

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and review of literature. Cent afr J. med 1997;43-:268-71. medline7. ehrlich Ce, nonaventura lm. nonpuerperal inversion of the uterus by endometrial stromal sarcoma of the uterine fundus. South med J 1977;70:872-3. medlineWeb of Science8. Silveira Pinheiro l, Ponte JG. acute nonpu--erperal inversion. int Surg 1975;60:559-60 med--lineWeb of Science9. Schulman Jm, Stanton JS. acute nonpuer--peral uterine inversion. South mJ 1981;74:1142-5. medlineWeb of Science10. Krenning ra, dorr PJ, de Groot WH, de Goey Wb. non-puerperal uterine inversion. Case report. br J Ob--stet Gynaecol 1982;247-9. medlineWeb of Science11. Wiedswang G, moen mH. non-puerperal in--version of the uterus. acta Obstet Gynecol Scand 1989;68:559-60. CrossrefmedlineWeb of Science12. lai fm, Tseng P, Yeo SH, Tsakok fH. non-puer--peral uterine inversion – a case report. Singapore med J 1993;34:466-8. medline

Lead intoxication mimick--ing a malignancy

To the Editor: A 51-year-old male presented to the hospital with a 3-month history of low to moderate grade fever, fatigue, weight loss and upper abdominal pain. Clinical examination was unremarkable except mild pallor. Investigations revealed low hemoglobin (9.8 g/dL) with normal blood counts and elevated transminase levels (SGOT: 345U/L, SGPT: 123 U/L). Other biochemical parameters were nor--mal. Blood and urine cultures were sterile. CT of the abdomen revealed pericholecystic fluid, favoring a diagnosis of chronic cholecystitis with acute exacerbation. He un--derwent laparoscopic cholecystec--tomy along with a wedge biopsy of liver. Liver biopsy showed only fatty change. In view of no response to broad-spectrum oral antibiotics he was further investigated. Contrast-enhanced CT of the chest showed bilateral parenchymal infiltrates with mediastinal lymphadenopathy. During the course of investigation he started developing pancytopenia. The presence of mediastinal nodes and cytopenias raised a suspicion of lymphoma with marrow involve--ment. A trial of naproxen further