Purpose: Adrenalectomy for primary aldosteronism (PA) lateralized to one gland yields significant biochemical cure rates, but clinical outcomes are less favorable, especially for patients with “non-classic” pathologies like multiple aldosterone producing nodules or hyperplasia. This study investigates why surgical results are poorer in “non-classic” PA, the ability of preoperative imaging to differentiate these, entities, and the existence of preoperative biochemical markers. Methods: The authors retrospectively reviewed 53 consecutive PA patients who underwent laparoscopic adrenalectomy at a tertiary care academic institution. Demographic data were collected and Statistical analyses compared pre- and post-operative blood pressure & antihypertensive medication use. Pathologic and radiographic results were examined by specialists. Results: Radiologically, “classic” and “non-classic” groups could not be distinguished. In the “classic” group, 95% achieved total cure and 57% showed improvement. Conversely, in the “non-classic group,” only 5% were cured while 43% improved. AVS data indicated that adenomas of the “classic” group secreted nearly twice the aldosterone as the “non-classic” group (8,074 vs. 4,423.5, P=0.02). The contralateral gland in the “non-classic” group secreted almost twice the aldosterone compared to the “classic” group though not statistically significant (419 vs. 273.3, P=0.1). Conclusion Patients with unilateral “non-classic” PA fare worse than those with unilateral “classic” PA after unilateral adrenalectomy. The non-classic variety may represent a form of asymmetrical bilateral hyperplasia. Cross table imaging is incapable of distinguishing between the 2 entities. AVS may identify non-classic unilateral PA and serve to address patient and physician expectations.

Summary Pyoderma gangrenosum (PG) of the breast is a rare rapidly progressive neutrophilic dermatosis, which usually co-exists with severe underlying systemic conditions. A woman presented with a non-healing ulcer over her right breast with characteristic sparing of nipple-areola complex (Bork-Baykal phenomenon). It was diagnosed as pyoderma gangrenosum on the basis of clinico-pathological correlation and managed successfully with systemic corticosteroids and anti-inflammatory drugs along with wound care. The diagnosis and treatment of PG is challenging particularly at unusual sites given the paucity of robust clinical evidence and lack of consensus opinion regarding specific management guidelines. It is imperative that PG is considered as a clinical diagnosis in any patient with enlarging, sterile, necrotic lesions unresponsive to appropriate antibiotics. Early recognition of PG at rare locations can prevent devastating sequelae such as over-zealous surgical debridement and deep tissue infections associated with a chronic open wound leading to severe cosmetic morbidity.
Pyoderma Gangrenosum

Overlap syndrome is a term used to describe a condition wherein a patient has features of more than one classic inflammatory rheumatic disease like systemic lupus erythematosus, polymyositis, scleroderma and rheumatoid arthritis. Individuals with an overlap syndrome may, but need not meet, complete diagnostic criteria for one or more than one classic rheumatic disease. Mixed connective tissue disease is a specific subset of overlap syndrome wherein patients have antibodies to the U1 small nuclear ribonuclear protein (anti- U1RNP) and clinical features like hand edema, synovitis, Raynaud phenomenon, acrosclerosis and biologically or histologically proven myositis. We came across an interesting case showing clinical features of both Systemic Sclerosis and Discoid Lupus erythematosus (DLE). On complete evaluation, a final diagnosis of Diffuse Systemic Sclerosis - DLE overlap was made on the basis of histopathopathological and serological findings. Patient was started accordingly on systemic and topical medications and responded well.