A Morel-Lavallée lesion (MLL) is a rare closed degloving injury that usually occurs around the hips and is associated with pelvic fractures after high-energy trauma, which is commonly overshadowed by other severe post-traumatic manifestations. An isolated MLL, mostly caused by low-energy violence, is even rarer. Thus, the rates of misdiagnosis and missed diagnosis are often high. In this case report and literature review, we review the pathophysiology, clinical manifestations, imaging data, and treatment of this lesion to increase awareness of this rare disease.We report the case of an isolated MLL in the right thigh caused by trauma, which happened to be one of missed diagnosis both at the initial visit and at the return visit of the patient, with a significant sign of a mass on MRI. Given the size of the lesion, open debridement and irrigation were adopted to treat the lesion, and the patient recovered well post-operatively.Young surgeons should pay attention to the MLL with sufficient recognization to avoid missed diagnosis and misdiagnosis. Comprehensive physical examination and imaging data play important roles in the diagnosis of MLL. In the early stages of this injury, a detailed history review combined with physical examination and MRI, can reduce the rates of missed diagnosis and misdiagnosis. The choice of the therapeutic scheme depends on the size and severity of the lesion. For an isolated MLL, compared with conservative treatments, we suggest that incision and drainage, along with tissue debridement and a surgically placed drain, will reduce the rates of infection and recurrence. A Morel-Lavallée lesion (MLL) is a post-traumatic closed degloving soft tissue injury that occurs following high-energy trauma by a shearing force, first described by the French surgeon Morel-Lavallée in 1863 . GeneralThis report presents a patient with an isolated MLL without fractures in the right thigh, which happened to be a case of missed diagnosis both at the initial visit and the return visit. Finally, the patient received surgical intervention including incision and drainage along with tissue debridement and a surgically placed drain. We also reviewed the relevant literature and summarized the pathogenesis, clinical manifestations, and treatment strategies for the MLL. Surgeons require an increased understanding of the lesion so that the rates of misdiagnosis and missed diagnosis could be reduced.1WI) (2WI)   and hypeI) (2WI) . The lesGiven the size of the lesion, the patient underwent surgical intervention which included an incision and drainage along with tissue debridement and a surgically placed drain. After completion of the sterile preoperative preparation, an incision in the skin and subcutaneous tissue was made along the anterolateral side of the right thigh, with profuse exudation of light red fluids. We found a space between the fascia lata and the subcutaneous fat, which should not exist in a standard anatomical structure. After irrigating the cavity with a large amount of iodophor, hydrogen peroxide, and saline, we used vacuum-assisted closure therapy to promote cavity closure. The cavity was filled with polyethylene alcohol–hydrated seaweed salt foam dressing, with a semi-permeable bio-membrane covering the incision. Then, a continuous vacuum sealing drainage (VSD) device and a percutaneous drain were used to exhaust blood, lymph, and fatty debris. After 1 week, we removed the VSD and used non-absorbable, non-braided sutures to close the deep fascia and skin of the incision , with anThe characteristics of this case report are consistent with those of a Morel-Lavallée lesion, including the injury mechanism, clinical manifestations, and imaging data. Generally, the lesion is caused by a shearing force, separating the subcutaneous fat and deep fascia and creating a space between them. At the same time, capillaries and lymphatics in soft tissue become disrupted with shearing injury, leading to an accumulation of lymph, blood, debris, and fat in the interfacial plane. After this, necrosis of fat liquefaction occurs in the lacunae, and these components are gradually absorbed to form a serum fluid wrapped in hemosiderin layer, leading to local inflammation and pseudo capsule formation . Due to The clinical presentations of an isolated MLL without fractures are non-specific and include pain, ecchymosis, swelling, and fluctuating sensations in the injured area . In the 1WI and hyperintense on T2WI, and occurs in acute and chronic lesions without forming a fibrous capsule. In comparison, subacute hematoma is hyperintense both on T1WI and on T2WI due to the presence of methemoglobin. Internal inhomogeneity can be observed on MRI, with the presence of fat globules and internal septations. Furthermore, variations in the MLL tend to be more pronounced after fibrous capsule formation. Chronic-organizing hematoma is hypointense or intermediate-intense on T1WI and heterogeneous intermediate–intense on T2WI, with the formation of capsule. As different contents of lesions such as hemosiderin granulation tissue, necrotic debris, fibrin, and blood clots exist in the cavity, different signals will be seen on MRI , computed tomography (CT), and magnetic resonance imaging (MRI) can be used to provide additional information. US demonstrates heterogeneous echogenicity, appearing as a fluid collection in the area of the lesion. This variation is often not specific, and a simple hematoma, effusion, abscess, and tumor can show similar characteristics to this lesion, making it difficult to determine the nature of heterogeneous echogenicity. However, their imperceptible specific appearance in the acute lesion  is more likely to be observed using a high-frequency linear probe in US –10. Typipsulated .However, there is no guideline or consensus on the treatment of an MML, despite many MLL reported treatments. Conservative management options include compression bandaging, percutaneous puncture aspiration, and sclerosants, either provided separately or combined together. In clinical practice, the management of an MLL is highly variable, and therapeutic scheme choice depends on the size and severity of the lesion. Local compression bandaging is considered a simple but effective therapy for minor lesions and is frequently coordinated with adjuvant therapy such as physical therapy, bed rest, and oral NSAIDs. A retrospective review showed that all 25 adolescents with an MLL, treated with compression bandaging, yielded favorable outcomes . NeverthIn this report, surgical interventions were adopted to treat an isolated MLL. The patient had been misdiagnosed, and was admitted to the hospital for treatment after oral analgesics and rest proved ineffective. Because of the extensive range of skin and high liquid accumulation, it was not suitable to apply a compression bandage. Although percutaneous puncture drainage can remove effusion in the cavity, a high risk of recurrence and infection may exist due to multiple skin contusions in the right thigh. Furthermore, when we reviewed the patient's imaging data, no fibrous capsule was visible in MRI. Given the above, we opted for performing incision and drainage, along with tissue debridement and a surgically placed drain to clean the content of the cavity. Elastic bandage compression was used to close the cavity. As a routine therapy, incision and drainage, along with tissue debridement, is successful in adequately debriding necrotic components and creating good preoperative conditions for other injuries. Interestingly, compared with compression bandaging or percutaneous puncture aspiration, incision debridement and drainage have minimal recurrence rates . MoreoveIn summary, young surgeons should pay attention to an MLL, with sufficient recognization to avoid both missed diagnoses and misdiagnoses. Comprehensive physical examination and imaging data play essential roles in diagnosing an MLL. In the early stages of this injury, a detailed history review combined with physical examination and MRI can reduce the rates of missed diagnosis and misdiagnosis. The choice of the therapeutic scheme depends on the size and severity of the lesion. For an isolated MLL, compared with conservative treatments, we suggest that incision and drainage, along with tissue debridement and a surgically placed drain, will reduce infection and recurrence rates.


Osteochondritis of the ischiopubic area is a rare disease of children that presents with hip pain and limping. Careful examination and appropriate investigations are essential to establish a definite diagnosis. We report a case series of four children, ages 10–14-year-old, with osteochondritis of the ischiopubic area. Plain X-ray examination showed an area of diffuse irregular calcification of the ischium in two of the children, while in the other two there was an asymmetrical enlargement of the ischiopubic synchondrosis. MRI investigation was the most helpful examination. Bone edema was found in all four children. A calcified mass separated from the host ischium was found in the first two children. The cortex was normal, without irregular destruction. Bone edema of both the ischium and pubic alongside the synchondrosis was found in the following two children, with intact cortices and asymmetrical enlargement. Osteochondritis lesions of the ischium and the ischiopubic area have radiological findings similar to several severe diseases. Bone edema on MRI investigation in children must be properly evaluated. Appropriate radiological examination enabled us to confirm the diagnosis of the osteochondritis and to avoid unnecessary procedures. We want to draw attention to the rare diagnosis of osteochondritis of the ischiopubic area, and the clinical significance, as a cause of hip pain and limping in children. The definite diagnosis of adolescents with pelvic pain, usually accompanied by a limp, requires a thorough examination. The differential diagnoses include slipped capital femoral epiphysis (SCFE), infection, benign and malignant lesions, and autoimmune disorders. Among the rare diagnoses are osteochondritis lesions. Osteochondritis of the ischiopubic area refers in enlargement and abnormal calcification of the pubic, ischium and the ischipubic synchondrosis. It can be found either as calcified apophysitis due to overuse lesion either as an atypical painful enlargement of the ischiopubic synchondrosis, as described from Van Neck-Odelberg. Plain X-rays may have low specificity and confusing findings. Further radiological examination is required to confirm the diagnosis –7.We present a case series of four children, with osteochondritis lesions in the ischiopubic area, diagnosed in our institution. Our paper combines the results of clinical and radiological investigations that are usually nonspecific and often confusing, providing elements for an accurate diagnosis. Invasive procedures are unnecessary when a diagnosis of osteochondritis lesions (either traumatic or idiopathic) is established.During the last 5 years, we identified four children referred in our institution for hip pain and limping, who were diagnosed with osteochondritis of the ischiopubic area. Their ages ranged from 10 to 14 years. Their data regarding the clinical and radiographic examinations were obtained retrospectively from the records Tables One adolescent participating in high-level football sports presented with a limp and pain in the right hip region that had lasted for 3weeks. He was unable to recall any severe injuries while playing. He was unable to hop on the affected side. Clinical examination showed that the hip movements were unaffected. Palpation revealed localized pain of the right ischium.The results of initial X-ray examinations of the anterior-posterior (AP) and frog lateral views excluded SCFE. The periphery of the right ischium showed an area of diffuse irregular calcification with smooth boundaries and a normal ischial structure .Magnetic resonance imaging (MRI) revealed a chondral calcified mass separated by fluid from the host ischium bone. The ischium had a normal structure, without signs of elevated periosteum. The surrounding muscles were edematous and the hamstring tendon was attached to the osteochondral mass. A diagnosis of traumatic avulsion of the ischium resulting from repeated small injuries was established Figures .After 1 month of bed rest and use of crutches for partial weight-bearing (PWB), the patient reported relief of his discomfort. X-rays performed 3 months later showed union of the osteochondral mass to the ischium. The patient returned to his sports activities .The next two male adolescents presented with pain in the pelvis along with a limp.Their symptoms had lasted for 3 months and included mild pain that was exacerbated during sports activities. They were also active in football activities, as is common for their age group. Clinical examination showed normal ranges of hip movements, with pain at the end of internal and external rotations. Both adolescents expressed discomfort upon palpation of the ischium tuberosity on the left side.X-ray examination of the first child showed signs of irregular cortex on the inferior part of the left ischium, with a smooth line of calcification .MRI examination revealed bone marrow edema in the ischium and a minimally displaced lesion. The adjacent muscles showed no edema. These were diagnosed as apophyseal lesions of the ischium Figures .X-ray examination of the other boy showed enlargement of the ischiopubic synchondrosis, which was asymmetrically enlarged on the left side . MRI revThe treatment for both patients was the elimination of the activities and use of crutches for partial weight-bearing, for a month. This treatment resulted in symptom relief and both children returned to their activities after 4–5 months of rest.The fourth patient was a 10-year-old girl who was initially diagnosed with subacute osteomyelitis of the pelvis. She had experienced pain and discomfort around her left hip that had lasted for 2 months. She was admitted to the pediatric department of a state hospital. MRI revealed edema of the ischiopubic area, which was diagnosed as subacute osteomyelitis, for which treatment with antibiotics was provided.Clinical examination revealed a normal active girl with occasional discomfort in activities. A review of the MRI revealed edema of the ischium, with intact periosteum and absence of periosteal reactions. The adjacent muscles were normal Figures .Blood tests showed normal erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood count. We diagnosed the patient with osteochondritis of the ischiopubic area. Therefore, the patient discontinued the medication and returned to her normal activities within two months. She did not require the use of crutches. X-ray examination confirmed asymmetry of ischiopubic synchondrosis.Adolescents who present with pain and the hip region accompanied by a limp must be properly evaluated for an accurate diagnosis. It is important to exclude SCFE, which is a commonly missed diagnosis. The potential causes for these symptoms include benign or malignant tumors, infection, autoimmune disorders, and stress fractures –3, 5, 6.Avulsion fractures of the ischium are usually acute injuries, mainly in young athletes, that occur after a sudden contraction of the hamstrings, which present as pain and difficulty in jumping. They are uncommon injuries, mainly observed in adolescents participating in sports activities such as gymnastics, soccer, and dancing. In acute injuries, a history of recent trauma is usually well documented and a curved bony fragment with sharp margins adjacent to the parental bone is typically observed in all imaging modalities, leading to the correct diagnosis –9.Computed tomography (CT) and MRI can be used to the diagnosis, mainly by confirming and evaluating the displacement of the fragment. MRI shows muscle edema; moreover, in cases where plain X-rays cannot detect a bone fragment, this appears as an avulsion lesion on MRI. Depending on the displacement, it can be treated either conservatively or surgically with appropriate stabilization. Surgery is usually indicated for larger fragments, with more than 1.5 cm of avulsion. Painful nonunion may also require surgical stabilization –13.In contrast to typical avulsion ischial tuberosity lesions, our first patient presented with layers of calcification with smooth lining attached to the inferior part of the ischium, which were visible by X-ray. Avulsion injuries in the ischiopubic area in young athletes are usually caused by chronic repetitive trauma. Instead of a distinct detached bony fragment, these injuries present with irregular, ill-defined margins of the parental bone, with concomitant rarefaction and lysis. This type of injury can be mistaken for more aggressive processes, such as infection or Ewing sarcoma, particularly in cases with no clear history of trauma .The radiological image findings showed similarities to osteochondritis of the tibial tuberosity, with layers of calcification. The cortex was intact and there were no areas of moated bone. The periosteal reaction on X-rays must be differentiated from Ewing sarcoma. In sarcoma, MRI shows a destroyed or irregular cortex, with possible extension of the tumor into soft tissues. In our first patient, MRI showed a smooth semilunar ossified mass, with a minimally detached periosteum of the ischium, along with edema of the ischium and fluid between the mass and the host bone. The bone cortex was normal and the hamstring muscles were attached to the bone.MRI allowed confirmation of the diagnosis of ischium osteochondritis in the second and third adolescent. In their initial radiographs, the second patient had a smooth calcification off the ischium; the third showed irregularity of the ischiopubic synchondrosis, which is a common finding in pelvic X-rays, due to asymmetrical union. Such an asymmetrical union was also reported as a misdiagnosed fracture of the ischiopubic area in a child after a road traffic accident. Proper clinical evaluation and knowledge of asymmetrical union showed normal variation MRI showed bone edema of the ischium with a small calcified chondral mass attached to the bone in the second patient. The area around the ischium showed no fluid, and the muscles remained attached to the bone. The third patient showed edema in both the ischium and pubic areas, with smooth enlargement and irregularity of the synchondrosis. The cortex and adjacent soft tissues were normal in our fourth patient. Bone edema is the main characteristic of osteochondritis in the growing bone before the completion of apophysis union. It is important to appropriately evaluate the signs of bone edema in growing children. Malignant lesions, including leukemia or Ewing, may also show bone edema but are accompanied by irregular cortex destruction, mass adjacent to the cortex, and asymmetrical destruction. While benign lesions such as osteoid osteoma also show bone edema, the clinical findings differ, and CT scan is the most appropriate method to detect the nidus. On MRI, benign chondral tumors show signs of chondral enlargement. Autoimmune disorders of the pelvis mainly occur in the sacroiliac joint and show joint irregularity and edema on both sides, affecting both the ilium and sacrum.Irregular enlargement of the ischiopubic joint is usually an area of confusion for accurate diagnosis. Osteochondritis of the synchondrosis, known as “Van Neck–Odelberg,” is characterized by an irregular enlargement of the joint on X-ray –18.Painful enlargement of the synchondrosis must be investigated by MRI or CT to confirm the diagnosis. The characteristic MRI finding is a normal cortex off the bone, edema on both sides, and smooth enlargement of the area, in addition to hyperintense signal in T2 and STIR images and hypointensity in T1 sequences.Diagnostic procedures, including biopsies, are unnecessary when appropriate investigations are performed. Acute or subacute infections show signs of periosteal reaction on plain radiography, along with signs of localized osteoporosis. MRI of cases of infection shows diffuse edema with periosteal reactions and signs of diffuse edema of the adjacent muscle . Blood tests with elevated ESR and CRP levels are helpful in acute infections but may be normal or slightly elevated in subacute infections. Our fourth patient had edema of the ischium with a normal cortex and no muscle edema. In cases of acute or subacute osteomyelitis, an extended irregular area of edema is expected, with periosteal reaction and periosteal edema –22. In tStress fractures of the ischium are rare. Radiological examinations show periosteal reaction and calcification on both sides of the ischium. In MRI, edema is the main feature, in the presence of a hypointense line perpendicular to the bone line, that is, the fracture line. CT scans further increase the diagnostic ability by showing disruption of the cortex .We managed our patients with bed rest and PWB. While physical therapy (PT) is recommended, we have not provided PT since our patients presented with regular ROM after the resting period. Use of nonsteroid anti-inflammatory medication is helpful for children with severe discomfort , 18. OurOsteochondritis of the ischiopubic area is a rare diagnosis that is established after a complete evaluation of children with pain in the pelvic region and a limp.Osteochondritis of the ischiopubic area remains a condition that is difficult to be diagnosed. Accurate clinical examination and appropriate radiographic evaluation is essential. Calcification of the area, edema, and enlargement of the synchondrosis must be combined in order to avoid unnecessary procedures. Conservative treatment with rest and PWB is the recommended treatment.


This reports outlines a rare case of primary right atrial angiosarcoma with multiple metastases. Multimodality imaging and histopathology confirmed the diagnosis of primary cardiac angiosarcoma and multiple metastases. We present the details of the presentation, multimodality imaging findings, and clinical management. The patient was followed up by cardiac MRI (CMRI) 2 months after therapy, the cardiac tumor and pulmonary metastases decreased markedly. Up to now, the patient has undergone four cycles of chemotherapy and immunotherapy. Primary cardiac angiosarcoma (PCA) is extremely rare, and accounts for 33% of all primary malignant cardiac neoplasms . It origA 28-year-old man was admitted to the orthopedics department on 13 January 2022 with low back pain for one month. On admission, the patient had neither previous cardiovascular antecedents nor family history. He also denied medication use. The patient's body temperature was normal, 36.6°C with a blood pressure of 102/68 mmHg, and a heart rate of 96 bpm. The patient body mass index was 20.2.9/L and 165 × 109/L, respectively.The biochemical investigation showed no alteration in the following serum levels: total bilirubin, alkaline phosphatase, urea, creatinine, potassium, glucose, and sodium. Hemoglobin level was 144 g/l, hematocrit level was 43.2%, and serum leukocyte and platelet levels were 9.2 × 10Physical examination revealed pain in the sternocostal and lumbosacral region, other body systems showed no abnormalities. Electrocardiography was normal.A CT examination from the chest to the pelvis was performed, which revealed a right atrial mass, multiple small ground-glass pulmonary nodules, and bone destructions . TransthTo get a definitive diagnosis, the patient underwent the sacral biopsy, but the result was a benign vascularized lesion, which was in contradiction with the presentations on images, so the left lower lung nodule resection was performed. The histopathology examination and immunohistochemical staining supported the diagnosis of angiosarcoma positive for CD31, CD34, ETS-related gene (ERG), and Ki67 (LI: 60%) . CombineRepeat CMRI and chest CT showed significant regression of the tumor and pulmonary metastases . Now, thPCA is one of the most common primary cardiac malignancies , originaEchocardiography has become an initial imaging technique because of its wide availability and high sensitivity, non-invasiveness, and cost-effectiveness , 11, 12,There is more efficiency in using CT for tissue characterization and systemic metastases, especially in the lungs . PCA oftCardiac MRI is considered to be the most sophisticated imaging method to display the cardiac tumor size, location, and signal characteristics . T1-weigPositron emission tomography/CT has advantages in non-invasively characterizing cardiac tumors and disease staging, scarce case reports have described the use of FDG PET-CT in differentiating the benign and malignant mass, metastatic workup, preoperative staging, and assessment of response to treatment in primary cardiac angiosarcomas –19. RahbAlthough multimodality images can help diagnosis, definitive diagnosis and classification depend on the pathological examination, which is the gold standard based on immunohistochemistry as evidence for chemotherapy and radiotherapy. Immunohistochemically, angiosarcomas are usually positive for vimentin, CD31, CD34, and factor VIII-related antigens . ERG wasThe most common organ for metastasis of primary angiosarcoma is the lungs and bone, occasionally in the liver and spleen, and extremely rarely in the brain , 23. PulDue to the rarity of these tumors, the optimal management strategy is still argued. Current treatment options include surgery, radiotherapy, and chemotherapy. Surgical resection remains the gold standard for the treatment of primary malignant cardiac tumors. The limits of surgical resection have been related to the degree of extensive involvement of nearby structures and other cardiac chambers . In addiThere were limitations in this study. First, the patient did not conduct surgical resection, and no pathology of the tumor was obtained. We speculated the diagnosis according to histopathologic findings of lower left lung and multimodality images. Second, at present adjuvant immunotherapy and chemotherapy is very effective, but we should follow up closely to observe the future effect.Evaluation and diagnosis of PCA can be complex and should include multimodality imaging, multidisciplinary discussion is important. The case demonstrates the typical presentation of primary cardiac angiosarcoma and its associated features on multimodality imaging. More experience is needed to better understand the imaging characteristics of angiosarcoma.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Medical Ethics Committee of Zhongnan Hospital of Wuhan University. The informed consent was waived.XL contributed to MRI scanning of the patient and collecting clinical data. HH contributed to editing, revising, and approving the manuscript. LL contributed to interpreting the data. XL, HH, and LL contributed to the writing and revision of the manuscript. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cystic teratomas are a common ovarian neoplasm that are rarely found in other locations of the body, namely the sacrococcygeal region and anterior mediastinum. Localization to the urinary bladder is exceedingly rare, with only a few cases documented in the literature. Cystic teratomas are usually asymptomatic and found incidentally, but localization to the bladder can present as irritative lower urinary tract symptoms and/or mimic urinary tract calculi. We report the rare case of a mature cystic teratoma of the urinary bladder, presenting as foul-smelling urine with recurrent urinary tract infections and microhematuria, that was originally misdiagnosed as a bladder calculus. MCTMature Cystic TeratomaUTIsUrinary Tract InfectionsEREmergency RoomCTComputed Tomography1Cystic teratomas are the most common ovarian neoplasm, with an estimated incidence of 1.2–14.2 cases per 100,000.2Escherichia coli at this time. Her obstetric history is notable for three normal standard vaginal births and one Cesarean section with a bilateral tubal ligation, but she retained her ovaries. She has no family history of gynecologic or obstetric conditions.A 48-year-old Gravida 4, Para 4 Hispanic female presented to our Urology clinic for persistent foul-smelling urine. She denied symptoms of dysuria or fever. Past medical history was notable for recurrent UTIs and a 6-cm bladder calculus discovered during an Emergency Room (ER) visit for a complicated UTI three years prior. This was treated with cystoscopy laser lithotripsy by an outside urologist at that time. Of note, her urine grew extended-spectrum beta-lactamase (ESBL) Vital signs were within normal limits. Urinalysis was notable for large leukocyte esterase and small blood. Diagnostic cystoscopy appreciated a 10-cm calculus, or calcified mass, arising from the left wall of the bladder and extending deeply into the lumen of the bladder. An empty right-sided diverticulum was also observed. Computed tomography (CT) imaging showed a bi-lobed calcification radiographically interpreted as a 5-cm calculus in a left-sided bladder diverticulum with a 5-cm extension into the bladder .Fig. 1A)A plan was developed for her to undergo robotic-assisted laparoscopic partial cystectomy. This decision was made with the understanding that the lesion could be removed if it were either a solid mass or a stone in a diverticulum. Transperitoneal robotic surgery provided direct access to the bladder and adnexa without having to move any other structures. Supraumbilical camera port placement revealed the lesion for immediate inspection, and it was easy to triangulate the robotic arms for excision of the mass and repair of the bladder. First, the diverticulum and its calculus were completely excised from the urinary bladder. Intraoperative inspection of the presumed bladder calculus revealed that the bladder lesion did not look typical for a calculus; instead, its appearance favored an atypical solid tumor. The tumor was completely excised from the urinary bladder and retrieved .https://doi.org/10.1016/j.eucr.2023.102320Supplementary video related to this article can be found at Intra-operative video showing removal of the diverticulum with its calculus and the remaining calculus in the bladder.VideoThe following is the supplementary data related to this article:Enterococcus faecalis.Both the diverticulum with calculus and additional calculus retrieved from the bladder were sent to pathology for analysis. Gross examination revealed two tan, irregular, hard calculi (4.2 × 3.5 × 3.2 cm and 5.5 × 4.9 × 4.2 cm). Histological examination found them to be a mature cystic teratoma with associated calcifications and clear margins. Cartilage, skin, and apocrine glands were observed throughout the lesion . No atypShe tolerated the procedure well and was discharged the following day. At four-month follow-up, diagnostic cystoscopy noted a small residual bladder scar in the left wall of the bladder. Transurethral resection of the scar demonstrated areas of granulation tissue and calcifications, without recurrence of the teratoma and no malignancy. Her urinalysis was also negative; and she reported no recurrence of UTI symptoms and resolution of her foul-smelling urine.3MCTs are the most common ovarian neoplasm; however, localization to the urinary bladder is exceedingly rare with few cases reported in the literature. This makes accurate diagnosis difficult. The clinical presentation, localization, and notable calcification appreciated on imaging studies create a pitfall in which a bladder calculus may appear a reasonable diagnosis. However, as seen in our case, the discovery of a different pathology only occurred intra-operatively. Surgical removal with diverticulectomy successfully removed the tumor, with histology determining it to be an MCT. Resolution of the patient's foul-smelling urine was achieved and there has been no subsequent UTIs in the six months following the procedure.,,The first case of a mature cystic teratoma of the urinary bladder was published in 1981.,MCTs have an age-related incidence, most frequently occurring in female patients between 20 and 40 years of age with a median age of 30.Treatment of MCTs involves complete removal of the tumor, with recurrence uncommon when performed successfully.4Our case highlights the rare phenomenon of a mature cystic teratoma of the urinary bladder. The presentation mimics that of bladder calculi, making definitive preoperative diagnosis challenging. Mature cystic teratoma should be considered on the differential of perceived bladder calculi, especially in the setting of recurrent UTIs and prior unsuccessful lithotripsy. Treatment involves complete surgical removal of the MCT, preventing recurrence and alleviating the urinary symptoms.We kindly ask that our media be printed in color.Informed, written consent was obtained from the patient for publication of this case.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.There are no conflicts of interest. The author(s) received no financial support for the research, authorship, and/or publication of this article.


Abdominal cystic tumors are highly prevalent. Due to the availability of superior imaging techniques, they are now diagnosed more commonly and considerably earlier. Although giant masses are seen sporadically, particularly in the rural scenarios. A 74-year-old multipara with distension of abdomen and breathlessness misdiagnosed as ascites initially was later on confirmed as giant borderline mucinous cystadenoma. We wish to highlight this case to bring forth the plight of rural women who are deprived of standard health care. The case of ovarian tumor presented seems to be the largest documented ovarian tumor in central India to the best of our knowledge. The risk of getting diagnosed with an ovarian tumor is about 1% to 1.5% , which mCystic lesions with loculi lining that has mucin secreting epithelium, which appears like the endocervical glands and the gastrointestinal epithelium constitutes mucinous ovarian tumors . Such tuManagement of ovarian tumors essentially starts with an assessment of the malignant potential of the tumor by the risk malignancy index which depends on the menopausal status, ultrasonographic findings and levels of ca 125 [2 92% on room air.A 74-year-old woman, grand multipara, presented to the casualty of a tertiary Centre of a rural hospital in central India, in emergency hours with massive ascites and breathlessness (NYHA III), with a history of gradual abdominal distension over the past seven years, with sparse episodes of dull-aching pain in the abdomen, weight loss, and chronic constipation. On examination, the patient was cachexic and pale, with a weight of 75 kilograms, her pulse was 124 beats per minute, and blood pressure was recorded as 160/100 mmHg, with SpOOn abdominal examination, the skin was tense and shiny with a uniformly large cystic mass extending from the pubis to the xiphisternum Figure . There wChest x-ray revealed obliteration of costophrenic angles and pushed up diaphragm Figure . 2D-echoUltrasonography of abdomen and pelvis reported huge cystic mass having thickened wall (5.0 mm) with multiple septations and low-level echogenic foci, centrally positioned present in all nine quadrants of abdomen compressing the bowel arising from behind uterus and cephalad of urinary bladder, but anterior to the rectum Figure . Risk maAfter taking informed very high-risk consent with counselling about intraoperative post operative complications such as sudden hypotension and ventilatory support amongst others, staging laparotomy was performed under general anesthesia, with left lateral tilt to the operating table. Abdomen was opened in layers with infraumbilical midline incision. Minimal ascites was present in peritoneal cavity, grossly whitish glistening capsule of tumor was identified which was extending up to xiphisternum, no adhesions of the mass was present in the peritoneal cavity, size of mass was identified as 36 x 30 x 18 cm, mass could not be removed en bloc due to large size of it Figure . FollowiOvarian cysts more than 10 cm in dimension are labeled as giant ovarian cysts . MucinouMucinous tumors have a tendency to occur in the fifth or sixth decade of life, although their actual incidence in postmenopausal women remains underreported due to early detection. This patient also first started exhibiting symptoms in her late sixties. It is imperative to calculate to risk malignancy score (RMI) based on the ultrasonographic assessment and levels of CA 125 prior to operating, so as to formulate an optimal surgical plan and further chemo-radiation needs. This patient had an RMI of 159 well below the cut-off level of 200 [Tumor markers have remained the cornerstone while investigating the patient for ovarian tumors, CA 125 and CA 19.9 are quite sensitive to epithelial tumors. Cancer antigen 19‐9 (CA19‐9) raise is predominantly seen in the gastrointestinal, biliary tract, or ovarian malignancies, notably in mucinous form. In this case as well level of 19.9 was well above the normal of 37 U/mL .Management of the patient depends on various factors such as the patient’s age, menopausal status, whether desirous of fertility, nutritional status of the patient, access to medical facilities, and surgeon’s expertise. Patients with ovarian tumors require surgery at some point of time during the course of the disease, that being said careful planning with a multidisciplinary approach toward management both pre and postoperatively by a team of gynecologists, onco-surgeon, anesthetists, intensivists, and dietician leads to positive outcomes. The patient here had a unilateral tumor for which a staging laparotomy was performed, some surgeons advocate removing the tumor en bloc to avoid any peritoneal spillage of fluid which can further lead to pseudomyxedema peritonei, and/or upstage the disease , but at Various cases of giant tumors have reported in the past, the largest on record being 148.6 kg tumor by Spohn  while thIn spite of advances in screening methods available for ovarian masses, rural women still suffer the agony due to lack of facilities and misdiagnosis as seen in this case where the patient was initially misdiagnosed as having ascites. We wish to highlight this case to bring forth the plight of rural women who are deprived of standard health care.


Uterine leiomyomas may occasionally spread to the lungs forming nodular lesions detectable on chest X-ray. This condition known as benign metastasizing leiomyoma (BML) usually occurs in females with a history of hysterectomy or myomectomy. We present three cases of BML demonstrating the diagnostic process and treatment approaches. Two patients presented with the more common multiple-nodule variant while the other had a single mass, but all were symptom-free. The age of presented patients at diagnosis of BML ranged from 46–53. The first patient was diagnosed with BML at the age of 50, and 12 years prior to the diagnosis, underwent a supracervical hysterectomy. The second patient had a myomectomy at 36, and BML was diagnosed 17 years later at the age of 53. The third patient had a hysterectomy with bilateral salpingo-oophorectomy at the age of 46, with lung lesions present before the hysterectomy. Immunohistochemical studies of postoperative materials showed positive staining of spindle cells with antibodies against desmin and smooth muscle actin, as well as estrogen and progesterone receptors. The final histopathological diagnoses were pulmonary BML. All patients are stable and symptom-free: two at two years follow-up and one at six months follow-up Uterine leiomyomas  are the most common pelvic tumors in females . They arLeiomyomas sometimes spread to distant sites, resulting in pulmonary, cardiac, nervous, skeletal, or soft tissue involvement, with the lungs being the most common extrauterine location (80% of cases) ,8,9,10. We present three cases of BML demonstrating the diagnostic dilemmas, differentials and therapeutic approaches.A 50-year-old female patient with a history of hypertension, thyroid gland tumors, and laparotomy with supracervical hysterectomy due to leiomyoma presented with numerous subcentimeter nodules in both lungs with no pulmonary symptoms. She had never smoked, although radiologic imaging corresponded to advanced neoplastic spread. She had her first period at age 12, and her last at age 38. Her periods had been regular. She was pregnant twice, and she has two children. Her mother suffered from tuberculosis and leukemia. The first discovery of pulmonary changes in this patient was in August 2017 when, during preoperative preparatory examinations before spine surgery, a routine chest X-ray visualized bilateral nodular changes. In October 2017, a chest CT showed subcentimeter nodules in the lungs. Control CT imaging in February 2018 and in June 2018  confirmeA 53-year-old female patient with a history of hypertension and laparotomy with leiomyoma resection presented with a tumor of unclear origin in the right lung. She had never smoked. She had her first period at age 14 and her last period at age 44. Her periods had been regular. She was never pregnant. The mass in her lung was first detected in a routine chest X-ray in June 2018. The presence of a lesion was then confirmed in a chest CT in July 2018 . Liver fA 48-year-old patient with a history of an appendectomy at the age of 17, abdominal hysterectomy with bilateral salpingo-oophorectomy due to myoma at the age of 46, right nephrectomy due to oncocytoma at the age of 46, and papillary thyroid cancer necessitating total thyroidectomy and radioactive iodine treatment at the age of 46 presented with numerous nodules in both lungs with no pulmonary symptoms. Additionally, she suffered from metabolic syndrome , hepatic steatosis, reflux esophagitis, and osteoarthritis of the spine. She has never smoked. Her first period was at 11 years of age and her last was at 46 years. Her periods were regular. She was pregnant twice and she has two children. The first discovery of pulmonary changes in this patient was in January 2018 when, during preoperative preparatory examinations before a hysterectomy with bilateral salpingo-oophorectomy, a chest CT visualized bilateral nodular changes. A suspicious lesion in the liver was discovered on an abdominal ultrasound. Fine-needle aspiration biopsy of the lesion in the liver was conducted. Despite the tests, no diagnosis was made. In April 2019, positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) showed that the lesions in the lungs were not metabolically active. In addition, there were lesions in the pancreas and one in the left breast with a strong suspicion of neoplastic spread. Chest CT was conducted again in May 2020. The result was compared with the previous chest CT: the size of the biggest nodules remained the same, and the micronodules had become slightly bigger . The resBenign metastasizing leiomyomas (BMLs) are relatively uncommon tumors morphologically similar to uterine leiomyomas . At leasThe three cases described in this paper differed in their tumor morphologies; two presented the most common multiple nodule variant, while the other involved a single mass. On gross examination, the BML analyzed presented as a well-demarcated solitary lesion or multiple tumors with a whorled cut surface resembling its uterine counterpart. Occasionally a miliary pattern of numerous nodules occupying large areas of the lung parenchyma and leading to respiratory failure was observed . MicroscIHC markers expressed by BML include ACTA2, ESR1, PGR, desmin, and caldesmon ,27. In aIn all cases, the patients underwent a significant number of tests before a decision to use invasive diagnostics and surgery was made. This is the typical course of events for “yet to be diagnosed” PBML patients: only unspecific clinical features are revealed by the examinations of first resort . As for surgical treatment, different approaches were taken. Minimally invasive surgery such as the VATS uniportal approach is currently used worldwide. In the case of the first and third patients, only a few of the multiple subcentimeter nodules were obtained, while in the second patient, the solitary mass of the tumor was resected in toto. The resected material was sent for postoperative histopathological examination, which remains the only method of obtaining the definitive and truly diagnosis ,20,21,22The cases described in this paper represent typical patients with BML, given the type of surgery they received in the past. BML has been chiefly described in women after total hysterectomy; only a few case reports describe BML in patients after supracervical hysterectomy. Our first patient had undergone a supracervical hysterectomy, and the second one abdominal myomectomy. In the latter patient, prophylactic total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed two months after the diagnosis of BML and 17 years after the primary surgery. The third patient had an abdominal hysterectomy with bilateral salpingo-oophorectomy after the lung lesions had been found. According to the aforementioned literature review, of 161 cases of BML diagnosed worldwide to date, only seven patients had a history of supracervical hysterectomy, and 32 patients underwent a previous myomectomy. Most cases (122) occurred after a total hysterectomy . NeverthNo standard management guidelines have been formulated regarding the treatment of BML. Management of BML varies with the presentation pattern and the extent of symptoms. Surgical resection may be the treatment of choice for isolated lesions, and cases with the diffuse disease are more likely to benefit from a systemic approach. Observation, surgical resection, hysterectomy, bilateral oophorectomy, administration of progestins and aromatase inhibitors, and luteinizing hormone-releasing hormone analogs have all been reported as potential treatment options ,30. In the majority of published cases, benign metastatic leiomyomas express estrogen and progesterone receptors. This is associated with their hormonally dependent growth and spontaneous regression during pregnancy or menopause ,31. EvidAlthough ulipristal acetate (a selective PGR modulator) is frequently used as an effective treatment for uterine fibroids, its effect on BML is uncertain. Ulipristal acetate reduces the proliferation of leiomyoma cells, remodels the extracellular matrix, and induces apoptosis. It also inhibits gonadotropin secretion and suppresses ovarian function, thus contributing to a hypoestrogenic environment. This induces endometrial hypotrophy and reduces the size of the fibroids. We are aware of three case reports confirming ulipristal acetate as a possible novel non-surgical treatment of BML. All concluded that it might reduce the size of BML nodules. The hypothesis is that ulipristal acetate blocks the progesterone receptors of the lesions, thereby restraining lesion growth ,34. In oIn this paper, we have described three interesting new cases of BPML: two presented with the multiple-nodule variant and one with a single mass. Follow-ups occurred for the three patients after surgery. BPML is rare but should be considered in a differential diagnosis of single or multiple lung nodules, especially among late reproductive-age women with a history of leiomyoma. Histopathological examination is required for final diagnosis and to rule out primary or metastatic malignancy. No standard treatment for BML has been formulated, and treatment should be individualized for each patient.


Glucagonomas are rare pancreatic neuroendocrine tumors (pNETs), malignant in 80% of cases, thus highlighting the importance of early diagnosis and treatment. Primary manifestations are diabetes, dermatosis, depression, weight loss, and deep vein thrombosis. Unlike other pNETs, glucagonomas are associated with a higher incidence of thromboembolic events, often resulting in death. We present the case of a glucagonoma patient whose primary manifestation was cerebral sinus venous thrombosis (CS-VT). Early diagnosis enabled curative resection. The purpose of this paper is to review the underlying mechanisms associated with increased coagulopathy in glucagonomas. Glucagonoma is a rare, functional, pancreatic neuroendocrine tumor (pNET) in which the islet alpha cells of the pancreas oversecrete glucagon . AccountA 68-year-old man with a history of psoriasis and benign prostate hyperplasia experienced severe headaches, insomnia, and dizziness for three consecutive days. On the fourth day post symptom onset, he presented to the emergency department due to a worsening right-sided headache, along with new-onset vomiting and left-sided weakness/discoordination. A brain CT scan showed multicompartmental right parietal hemorrhage adjacent to the superior sagittal sinus with a surrounding meningioma. A CTA scan revealed an extensive superior sagittal sinus thrombosis extending into the right transverse and right sigmoid sinus. Treatment with intravenous heparin was initiated. During his hospitalization, the patient's headache improved, and his left-sided weakness resolved within one week. Left sensory ataxia remained. Workup for occult malignancy revealed, on a CT abdomen, an exophytic hyperdense enhancing lesion, measuring 1.1 × 2.2 cm, in the posterior aspect of the tail of the pancreas, suggestive of a neuroendocrine tumor. There was no evidence of primary malignancy or metastatic disease involving the chest, liver, or prostate. During this admission, a new diagnosis of hypertension and type 2 DM were made as he remained hyperglycemic, and his HbA1C was 11.8%. The patient denied a history of diarrhea, flushing, or abdominal pain but endorsed night sweats and weight loss. His family history was significant for a brother with a pancreatic neuroendocrine tumor (pNET) and sister with multiple meningiomas. Endocrinology was consulted, and a pertinent workup for pNET was ordered. Chromogranin A (CgA) was elevated at 439.9 ng/ml (≤82); however, the patient was already on proton pump inhibitors (PPIs). The urinary cortisol was normal. PTH, serum calcium, and the pituitary hormonal panel were all normal. hCG and CEA were also normal. Factor V Leiden and prothrombin were normal. Given the combination of new-onset DM, DVT, and pNET, serum glucagon was requested and reported as increased at 202 pg/ml and 174 pg/ml (reference range <80 pg/ml). A pancreatic MRI identified a well-defined round, T2 iso/hypointense lesion, measuring 10 x 11 × 10 mm in keeping with a pNET. A Ga68-DOTATATE PET scan identified the pancreatic lesion as DOTATATE-avid. Additional lesions were identified in the cranial cavity, compatible with meningiomas.MEN1, VHL, NF1, NF2, TSC1, TSC2, PRKAR1A, PTEN, TP53, SMARCB1, and SMARCE1). Two heterozygous variants of uncertain significance not thought to be associated with the patient's phenotype were detected, namely, TSC2 (c.1952C > T) and NBN (c.806G > A). To date, the patient's brother with pNET has not been assessed in genetics.Based on the unusual presentation of pNET in two siblings, the patient was assessed in medical genetics and underwent germline testing for an 86-gene panel through a commercial laboratory (Invitae). No pathogenic/likely pathogenic variant was identified by next-generation sequencing, including all possible candidate genes known to be associated with hereditary predisposition to neuroendocrine tumors , LMWH anti-factor X was low at 0.37 U/mL (0.50–1.00 U/mL) presurgical resection, and factor X level was normal at 0.78 U/mL (N = 0.50–1.50 U/mL) post surgical resection.The patient underwent laparoscopic distal pancreatectomy and splenectomy, with no complications. Pathology described a well-demarcated, white appearing, firm, homogenous nodule, measuring 13 x 10 × 9 mm, pT1N0M0, with a Ki-67 index of 2% (G1). The tumor cells showed moderate and diffuse glucagon staining with patchy insulin staining. Plasma glucagon decreased from 202 pg/ml to 47 pg/ml post surgical resection. Although measured while on an anti-factor Glucagonomas are estimated to have an incidence rate of 1 case in 20 million people per year , 6. CaseX by the tumor alpha cells of the pancreas has been a suggested mechanism [Although glucagonomas are associated with a high incidence of thromboembolic events and cerebral sinus venous thrombosis (CS-VT) as the presenting manifestations, as seen in our case, are novel and merit recognition. Thromboembolic events have been reported in 30–80% of glucagonoma patients, particularly DVT of lower limbs and pulmonary embolism (PE). Over 50% of deaths in patients with glucagonoma are directly attributed to thromboembolic events . Howeverechanism . It is mechanism , a potenechanism , imbalanechanism .In 70 to 90% of patients, CS-VT presents as acute or subacute headache lasting 1–3 days. Focal neurological deficits (mono- or paraparesis or hemiparesis) occur in about half of patients, hours or days after headache onset . GlucagoWhile literature suggests varying severities of glucose intolerance associated with glucagonoma, DM remains a cardinal sign of glucagonoma . GlucagoWeight loss is a very common finding in the initial presentation of glucagonomas, occurring in 56% to 91% of cases . The catSuch nutritional deficiency influences the integumentary system, causing cutaneous lesions characteristic of the glucagonoma syndrome . OccurriIn summary, the case described here is a reminder to clinicians to keep alert for clues pointing in the direction of a treatable common denominator in a patient with an atypical constellation of symptoms or atypical presentation of common conditions. In reference to glucagonomas, we would like to highlight the fact that staying alert to concurrent clinical manifestation in the case of PNETs may lead to early recognition of this deadly tumor. At such early stage of the evaluation, surgical resection can potentially lead to a cure.


Teaching point: Hypertrophy of the m. tensor fascia lata mimics a soft tissue tumor, but understanding of its presentation on MRI prevents unnecessary biopsy. A 62-year-old woman presented with a swelling on the proximal aspect of the thigh. The patient stated the swelling started several weeks ago and increased ever since. The patient had an unremarkable medical history and did not present with fever, weight loss, night sweats, or disturbed sleep. She stated that she had no pain when walking, but the pain was present when she laid on the left thigh.Physical examination showed a swelling of the proximal thigh, just below the anterior superior iliac spine, which was not painful on palpation.Figures 1 and 3, arrows). This was more prominent on the left side. Besides hypertrophy, the images showed fatty degeneration of the muscle. The T2-weighted images with fat suppression showed neither oedema of the muscle belly, nor soft tissue inflammation. However, on the left side, there was an enlarged trochanteric bursa  consistent with bursitis, and both a tear of the m. gluteus minimus tendon  and tendinosis of the m. gluteus medius.The patient was referred to the radiology department for magnetic resonance imaging (MRI). The T1-weighted images showed bilateral hypertrophic tensor fasciae latae (TFL) muscles (A palpable soft tissue mass is a common problem in clinical practice. It has a broad differential diagnosis which includes neoplasms, hematomas, and hypertrophied muscle. Due to the possibility of malignancy, further investigation is mandatory. MRI is the first-choice imaging technique, due to its superior soft tissue contrast and multiplanar image capability .Common etiologies of muscle hypertrophy include: exercise, denervation, radiation, and myopathies. Muscle hypertrophy of the TFL is rather uncommon, with only case series published including three patients and reporting biopsy-proven muscle hypertrophy in three patients with concomitant necrotizing myopathy and non-inflammatory myopathy in one patient respectively . In our


Ao exame físico apresentava frequência cardíaca de 132 bpm, sopro sistólico 2+/6+, desdobramento fixo de segunda bulha cardíaca, perfusão adequada, com pulsos amplos. Pelos sinais de insuficiência cardíaca, foi realizado um ETT evidenciando uma massa heterogênea e multilobulada no ventrículo direito (VD), junto ao septo interventricular, com área estimada de 7,8cm², algumas áreas císticas e sinais de calcificação com sinais de obstrução na via de saída do ventrículo direito (VSVD) .Foi feita RMC  e 3 que A paciente foi submetida a quimioterapia com cisplatino, porém em controles evolutivos não houve alterações significativas dos achados no ETT. Atualmente, programa-se abordagem cirúrgica devido à refratariedade à quimioterapia.8 Dos tumores de células germinativas as principais características visualizadas por RMC são o realce tardio com gadolínio heterogêneo e na cine-ressonância e nas sequencias ponderadas em T1 e T2, também uma intensidade heterogênea.8As características dos tumores cardíacos malignos, dentro os quais estão os germinativos, tem sido estudada em algumas revisões. Considera-se a RMC o método de escolha para sua avaliação, visto que tem uma alta acurácia em discriminar lesões benignas de malignas, por avaliar a localização, tamanho e contornos da lesão. Além disso, a RMC tem um valor diagnóstico significativo para as características do sinal dos componentes do tecido dentro dos tumores, incluindo calcificação, gordura, fibrose, hemorragia, e mudanças císticas.10Das principais características que sugerem malignidade temos as dimensões >5cm, contornos irregulares, lesões múltiplas, envolvimento pleural ou pericárdico, invasão direta dos planos dos tecidos, localização no coração direito, e características tecidulares tais como a heterogeneidade de sinal nas sequências ponderadas em T1 e T2 e presença de realce com contraste na primeira passagem sugerindo vascularização da lesão.Assim, destacamos a grande utilidade da RMC, neste caso, como auxiliar no diagnóstico e suspeita de um tumor de etiologia maligna, por meio de algumas das características já descritas, como a localização no VD, contornos mais irregulares, sinais heterogêneos nas sequências T1 e T2 e RTG, além de captação de contraste na sequência de perfusão, que foram descritas em nosso paciente.11O tratamento padrão dos tumores primários não seminomatosos, tal qual o TSV, é uma combinação de quimioterapia sistêmica neoadjuvante com bleomicina ou cisplatina, com tentativa de ressecção cirúrgica.Foi relatado um caso muito infrequente de tumor cardíaco primário de saco vitelino com características malignas confirmado por biopsia sem adequada resposta à quimioterapia. A RMC da paciente apresentou algumas das características que acrescentaram a possibilidade de malignidade como o tamanho e o RTG heterogéneo. Atualmente as técnicas de imagem como a RMC são de grande ajuda, e em alguns casos são os métodos de escolha para um adequado diagnóstico. 1Primary cardiac tumors are extremely rare, with their incidence varying between 0.0017 and 0.28%, among which is the malignant germ cell yolk sac tumor (YST).3 The intracardiac YST is a rare neoplasm, with few reported cases.7Although transthoracic echocardiography (TTE) is often the first line in the evaluation of cardiac tumors, currently, due to its good spatial resolution and tissue characterization, cardiac magnetic resonance (CMR) imaging is the technique of choice for the evaluation of these tumors.A one-year-old female patient presented with episodes of cyanosis when crying. On physical examination, she had a heart rate of 132 bpm, a 2+/6+ systolic murmur, fixed splitting of the second heart sound, adequate perfusion, with wide pulses. Due to the signs of heart failure, a TTE was performed, which showed a heterogeneous and multilobulated mass in the right ventricle (RV), next to the interventricular septum, with an estimated area of 7.8 cm², some cystic areas and signs of calcification, with signs of obstruction in the right ventricle outflow tract (RVOT) .A CMR  and 3 waThe patient was submitted to chemotherapy with cisplatin, but the control exams to assess disease evolution showed no significant changes in the TTE findings. Currently, a surgical approach is scheduled due to refractoriness to the chemotherapy.8 Of the germ cell tumors, the main characteristics visualized by CMR are the delayed heterogeneous gadolinium enhancement, and on cine-resonance and T1- and T2-weighted sequences, also a heterogeneous intensity.8The characteristics of malignant cardiac tumors, which include the germ cell ones, have been studied in some reviews. CMR imaging is considered the method of choice for their evaluation, since it shows high accuracy in discriminating benign from malignant lesions, assesses the location, size and contours of the lesion. Moreover, the CMR has a significant diagnostic value for the signal characteristics of tissue components inside the tumors, including calcification, fat, fibrosis, hemorrhage, and cystic changes.10Among the main features that suggest malignancy are tumor size >5cm, irregular contours, multiple lesions, pleural or pericardial involvement, direct invasion of tissue planes, right heart location, and tissue characteristics such as signal heterogeneity on T1- and T2-weighted sequences and presence of contrast enhancement in the first pass, suggesting lesion vascularization.Therefore, we highlight the great usefulness of CMR, in this case, as an aid in the diagnosis and suspicion of a tumor of malignant etiology through some of the previously described characteristics, such as location in the RV, more irregular contours, heterogeneous signals in the T1 and T2 and LGE, in addition to contrast uptake in the perfusion sequence, which were described in our patient.11The standard treatment of primary nonseminomatous tumors, such as the YST, is a combination of neoadjuvant systemic chemotherapy with bleomycin or cisplatin, together with attempted surgical resection.This case report describes a very rare case of primary cardiac yolk sac tumor with malignant features confirmed by biopsy, which did not show an adequate response to chemotherapy. The patient’s CMR showed some of the characteristics that added to the possibility of malignancy, such as the size and heterogeneous LGE. Currently, imaging techniques such as CMR are very useful and, in some cases, they constitute the methods of choice to attain an adequate diagnosis.


Aneurysms of the iliac veins are very rare; thus, the best approach to management has not yet been defined. We have presented the case of a 17-year-old boy with incidentally identified large bilateral external iliac vein aneurysms. Given the risks of potentially fatal thromboembolism or rupture, he underwent definitive repair of his aneurysms using staple aneurysmorrhaphy combined with additional vein tailoring by suture venoplasty, a technique not previously described for these aneurysms. We have also discussed the etiology, presentation, and our surgical technique to manage this rare condition. He had recently developed an episode of self-resolving hematuria after being hit in the abdomen by a ball, prompting an abdominal imaging study. He denied lower extremity or groin pain, lower extremity swelling, chest pain, and shortness of breath. Additionally, he denied a history of abdominal or pelvic trauma, prior surgical intervention, and a family history of vascular anomalies or connective tissue disorders. The physical examination findings were unremarkable, including no findings to suggest additional venous anomalies or an underlying connective tissue disorder.Computed tomography angiography confirmed the presence of large bilateral iliac vein aneurysms extending nearly from the inferior vena cava confluence to the internal aspect of the inguinal canal . The rigGiven the risks of thrombosis, pulmonary embolism, and spontaneous rupture, surgical repair was recommended. After a multidisciplinary discussion, low-molecular-weight heparin was initiated in the interim to decrease the risk of thromboembolism since the history of these aneurysms could not be clearly defined without prior imaging studies.A), with care taken to identify and protect the vas deferens, ureter, and gonadal vessels. The aneurysms were carefully separated from the iliac arteries. Vessel loops were placed for proximal and distal control at the level of the junction with the common iliac vein and at the inguinal ligament, respectively. Circumferential dissection of the aneurysms was performed. To repair the aneurysm in our patient, a fully grown adolescent, we elected to perform bilateral staple aneurysmorrhaphy, combined with additional suture venoplasty to tailor the veins.The patient was taken to the operating room electively for excision. The bilateral external iliac vein aneurysms were exposed through a lower laparotomy incision , A, withB). At completion, the shape and size match between the proximal and distal nonaneurysmal segments of the vein were excellent, with good flow visualized via Doppler ultrasound examination to ensure the manipulation had not caused thrombosis. The same procedure was then performed on the left aneurysm, with similarly excellent size, shape, and venous flow found at completion  were fired longitudinally along the anterior portion of the vein, using the nonaneurysmal proximal and distal vein as a guide and intentionally leaving the vein larger than normal to allow for additional tailored tapering using suture venoplasty. Running 5-0 Prolene suture was used along the length of the staple line, imbricating the vein further with each bite to tailor it to a size that was intentionally somewhat larger than a normal iliac vein , B. At cmpletion , CandDA). He was transitioned to aspirin, 81 mg daily, with annual duplex ultrasound. Computed tomography was performed 4 years postoperatively to allow for complete evaluation of the iliac venous system, which showed stable, mild residual ectasia (B). At last follow-up, he remained without symptoms.Computed tomography of the abdomen and pelvis was obtained 6 months postoperatively to guide anticoagulation management. The scan showed mild residual dilation bilaterally, as expected, with a maximal diameter of the external iliac vein of 1.9 cm on the right and 2.1 cm on the left without evidence of thrombosis , A. He w ectasia , B. At l,,Venous aneurysms are uncommon vascular abnormalities, with aneurysms of the iliac veins being particularly rare.,,The only three previously reported patients with bilateral iliac vein aneurysms were very active athletes.,The presentation of these aneurysms is highly variable. In a recent review, 16% of patients were asymptomatic, with the aneurysms identified incidentally.Given the rarity of this condition, the approach to management has varied widely and has included observation, anticoagulation, and/or endovascular or open surgical intervention.,Multiple surgical techniques, including open and endovascular approaches, have been successfully used. The most commonly used technique for primary aneurysms has been tangential aneurysmectomy with lateral venorrhaphy.Iliac vein aneurysms are exceedingly rare but warrant strong consideration for intervention owing to the risk of potentially fatal complications. Staple aneurysmorrhaphy, combined with suture venoplasty, offers a safe and effective approach for the repair of iliac aneurysms, including bilateral aneurysms.


Ureteral granulation tissue hemangiomas are rare benign vascular lesions, and they may be clinically asymptomatic or present with massive or recurrent hematuria. Sometimes hemangiomas are difficult to distinguish from malignant ureteral tumors, and most ureteral hemangiomas are confirmed by postoperative pathological examination. This article aims to present a case of granulation tissue-type hemangioma of the ureter and briefly review the current literature on this condition.A 30-year-old male patient presented with complaints of painless macroscopic hematuria for 2 months. Computerized tomography of the urinary system showed that the upper 1/3 of the right ureter was occupied, and then the possibility of tumor lesions was considered. The urine cytology showed occasional nuclear abnormalities and many light-stained crystals in urine. Because of suspicious radiological and cytological findings, the patient underwent the right ureteroscopy and the laparoscopic right ureteral mass resection. The postoperative pathological report showed that it was a mesenchymal tumor. The morphological and immunohistochemical staining was consistent with that of hemangioma, tending to granulation tissue hemangioma. After surgery, the patient was in a good state and recovered well at the last follow-up.Ureteral granulation tissue hemangiomas are an easily misdiagnosed disease. Intermittent painless hematuria is an important characteristic of this disease. Therefore, we suggest that unnecessary radical surgery can be avoided when clinicians consider the possibility of benign ureteral tumors during the evaluation. Ureteral granulation tissue hemangiomas are rare benign vasculopathy that is prone to misdiagnose and mistreat due to the atypical clinical manifestations of this disease and lack of relevant knowledge. Granulation tissue-type hemangiomas are common tumor-like vascular lesion of the skin and mucous membranes of the oral cavity that has traditionally been considered reactive proliferative lesion rather than tumor process . GranulaThe patient was a 30-year-old male with painless macroscopic hematuria for 2 months. After examination, the patient had no hypertrophy of the prostate and normal sphincter tension. Meanwhile, the patient's external genitalia, bilateral spermatic cords, and testicles were normal. The urology color ultrasound showed hydronephrosis in the right kidney and dilation of the upper segment of the right ureteral canal. Intravenous urography showed no obvious abnormality in left renal function and morphology, decreased right renal function, and no obvious abnormality in the bladder. Computerized tomography of the urinary system showed that the upper 1/3 of the right ureter was occupied, and then the possibility of tumor lesions was considered. Meanwhile, the results showed that the peripheral lymph nodes were slightly enlarged, secondary right hydronephrosis, right renal parenchyma perfusion decreased, and right perirenal exudative changed Fig. . And theGranulation tissue-type hemangioma was first identified by Poncet and Dor in 1897 who described it as a vascularised mass and named it “Human Botryomycosis” . And theReviewing the current literature, there appears to be only one report of ureteral granulation tissue-type hemangioma. In that report, the patients took microscopic haematuria and loin pain as the main symptoms. Given the minimal number of reports on ureteral granulation tissue-type hemangioma, we could draw evidence from similar manifestations of the hemangioma within the bladder . There wAs part of the diagnostic evaluation for haematuria, a polypoid or sessile lesion is found incidentally extending from the urothelium, either on contrast-CT scanning as a filling defect or endoscopically , 10, 12.In our case, the laparoscopic right ureteral mass resection was performed and the patient remained well for more than six months following surgery, with no evidence of recurrence. There are no reliable follow-up data for haemangiomas within the urinary tract. Once diagnosed, CT and ureteroscopy could be performed during follow-up. The patient recovered well and had a good prognosis during the last follow-up. This is a rare case of granulation tissue-type hemangioma, and the excision biopsy is necessary for diagnosis. However, because of the relatively high incidence of ureteral malignancies, the choice of treatment is difficult and challenging.In Conclusion, granulation tissue-type hemangiomas are rare benign vascular lesions, which mainly affect the skin and oral mucosa. Usually, it is confirmed by pathological examination. However, urinary cytology, ureteroscopy, and intraoperative frozen edge examination can guide surgeons to perform more conservative surgery, but it is necessary to keep in mind the benign nature of the mass. We performed ureteral mass resection and the patient recovered well at follow-up. Therefore, we recommend that clinicians avoid unnecessary radical surgery when evaluating the possibility of benign ureteral tumors.


Diaphragmatic hemangiomas are rare tumors and the preferred resection range in surgical procedures is considered on a case-by-case basis. We report a case of diaphragmatic hemangioma that was completely resected by partial diaphragmatic resection. An 81-year-old man was referred for the examination of right diaphragmatic mass. Computed tomography revealed two contrast-enhanced nodules  on the right diaphragm. The nodules were completely resected by partial resection of the diaphragm via video-assisted thoracic surgery using an ultrasonic coagulation and incision device. Resection was performed leaving part of the muscular layer of the diaphragm. Histopathology confirmed the nodule to be hemangioma originating from the diaphragm and no hemangiomatous lesions were noted in the normal connective tissue in the resected stump. Partial diaphragmatic resection is a less invasive treatment method and may be a useful surgical procedure for diaphragmatic hemangioma. Primary tumors of the diaphragm are rare and there have been few case reports  on diaphAn 81-year-old man who underwent surgical resection for lung cancer 2 years previously was referred for the examination of a right diaphragmatic mass that was pointed out during follow-up. Computed tomography (CT) revealed pleural effusion and two contrast-enhanced nodules (17 × 10 and 10 × 10 mm) in the right diaphragm ; howeverDiaphragmatic tumors are rare, with less than 200 cases reported in the literature to date since the first report by Grancher in 1868 . Kim repKim reported that the common symptoms of diaphragmatic tumors are chest pain and abdominal pain and that the proportion of cases in which diaphragmatic tumors were incidentally found was 10–15% . Eleven Regarding surgery, there are two main resection methods. In previous reports, when the tumor size exceeded 40 mm, full-thickness resection and reconstruction were performed using Gore-Tex sheet. On the other hand, for tumors of 20–30 mm or smaller, partial resection with an automatic suture machine or direct suturing after full-thickness resection has been performed. In our case, malignancy was ruled out during the operation. Therefore, the base of the tumor was also resected, leaving part of the muscular layer of the diaphragm. The diaphragm has multiple layered structures  allowingIn partial resection in the clinical setting, the use of an electric scalpel is difficult because electrical stimulation stimulates the movement of the diaphragm. Therefore, in this case, the operation was performed using the active blade of the ultrasonic coagulation and incision device, and the root excision operation was completed.No residual hemangioma lesion was noted in the normal connective tissue in the pathological specimen after additional resection of the diaphragmatic stump in this case , thus deNo recurrence has been reported in the surgical cases of diaphragmatic hemangioma to date; however, recurrence has been reported in previous reports on systemic hemangioma ; thus, w


Hepatic abscesses are a seldom finding although they are the most common type of intraabdominal abscess. We find that this localized collection of pus can be a result of bacteria, ameba, or fungi. This study will mainly focus on the first type, the pyogenic liver abscess (PLA), in which management is predicated on size of abscess. There is no standard definition as to what constitutes a small or large hepatic abscess. Here, we present a case of a 10 cm PLA found in the right lobe of the liver. We aimed to discuss the relevant epidemiology, pathophysiology, clinical manifestations, and management of PLAs. Escherichia coli, being most prevalent. Among Gram-positive organisms, streptococci and enterococci species are commonly reported, and anaerobic infection with Bacteroides spp. is also a common source of PLA formation [Klebsiella pneumoniae [K. pneumoniae now accounts for 80% of all PLAs in Asia [A liver abscess usually presents as a single abscess, most commonly invading the right lobe of the liver, however, multiple abscesses can occur. The two most common types of liver abscesses, pyogenic and amebic, have a global distribution; however, in developed countries, pyogenic liver abscesses (PLAs) are far more prevalent, where amebic liver abscesses (ALA) reign supreme in developing regions . Fungal ormation . The inceumoniae . These c in Asia . Liver aOur patient is a 78-year-old male with a significant history of controlled diabetes mellitus type 2, essential hypertension, obstructive sleep apnea, and gastroesophageal reflux disease (GERD) who presented to an outside facility for evaluation of fevers with reported temperature of 104°F.He was recently hospitalized one month prior for treatment of coronavirus disease 2019 (COVID-19) pneumonia. During that stay, the patient was reported to have transaminitis, with a subsequent computed tomography (CT) abdomen revealing an approximate 8 cm lesion, noted to be possible necrotic abscess, in the superior portion of the right hepatic lobe  on differential and normal liver function tests. A right upper quadrant ultrasound was performed which showed a 9.21 cm hepatic mass in the upper right lobe, indicating growth of this lesion when compared to previous diagnostic imaging. He was treated with IV antibiotics for several days before being transferred to our facility for further care.Upon arrival at our facility, we obtained a set of blood cultures and antibiotic coverage was started with scheduled cefepime 2 g IV three times a day (TID) and scheduled metronidazole 500 g IV TID. A CT abdomen/pelvis with IV contrast was performed which showed the large liver lesion, now measuring 10 cm in diameter and with multiple well-defined low-density areas likely representing abscess. A “double target sign” could be appreciated this time, i.e., a rim-enhancing fluid collection with surrounding low attenuated outer ring-characteristic of a hepatic abscess  performed on the liver abscess aspirate detected DNA from e Figure . The patThe first case of PLA has been described since the time of the “father of medicine,” Hippocrates. He proposed that the prognosis of a patient correlated with the type of fluid within the abscess cavity . At presPLAs are usually identified on abdominal imaging. Ultrasound (US) and CT are the common modalities used, with CT usually being employed if US findings are nonspecific. CT is slightly more sensitive than US for liver abscess (95% versus 85%) ,8. PeripWe typically treat PLAs for four to six weeks with antibiotics and adequate source control. Source control, in this case abscess drainage, is predicated on abscess size. Generally, abscess size can be divided into two groups, less than or equal to 5 cm  and more than 5 cm (large abscesses) . Small aThere has been debate on the modality used for drainage, especially in regard to larger abscesses. Liao et al. have reported percutaneous drainage failure with abscess size greater than 7.3 cm, recommending surgical drainage for such abscess sizes . A giantB. fragilis via PCR and tailored antibiotic management accordingly. This case is unique in that the patient did not have any risk factors or common predisposing pathology for PLA formation. The patient was infected with B. fragilis, which is a part of the human gastrointestinal flora, specifically found in the colon [This case serves to remind us of another important fact - obtain abscess PCR along with cultures. Anaerobic bacteria are notorious for being difficult to culture. As in our case, the abscess culture did not grow any bacteria, but we confirmed the presence of he colon . Normal E. coli), Gram-positive cocci (largely streptococci and enterococci), and anaerobes (largely Bacteroides spp.) Right upper quadrant US and CT are the common modalities used for diagnosis, with CT being slightly more sensitive than US for liver abscess. Management of a PLA is centered around source control drainage and empiric antibiotic administration. All PLAs should be treated with antibiotics for four to six weeks with adequate source control drainage. Drainage modalities are determined by abscess size. Large abscesses, including giant PLAs, can adequately be drained via percutaneous methods and seldom require surgical intervention.The majority of PLAs are polymicrobial with the most common pathogens being Gram-negative bacilli (largely


Spinal epidural hematoma is a rare disease that may present as motor paralysis, sensory disturbance, and a sudden radiating pain from the hematoma site. Herein, we report two cases of cervical epidural hematoma diagnosed as left hemiplegia and treated with surgery. Case 1 was a 62-year-old woman who presented to our hospital with the chief complaint of posterior neck pain and left upper and lower limb paralysis. Cervical magnetic resonance imaging (MRI) showed a cervical epidural hematoma at the C4-C6 level. Case 2 was a 67-year-old man who presented to our hospital with a history of hypertension. Both patients had left hemiparesis, numbness in the left upper and lower limbs, and hypersensitivity. They were diagnosed with idiopathic cervical epidural hematoma and underwent emergency surgery . In case 1, the paralysis improved immediately after the surgery. In case 2, the paralysis and hypersensitivity improved markedly after the surgery, and the manual muscle testing grade of the left upper and lower limbs improved from 3 to 5 on the second day. Both patients were subsequently discharged home unaided. In cases where the paralysis does not improve, it is important to exclude stroke, diagnose cervical epidural hematoma as soon as possible, and consider surgery aggressively. Spinal epidural hematoma is a rare disease that may present with motor paralysis, sensory disturbance, and a sudden radiating pain from the hematoma site. It often presents as sudden paraplegia or tetraplegia due to a compressive lesion in the spinal cord, but it can also occur as hemiplegia, requiring careful differentiation from stroke. In recent years, remarkable progress has been made in the treatment of acute stroke, and treatments such as the administration of recombinant tissue plasminogen activator (rt-PA) and percutaneous cerebral thrombectomy are accepted standard of care for early-onset cerebral infarction in the modern world. In contrast, spinal epidural hematoma is a contraindication for the administration of rt-PA, and if not diagnosed properly, it may lead to accidental rt-PA administration and subsequent deterioration of the patient's condition. Herein, we report two cases of cervical epidural hematoma diagnosed as left hemiplegia and treated with surgery.Case 1A 62-year-old woman presented to our hospital with the chief complaint of posterior neck pain and left upper and lower limb paralysis. She had no relevant medical history.The patient experienced a sudden posterior neck pain while cleaning. Two hours later, numbness and incomplete paralysis of the left side of the body occurred, and the patient was referred to a local neurosurgery clinic. A head computed tomography (CT) and magnetic resonance imaging (MRI) were performed, but no cerebral hemorrhage or cerebral infarction was detected. Cervical MRI showed no signs of ligament injury and revealed a cervical epidural hematoma at the C4-C6 level Figures , 1B, andUpon arrival, the patient was clearly conscious . She had left hemiparesis , numbness in the left upper and lower limbs, and hypersensitivity. There were no other notable neurological findings. The patient’s blood pressure was 202/124 mmHg upon arrival.The patient underwent an urgent head and neck contrast CT Figures , 1D and Case 2A 67-year-old man presented to our hospital with a history of hypertension. The patient was driving a car when he suddenly experienced a posterior neck pain. One hour later, he went to a local doctor, who prescribed painkillers and sent him home. Four hours later, after taking a bath at home, he experienced incomplete paralysis of the left side of his body and was rushed to our hospital.Upon arrival, the patient’s consciousness was clear . He had left hemiparesis (MMT3), numbness in the left upper and lower limbs, and hypersensitivity. There were no other notable neurological findings. His blood pressure was 219/122 mmHg at the time of admission.The patient underwent head and neck CT Figures , 3B and Oral consent was obtained from both the patients for the publication of this case report.Spinal epidural hematoma is a rare disease with an incidence of 0.1/100,000 per year ,3. GroenIn addition, spinal epidural hematomas are predominantly distributed at the middle and lower cervical spine level (C4-C7), which is thought to be the region of greatest cervical spine mobility . IntracrIt is important to make an accurate and timely diagnosis of cervical epidural hematoma in order to consider treatment. If a cervical spine epidural hematoma is suspected during a head CT scan for stroke, CT scan of the neck can be performed consecutively, allowing for an early diagnosis. Based on our experience, the characteristic findings of cervical spine epidural hematoma include (1) clear consciousness and complaints of posterior neck pain, back pain, and numbness, (2) the absence of cerebral nerve palsy, and (3) strong sensory hypersensitivity.Although Horner's syndrome was not observed in any of the cases reported here, it is reported to be a clinical sign that occurs in a high percentage of patients . TherefoHara et al. reported that hematomas were predominantly found on the left side in 10 cases and on the right side in five cases . In the The efficacy of surgical treatment and conservative treatment is still controversial. Spontaneous recovery has been reported to be characterized by mild paralysis (MMT3 or higher) and improvement in paralysis within six hours, even in cases of severe paralysis . As mentIn both of our cases, surgical treatment was not started until about 6 hours after the onset of symptoms, and there was no improvement in paralysis. When symptoms do not improve over time, even with MMT3, surgical treatment is effective and neurological symptoms improve markedly, as in this case; hence, surgical treatment should be considered proactively. Cervical epidural hematoma is an important, albeit infrequent, condition that stroke neurologists, neurosurgeons, orthopedic surgeons, and emergency physicians must keep in mind during their daily practice.We encountered two cases of cervical spine epidural hematoma that were treated surgically. Based on our experience, the characteristic findings of cervical spine epidural hematoma include clear consciousness and complaints of posterior neck pain, back pain, and numbness; the absence of cerebral nerve palsy; and strong sensory hypersensitivity. We neurosurgeons need to be well informed about cervical epidural hematoma, and it is important to exclude stroke and diagnose properly and quickly. If the paralysis has not improved by the time the patient arrives and completes the initial consultation, we would suggest that surgery should be aggressively considered.


Meckel's diverticulum is a vestige of the vitello-intestinal duct. It is one of the most common congenital abnormality of the GI tract.We present a case of a male patient who presented with pain in the peri-umbilical region and in right iliac fossa. A clinical diagnosis of acute appendicitis was made, but, interestingly it turned out to be a Meckel's diverticulum having enterolith intraoperatively. The patient underwent wedge resection and the post-operative course was uneventful.Meckel's diverticulum containing enterolith is rare. This can mimick as acute appendicitis and the surgeon needs to be wary of this. •Meckel's diverticulum containing enterolith is rare.•This can present as an episode of acute appendicitis.•One needs to have a high index of suspicion for Meckel’s diverticulum in such cases.•Diagnostic Laparoscopy plays a pivotal role in such cases.•Segmental resection is the treatment of choice. Meckel's diverticulum is the vestige of vitello-intestinal duct which connects the embryo to the primitive gut In our case, patient had signs and symptoms of acute appendicitis, which is one of the differentials for Meckel's diverticulum.This work has been reported in line with the SCARE 2020 criteria 2A 40-year old male patient, known diabetic for last 6 years, presented to the outpatient clinic with a 1 day history of abdominal pain mostly in the right iliac fossa. Initially, the pain was at peri-umbilical, but then shifted to the right iliac fossa. He denied any history of constipation or any other surgical intervention. Pain was relieved with some analgesia but recurred after 1 to 2 h.On clinical examination, his vitals were normal with a blood pressure of 130/80 mmHg & a pulse rate of 88 bpm. On abdominal examination, his abdomen was non-distended, and he was tender in the right iliac fossa. Obturator, rovsing's and psoas signs were positive.3 cmm. There were no significant findings in his urine examination.His hemoglobin was 14 g/dl and total leukocytes count was 13 × 10A clinical diagnosis of acute appendicitis was made. Patients was prepared for surgery. Under General Anesthesia, diagnostic laparoscopy showed Meckel's diverticulum in addition to a mildly inflammed appendix. Decision was taken to convert the procedure to open by making a grid iron incision at the McBurney's point. On exploration, there was a huge meckel's diverticulum containing enterolith. Wedge resection of the Meckel's diverticulum was done by the consultant. Then appendectomy was performed. The patient made an uneventful recovery post-operatively , 2, 3.FiThe patient was sent home on the 3rd day post-operative day. The stitches were taken out on the 10th post-op day.On two weeks follow up, the histopathology revealed meckel's diverticulum with moderate acute and chronic inflammation, heterotropic pancreatic tissue in the mesentery of diverticulum & appendix with fecolith. There was no evidence of any malignancy [3Meckel's diverticulum is one of the most common abnormal development of the GI system that results from a fragmentary vitelline canal. The diagnosis of Meckel's diverticulum may be difficult as the condition remains asymptomatic or may imitate varied ailments and blanket the clinical likeness. Life threatening complications can arise including bleeding, obstruction, inflammation and perforation. Thus, it's imperative that anatomical and pathophysiological characteristics are comprehended in order to preclude complications which will influence morbidity and mortality Meckel's diverticulum is similar to the small intestine and has all the three layers. Because it is supplied by its own artery, it's sensitive to infection. In 50 % of cases it contains ectopic mucosa which can be pancreatic or gastric in origin. Infrequently a colonic or hepato-biliary tissue is found. Gastrointestinal hemorrhage may occur as a result of ulceration in the gastric or the adjoining ileal mucosa. Therefore, if simple resection of the diverticulum is performed in such cases, bleeding will reoccur in post-operative period. Therefore, segmental resection is recommended in these cases Diagnosis is tricky and infrequently made, and imaging, especially in a complicated case is frequently not helpful; still diagnostic laparoscopy has an important role. The same was true in our case. Our patient also underwent diagnostic laparoscopy and that led us to the diagnosis of Meckel's diverticulum. The onset of complications decreases with age, and the diagnosis of Meckel's diverticulum in the grown-up is infrequent. In case of complications, resection is indicated; although controversial when Meckel's diverticulum is found incidentally. A large series in the literature shows that surgery is not indicated in the absence of factors responsible for complications; i.e. age younger than 40, male gender, the presence of mucosal changes observed at surgery and diverticulum longer than 2 cm. Resection and anastomosis is preferable to tangential mechanical stapling or wedge resection, because of the hazard of leaving behind aberrant heterotopic mucosa Majority of the Meckel's diverticulum never develop their characteristic feature, however complications like bleeding or perforation has given rise to the debate whether a silent MD should be resected if discovered by chance during the operation. To the best of author's knowledge, this query has yet to be answered. Moreover, with the advancements in laparoscopic surgery, & better imaging modalities like computed tomography (CT), the epidemiology of MD demands to be reassessed.4Meckel's diverticulum – A remnant of the vitello-intestinal duct, is one of the most common congenital abnormality of the GI tract. MD containing enterolith is rare. MD must be considered in the differentials of acute appendicitis and the surgeon must be wary of this.5I was alright when suddenly one day I had pain around my umbilicus. I took over the counter pain killers that give me temporary pain relief. A few hours later, I again had an episode of the pain but this time I also noticed the pain was in my right flank region. I went to my colleague who is a surgeon. When he examined and investigated me, he told me that this is an episode of acute appendicitis and so I had to give him the go-ahead for the operation. Hence I was operated upon. But surprisingly I was told afterwards that in addition to a mildly inflamed appendix, I had a Meckel's diverticulum containing some sort of a stone which was causing all these symptoms. I was treated well in time and I am now alright. I thank the team at Surgical ‘A’ Unit, Khyber Teaching Hospital Peshawar who took really good care of me.There are no conflicts of interests.