The clinical presentation of a wandering spleen is characterized mainly by unspecific acute symptoms, ranging from diffuse abdominal pain to left upper/lower quadrant and referred shoulder pain to asymptomatic. This has challenged accelerated medical care and impeded the acquisition of confirmatory diagnosis; therefore, increasing morbidity and mortality risks. Splenectomy is an established operative procedure for a wandering spleen. However, there has not been enough literature emphasizing the clinical history of congenital malformations and surgical corrections as inferential tools for facilitating a decisive and informed procedure.The case presented is of a 22-year-old female who reported to the emergency department with a five-day persistent left upper quadrant and left lower quadrant (LLQ) abdominal pain, associated with nausea. According to the medical history, the patient had a significant history of vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL) associated with congenital anomalies. By the age of eight years, the patient had undergone multiple surgical interventions, including tetralogy of Fallot repair, an imperforate anal repair with rectal pull-through, Malone antegrade continence enema (MACE), and bowel vaginoplasty. Computed tomography imaging of the abdomen revealed evidence of a wandering spleen in the LLQ with associated torsion of the splenic vasculature (whirl sign). Intra-operatively, appendicostomy was identified extending from the cecum in a near mid-line position, to the umbilicus, and carefully incised distally, preventing injury to the appendicostomy. The spleen was identified in the pelvis, and the individual vessels were clamped, divided, and ligated. Blood loss was minimal with no post-operative complications. This rare case report adds valuable teaching points about the treatment of wandering spleen in individuals with VACTERL anomalies. Wandering spleen is a cause of acute surgical abdomen that can result in deleterious consequences if not identified or treated expeditiously. Often the challenge of accelerated medical care is increased by a delayed diagnosis due to the non-specific clinical presentation . SymptomAnatomically, the spleen is tethered to the stomach by the gastrosplenic ligament and to the left kidney by the splenorenal ligament. The spleen also is tethered between the spleen and left colic flexure by the splenocolic ligament and between the spleen and diaphragm by the phrenicosplenic ligament. Congenital anomalies or previous surgical interventions can distort the normal anatomic position of the spleen, leading to the spleen wandering within the abdomen. Radiologists have termed the whirled appearance of vessel torsion as a “whirl sign,” first described in 2003 as a description on computed tomography (CT) for the finding of a midgut volvulus .Vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL) association is classified as a non-random association of birth defects that affect multiple parts of the body. The typical findings are vertebral segmentation defects, anal atresia, tracheoesophageal fistula, cardiac defects, esophageal atresia, single umbilical artery, and radial and renal defects . The assIn this case, the authors describe the importance of recognizing anatomical variations associated with VACTERL congenital anomalies and demonstrate how previous surgical interventions can contribute to the complexity of the case. This article was previously presented as a meeting poster abstract at the 2022 Annual Mercy Research Colloquium on April 28, 2022.This 22-year-old female presented to the emergency department for evaluation of LUQ and left lower quadrant (LLQ) abdominal pain. The patient experienced approximately five days of unrelenting abdominal pain, along with associated nausea. She rated her colicky pain as 6-7 out of 10 and endorsed worsening pain with movement or lying on her left side. No fever or chills were present.The patient presented with an extensive medical history significant for the following: tetralogy of Fallot repair, repair of imperforate anus with rectal pull-through, and Malone antegrade continence enema (MACE). The patient was catheterized of her umbilicus with antegrade continence enemas for stool continence. The patient has a complicated urological history going back to when she was a young child. Bladder augmentation, urethroplasty, and bowel vaginoplasty occurred at the age of eight. The patient has a congenitally absent left kidney. She also reported self-catheterization for neurogenic bladder.On examination, the patient was hemodynamically stable. She was afebrile. Her abdominal exam revealed tenderness to palpation in the LUQ of the abdomen without rebound tenderness, abdominal guarding, or rigidity. There was a palpable mass in the LLQ of the abdomen that was tender to palpation. Laboratory studies (complete blood count and comprehensive metabolic panel) were within normal limits. The CT imaging revealed evidence of a wandering spleen in the LLQ of the abdomen associated with torsion of the splenic vasculature (whirl sign) Figure . The splHaemophilus influenzae type B, pneumococcal 13-valent conjugated, and meningococcal B. Postoperatively, the pain was controlled with intravenous therapy and oral medications. The patient remained in the hospital for an additional two days prior to discharge.After informed consent was obtained, the patient was transported to the operating room and administered general anesthesia. An upper midline incision was carried through the subcutaneous fat and midline fascia using cautery. An appendicostomy was identified extending from the cecum, which was in a near midline position, to the umbilicus. The fascial incision extended distal to the umbilicus to avoid injury to the appendicostomy. The spleen was identified in the pelvis and removed through the upper midline incision Figure . The splThis case demonstrates the importance of obtaining a thorough history of past medical interventions. Without a prior history of VACTERL association congenital anomalies and surgical corrections, the patient could have been at a greater risk for intra- and postoperative complications. The reason being previous intra-abdominal surgery could have potentially caused the disruption of ligaments stabilizing splenic position; in addition to an absent left splenorenal ligament. Surgically, this case supports the importance of sufficiently taking time to identify, mark, and protect fragile anatomical structures. In this case, the patient had an appendicostomy structure at her midline that could have easily been overlooked and damaged with a midline incision. Resection or strangulation (from closing sutures) of her appendicostomy conduit would have led to a greater postoperative complication with the ability to induce bowel movements.As described earlier, the wandering spleen can present as non-specific abdominal pain and is often a delayed diagnosis due to the vague clinical presentation. As a result, confirmatory imaging studies are stalled leading to increased morbidity and mortality. Thomas and Thomas 2021) described two cases of a wandering spleen with acute splenic torsion in the setting of an absent left kidney causing acute surgical abdomen with serious consequences [021 descrAn important question that arises from this case is whether prophylactic spleen removal from a patient with VACTERL congenital anomalies is warranted. Patients with absent, acquired, or iatrogenic loss of their splenic ligaments, especially splenorenal and gastrosplenic ligaments, predispose to a possible necessity for emergent surgical intervention in the future. While prophylactic removal of the spleen could prevent the need for emergent surgical intervention, asplenia would cause reduced hematologic filtering and immunologic responses to pathogens. While additional research regarding this topic could pose some clinical and ethical challenges, ultimately, further investigation is needed to better characterize whether the risks would outweigh the benefits.This rare case adds valuable teaching points to the literature on radiological and preventative health maintenance. Radiologically, this case provides an appreciable illustration of the “whirl sign” that is associated with the torsion of splenic vasculature. In addition, this case supports the precedence of preventative health maintenance in patients with asplenia. Splenopexy should be considered unless significant torsion and/or infarction is identified. A thorough medical and surgical history should be obtained to ensure previous surgical interventions in infancy/childhood are identified and spared, especially in an emergent situation.


Endovascular aneurysm repair (EVAR) has created new possibilities for patients with abdominal aortic aneurysms (AAAs), and in recent years it has become tremendously popular. Use of EVAR in selected groups of patients allows mortality and morbidity to be reduced in comparison to open repair. However, complications such as endoleaks (ELs) can be of great concern and warrant urgent therapy to prevent sac rupture.The case report presents urgent endovascular treatment of a high-risk type IA EL in a polymorbid 68-year-old patient 7 years after primary EVAR. The principle of treatment was parallel implantation of the proximal SG extension with the renal SG into the right renal artery (chimney technique). The subsequent type II collateral EL was treated by direct transabdominal AAA sac puncture and thrombin embolization.EL can be a cause for urgent intervention, but specific anatomic features often require specialized SG types which are not readily available. The chimney technique allows the use of immediately available stent grafts to address endoleak in the setting of impending abdominal aneurysm rupture. In order to reduce the invasiveness and lethality of treatment of unruptured abdominal aneurysms (AAA), endovascular (EV) treatment (Endovascular Aortic Repair—EVAR) was introduced into clinical practice in the 1990s [Although EVAR is less risky, it is burdened by a higher incidence of late complications . The mosIn relation to the danger of AAA rupture, ELs are divided into high-risk types  requiring urgent treatment, and low-risk types  which, if not leading to significant AAA sac progression, can be treated conservatively .A polymorbid, 68-year-old man with a solitary left kidney and an ejection fraction of 25% underwent percutaneous insertion of a bifurcated SG into the subrenal AAA (sac width of 58 mm). Considering the short subrenal neck , a type of SG with a suprarenal fixation of 28 mm in diameter  was selected. The inferior mesenteric artery (IMA) and the L4 lumbar artery were embolized with coils to prevent the development of type II EL. The procedure was uneventful, the left solitary renal artery (RA) remained patent and no EL or progression of AAA sac size was evident on follow-up CTA (1 and 3 years after treatment). CTA examinations at 1 and 3 years after EVAR were negative without endoleak and even showed a reduction of the AAA sac from 58 to 55 mm. Subsequently, the patient was monitored annually by ultrasound, which showed stable AAA size until the 6th year after treatment.At a 7-year follow-up, the patient presented with sudden onset of severe abdominal pain and shortness of breath. Ultrasound examination showed enlargement of the AAA sac and blood leakage at the proximal SG end. Urgent CTA demonstrated a type IA EL and distal migration of the SG along with marked progression of the AAA sac diameter to 91 mm Fig. .Fig. 1TyOn CTA examination 4 days after the procedure, EL (30 × 30 mm in size) was detected in the dorsal aspect of the AAA sac. The washed-out residual at the lumbar artery origin was suggestive of a type II EL. Considering the EL extent, we opted for immediate treatment. Under local anesthesia with US guidance, the AAA sac puncture was performed through a transabdominal approach, and 1000 units of thrombin  were injected sequentially  is possible . This teThe disadvantage of the chimney technique compared to fenestrated and branched SGs is the more frequent occurrence of type IA EL between the parallel SGs. Therefore, it is not recommended to introduce more than two parallel SGs simultaneously and the distance between the AMS and AR should not be less than 2 cm . These cIn order to ensure the SG tightness to treat EL IA and/or to prevent its occurrence, an aortic endostapler  can be used to achieve internal–external fixation of the proximal section of the SG to the aortic wall using screws. According to available data, the method has a low complication rate , but it Type II EL is perceived as risky and is indicated for treatment only if it causes an enlargement of the AAA sac by more than 10 mm per year . This tyAnother option is minimally invasive treatment by direct paravertebral puncture of the AAA sac under CT navigation or transabdominal puncture with the application of embolization materials . This soIf endovascular and minimally invasive methods fail, type II EL can be resolved by surgical methods, which include ligation or laparoscopic clipping on the source vessel or resection of the AAA sac .Successful treatment of symptomatic proximal type I EL with preservation of solitary AR perfusion was achieved in a polymorbid patient by implantation of an extension into the original, dislocated SG in combination with parallel insertion of the SG into the AR. The subsequent type II EL was successfully resolved under ultrasound guidance by direct percutaneous thrombin injection into the AAA sac. This chimney technique should be used in emergency situations where it is not possible to wait for fenestrated stent grafts. The transabdominal approach to endoleak embolization is a reasonable approach in an enlarged AAA sac with a close relationship to the abdominal wall. Our complication arose 7 years after primary successful EVAR therapy. The long-term stability of abdominal SGs after EVAR should be verified by regular follow-up with ultrasound and CTA to reliably detect EL types at risk of rupture and other potential complications of this treatment.


Early diagnosis and aggressive treatment of acute osteomyelitis may improve prognosis and prevent further complications. Sonography is useful in the evaluation of osteomyelitis. It can demonstrate early signs of inflammation, such as soft tissue changes near the affected bone, periosteal thickening, periosteal elevation, and subperiosteal abscess.A 68-year-old female presented to the emergency department with 3 weeks of worsening left lower extremity pain. She was initially seen by urgent care for left shin erythema and swelling and treated for cellulitis with intramuscular ceftriaxone without improvement. On presentation, she was afebrile and hemodynamically stable with erythema, swelling, and tenderness of the left pretibial soft tissues. Her labs revealed leukocytosis and elevated inflammatory markers. Point-of-care ultrasound demonstrated a bidirectional flow of fluid through a disruption in the bone cortex visualized on greyscale imaging and confirmed with color and spectral Doppler. The patient was diagnosed with osteomyelitis and treated with antibiotics and incision and drainage by orthopedic surgery.The unique sonographic finding of pulsatile flow of fluid within an abscess near bone has not been previously described in the literature. The presence of Doppler signal in any fluid other than blood is known as pseudoflow. The presence of pulsatility in this case, which could represent either blood or pseudoflow, drew the ultrasound operator's eye to the cortical defect and lead to the diagnosis of osteomyelitis.The sonographic finding of pulsatility in an abscess near bone should raise the concern for communication with the medullary cavity.The online version contains supplementary material available at 10.1186/s13089-023-00339-0. Acute osteomyelitis is a new-onset infection with progressive inflammatory destruction of bone . Acute oProblematically, early diagnosis of osteomyelitis requires a high index of suspicion and obtaining appropriate imaging studies . A varieA 68-year-old female with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, gout, rheumatoid arthritis, and bilateral knee replacements on clindamycin prophylaxis for past infections presented to our emergency department with 3 weeks of worsening left lower extremity pain. She was initially seen at an urgent care for erythema and swelling of the left shin. Plain radiographs were unremarkable at that time and she was treated for cellulitis with intramuscular ceftriaxone for 10 days without improvement. On arrival, she was well-appearing, afebrile, and hemodynamically stable with erythema, swelling, and tenderness of the left pretibial soft tissues Fig. . She wasPoint-of-care ultrasound use was pivotal in this case, enabling the treating team to further characterize the extent of the patient’s soft tissue infection and reach the diagnosis of osteomyelitis. Bidirectional flow of fluid through a disruption in the bone cortex was visualized on greyscale imaging and confirmed with color and spectral Doppler. The pulsatile movement of fluid within an abscess has not been previously described in the literature. The presence of Doppler signal in any fluid other than blood is known as pseudoflow . AdditioPrevious studies have examined the utility of color and power Doppler to evaluate osteomyelitis, primarily in children , 11. DopSeveral studies have demonstrated sonography’s ability to detect early inflammatory changes in acute osteomyelitis when correlated with clinical findings , 11–15. Subperiosteal abscesses present as hypo- or anechoic lenticular-shaped fluid collections adjacent to bone cortex . When peEarly detection of acute osteomyelitis facilitates the efficient collaboration of medical and surgical specialties, expediting debridement and antibiotic treatment. Sonography has several advantages in the evaluation of osteomyelitis, including rapid speed of performance, high portability, repeatability due to the absence of ionizing radiation, and the potential for earlier diagnosis. Several greyscale and Doppler findings associated with osteomyelitis have been previously described. The additional sonographic finding of pulsatile flow or pseudoflow in an abscess near bone should raise the concern for communication with the medullary cavity, prompting a search for cortical defects and obtaining more advanced imaging. The ability to detect bony involvement in an abscess on point-of-care ultrasound allows the clinician to proceed with appropriate management of osteomyelitis and avoid performing an incision and drainage at the bedside that should occur in the operating room.Additional file 1. Video S1. Photograph of the patient’s lower extremity, Transverse and longitudinal ultrasound clips demonstrating a heterogenous hypoechoic fluid collection with pulsatile flow through a cortical defect, Ultrasound clips demonstrating color and power Doppler flow, Spectral pulsed wave Doppler tracing with the sample volume placed to measure flow through the cortical defect, Computed tomography of the patient's extremity demonstrating an abscess.


The anaphylactoid syndrome of pregnancy (ASP) is a rare emergency with significant mortality and morbidity, in which the amniotic fluid and fetal cells enter the maternal circulation leading to respiratory failure, altered mental status, hypotension, and disseminated intravascular coagulation. The term ASP was recently introduced to replace the term amniotic fluid embolism since the clinical manifestations of the entity were more similar to a septic or anaphylactic shock rather than that of an embolic event. Two autopsy cases are described, regarding a 35-year-old gravida 2 para 1 and a 34-year-old gravida 1 para 0, where the cause of death was determined to be ASP. The anaphylactoid syndrome of pregnancy (ASP) is a rare obstetric emergency occurring due to the entrance of amniotic fluid and fetal matter into the maternal circulation, leading to sequelae . The terIn the current autopsy reports, two fatal cases (one including both the mother’s and fetus’ death and the other only the mother’s) of ASP with DIC involvement are described, focusing on histopathology findings.Case 1A 35-year-old, G2 P1 on the 36th gestational week visited the hospital for a scheduled prenatal appointment. She has noticed an absence of fetal movements for the last 48 hours. The woman had a history of one previous, expected, spontaneous vaginal delivery, 15 years ago (weight 2750 gr). No significant health conditions or family history were present. Intrauterine fetal death was confirmed via ultrasound. Labor induction is followed to remove the fetus. During the active labor phase of cervical dilation (4-5 cm) and weak uterine contractions, spontaneous rupture of membranes took place, resulting in the outflow of a colored and malodorous amniotic fluid. During the dead fetus expulsion (weight 2030 gr) through vacuum aspiration, the mother presented loss of consciousness. The intrauterine death was provoked by six windings of the umbilical cord around the uterus's neck. Resuscitation was started immediately. Blood investigation during resuscitation didn’t reveal anemia . Minutes later, she developed vaginal bleeding due to uterine atony. Medication administration, uterine tamponade, uterine massage, and blood transfusion were performed and 35 minutes later, hemorrhage control was achieved. Bleeding reappeared half an hour later, which was initially, but unsuccessfully, treated conservatively. The woman was then admitted to the operating room, where uterine vessel ligation and hysterectomy were performed. During wound closure, the woman suffered a cardiac arrest. After resuscitation attempts, the woman succumbed approximately an hour later.According to the fetus’ autopsy maceration was witnessed, a finding indicative of intrauterine death at least two days before. Signs suggestive of intrauterine stress, with meconium exit, intense hyperemia, and cerebral anoxia, due to the umbilical cord incident were also witnessed. Finally, there were no congenital abnormalities - dysplasia or pathologies of the fetus. According to the mother’s autopsy, multiple organs’ histopathology findings presented hemorrhagic and inflammatory infiltrate, edema, amorphous eosinophilic material, as well as fibrin deposition in small and medium-sized vessels, suggestive of DIC Figure . The appCase 2A 34-year-old G1P0 woman, in the 40th gestational week, was admitted to the hospital. No significant health conditions or family history were present. After epidural anesthesia, labor induction took place. The newborn weighed 4020 gr. Ten minutes after delivery, she developed excessive bleeding due to uterine atony. Conservative treatment consisting of uterus tamponade was performed, followed by uterus vessel ligation. After suffering a cardiac arrest, the woman succumbed.According to the woman’s autopsy, the histopathological examination of the lungs revealed multiple thrombi in the small vessels and polymorphonuclear cells’ mobilization. The alveoli included macrophages that phagocyte hemosiderin. Keratin flakes were included in the lumen of the small vessels due to the ASP Figure . In the Specific criteria must be presented to clinically diagnose ASP Table  7]..7].Both cases did not have a history of fever and presented cardiopulmonary arrest minutes after delivery. Based on these criteria, due to the lack of provided information about investigation reports suggestive of DIC during hospitalization, criteria number 2 cannot be further discussed. In the first case, according to the literature, the unique included risk factor was the fetus’ death . In termIn the vast majority of ASP cases (83%), DIC is identified, with the latter occurring as quickly as 10-30 min from the onset of ASP symptoms . CoaguloASP continues to be a worrying entity in obstetric medicine due to its clinical unpredictability and associated maternal and neonatal mortality. Early diagnosis and supportive treatment may improve patient outcomes, although the entity’s mortality rates are still considerably high. It is essential for physicians to report such cases with precision regarding the diagnostic investigation results and timeline, not only to assist the utilization of diagnostic and therapeutic tools but also to support a more accurate estimation of the prevalence and mortality of ASP. Concerning the postmortem investigation, a forensic pathologist should be aware of any possible therapeutic intervention that may be performed, as knowledge of these parameters should help reduce any confusion during the postmortem examination and thus aid in establishing the correct cause of death. As always, histopathologic examination of tissues collected during the postmortem examination proves to be an invaluable tool to confirm or deny macroscopical diagnosis and thus should be performed in such cases. Finally, it is also important for pathologists to publish ASP cases so that evidence about the disorder can be established, resulting in a better understanding of the condition itself.


We herein illustrate a case of benign tenosynovial giant cell tumor, which was incidentally detected as FDG-avid lesion on PET/CT in a patient with radioiodine refractory thyroid cancer, with predominantly non-iodine concentrating disease. The lesion was followed up clinically and with local MRI annually for subsequent 3 years. The utility of hybrid PET-CT imaging, the non-iodine concentration of the tumor along with clinical knowledge, and findings on other imaging and pathological modalities in answering and diagnosing incidental benign musculoskeletal tumors in a patient with known thyroid malignancy are presented here. Patients with radioactive-iodine refractory (RAIR) thyroid cancer and thyroglobulin elevated negative iodine scintigraphy (TENIS) are considered as therapeutic challenges and possess guarded prognosis compared to their DTC counterparts. FDG-PET/CT has become a pivotal imaging tool in these cases, its sensitivity and is positively correlated with serum thyroglobulin (Tg) levels and plays a prognostic indicator in this patient subset.131I as per the institutional protocol, and the post-RAI therapy scan , with extensive capsular invasion and extra-thyroidal extension and bilateral neck lymph node, and lung metastasis , had undergone total thyroidectomy with bilateral central compartment clearance with bilateral modified neck dissection. The strap muscles also showed metastatic deposits, and multiple resected nodes were positive for metastases and showed extra-nodal extension. His RAI scan  showed py scan  showed The patient was asymptomatic except for some local swelling; on local examination, there was soft to firm swelling without skin fixity over the Achilles tendon of the right ankle, which, according to the patient, was stable over last 18 months and was non-tender. A local ultrasonographic examination done showed a heterogeneous soft tissue lesion in the subcutaneous plane superficial to the Achilles tendon in the dorsal aspect of the right ankle measuring 2.9 × 2 × 0.6 cm. The lesion was further elucidated with a local MRI done after RAI therapy . This rIn his further course, he developed non-radioiodine concentrating disease and elevated serum Tg with FDG concentrating multiple bilateral lung nodules and started on tyrosine kinase inhibitor (lenvatinib) therapy. At nearly 2 years down the line, follow-up FDG-PET/CT study  demonstBTSGCT is one of the rare benign bone tumors usually affecting adults and are limited to specific joint areas. A few case reports have reported this to be FDG avid, and FDG-PET/CT along with MRI is useful in evaluating its local extent and the response to CSF1-targeting therapies. Nervo et al recently performed an extensive study on bone disease in thyroid cancer and suggested the rare possibility of benign bone tumors in such setting and the utility of MRI, especially the DWI sequence, in their diagnosis.In the literature, there are descriptions of benign tumors concentrating radioiodine. This includes (1) parotid tumors such as Warthin's tumor or oncocytoma, (2) meningioma, (3) cavernous angioma, (4) cystic mesothelioma, (5) hepatic hemangioma, 6) breast fibroadenoma, (7) uterine myoma, (8) struma cordis and struma ovarii along with other types of ovarian tumors and teratoma. These findings have been related to NIS-dependent uptake or other mechanisms breast f


Type 1 gastric neuroendrine tumor (NET) is usually associated with chronic atrophic gastritis and forms multiple lesions. While most cases of type 1 gastric NET are generally slowly growing, some develop regional lymph node metastases even after long-term dormancy.A 73-year-old male patient with a 32-year history of multiple gastric NET was being followed-up at the study center after endoscopic submucosal dissection (ESD) of a large gastric NET. A blood examination revealed high serum gastrin (> 3000 pg/ml). An endoscopic examination found atrophic mucosa and multiple, elevated lesions in the upper to lower stomach body. Computed tomography (CT) revealed regional lymphadenopathy in the greater omentum along the gastroepiploic artery. Robotically assisted total gastrectomy was performed with D2 lymphadenectomy and Roux-en-Y reconstruction. Pathological analysis revealed a large number of gastric NET (grade 1) with a maximum size of 4.5 mm invading the submucosal layer. A single lymph node metastasis was also detected pathologically at station #4d. The postoperative course was uneventful, and serum gastrin normalized postoperatively. At postoperative year 3, the patient has been doing well without any recurrences.The present case of multiple gastric NET with a single regional lymph node metastasis at year 32 of follow-up was successfully treated with a robotically assisted total gastrectomy. The Rindi classification divides gastric neuroendrine tumors (NET) into three types based on their biological behavior. Rindi type I is associated with chronic, atrophic gastritis and has a favorable prognosis with a low frequency of lymph node metastasis (2–5%) and distant organ metastasis (< 2%) –3. The JWe herein report a case of multiple gastric NET which metastasized to a regional lymph node after 32 years of follow-up and was successfully treated using robotically assisted total gastrectomy.A 73-year-old male patient with a 32-year history of hypergastrinemia and multiple gastric NET with a comorbidity of type 2 diabetes mellitus was referred to the study center and found gastric tumors which led to a biopsy-based diagnosis of gastric NET. A blood examination revealed high neuron-specific enolase (NSE)  and serum gastrin . Endoscopic examination found atrophic mucosa with erosion and multiple, elevated lesions in the upper to the lower stomach. Based on an analysis of biopsy findings, the lesions were diagnosed as gastric NET. As none of the tumors were large, and no deep-tissue invasion or regional lymphadenopathy was present, the patient elected to receive endoscopic follow-up.In year 24 of follow-up, he underwent an endoscopic submucosal dissection (ESD) after an endoscopic examination demonstrated enlargement in one lesion in the greater curvature of the antrum Fig. . Histopa, the patient underwent a robotically assisted total gastrectomy, D2 lymphadenectomy, and Roux-en-Y reconstruction. The operative time was 399 min, and the blood loss was 50 ml. Histopathological examination of a surgical specimen revealed extensive endocrine micronests in the upper to middle gastric body , followed by the duodenum 16.7%) and the stomach (15.1%). The yearly, age-adjusted incidence of gastric NET is approximately 0.2 per population of 100,000 6.7% and .Type I gastric NET is associated with autoimmune atrophic gastritis and hypergastremia. Type A gastritis, corresponding to autoimmune gastritis and thought to be involved in the development of gastric NET, was described by Strickland and Mackey in 1973 . The chaA Japanese, multicentric study retrospectively investigated 82 patients with gastric NET and reported that vascular invasion, muscle-layer invasion, and lymph node metastasis occurred only in 9.8%, 1.6%, and 1.2% of cases, respectively. Furthermore, none of the cases had a distant organ metastasis, and the 5-year survival rate was 100% . The stuOn the other hand, two, previous studies raised concerns about the risks of under intervention posed by the administration of endoscopic treatment alone. Approximately 30% of patients with type I gastric NET required further intervention via endoscopic resection or surgery at a rate higher than 50% , 9. MoreThe European Neuroendocrine Tumor Society (ENETS) guidelines recommend endoscopic surveillance every 12 months in patients with tumor recurrence as the optimal form of treatment, and a surveillance every 24 months for patients with a history of NET with no current tumor recurrence . The preConsidering the potential for recurrence after a partial or subtotal gastrectomy, minimally invasive surgery, such as laparoscopic or robotically assisted surgery, is preferable to conventional open surgery, because it can be done with a small incision and causes less adhesion, enabling a second operation to be performed more easily and safely . MoreoveIn conclusion, the present case describes, after a 32-year follow-up period, a patient with multiple gastric NET and a lymph node metastasis underwent a successful robotic-assisted total gastrectomy. Although gastric NET shows a favorable prognosis, long-term follow-up is necessary to detect delayed recurrences and progression.


Edwardsiella tarda (E. tarda) is a Gram-negative facultative anaerobe belonging to Enterobacteriales and is commonly isolated from fishes and reptiles. Infection due to E. tarda is uncommon among humans, with a reported human retention rate of 0.001%. It can cause sepsis in the elderly or those with pre-existing conditions such as liver failure, autoimmune disease, or malignancy. E. tarda is susceptible to many antibiotics; however, a high mortality rate (approximately 40%) has been reported with sepsis.E. tarda, which was also detected in bile juice culture. Therefore, she was diagnosed with bacteremia caused by E. tarda, and postoperative antimicrobial therapy was continued. The patient improved, and there were no complications.A 65-year-old woman presented to our hospital with a chief complaint of fever and abdominal pain for 2 days. Her blood tests showed elevated inflammatory markers, and contrast-enhanced computed tomography showed distention and wall thickening of the gallbladder and inflammation of peri-gallbladder fat. Subsequently, a diagnosis of cholecystitis with systemic inflammatory response syndrome was made. Laparoscopic cholecystectomy was performed after starting antimicrobial therapy. Blood culture of samples obtained on admission were positive for E. tarda. Only a few cases of acute cholecystitis due to E. tarda have been reported. Furthermore, similar to this case, no previous study has reported the detection of E. tarda in both blood and bile cultures in acute cholecystitis cases. In addition to appropriate surgical intervention, continuous administration of antibiotics based on culture results resulted in a favorable outcome.We experienced an extremely rare case of acute cholecystitis caused by  Edwardsiella tarda (E. tarda) is a Gram-negative rod-shaped bacterium that belongs to the Enterobacteriaceae family. E. tarda is isolated from fish and reptiles as a normal inhabitant. Although rare, it can be transmitted to humans through ornamental fish, pet turtles, snakes, catfish, and other animals, with a reported human carriage rate of 0.001% [E. tarda may cause both intestinal and extraintestinal infections. Generally, intestinal infections are spontaneously resolved, whereas extraintestinal infections can lead to meningitis, liver abscess, necrotizing, fasciitis, and wound infection. Although sepsis caused by E. tarda is rare, it has a rapid course and a high fatality rate (approximately 40%) [E. tarda wherein laparoscopic cholecystectomy was performed.ely 40%) , 3. HereE. tarda  and a history of underlying diseases such as malignancy, autoimmune disease, liver disease, and diabetes mellitus [Intestinal infections account for approximately 80% of all fections . E. tardnteritis . Generalis small , 14–18. is 44.6% . Risk famellitus , 9, 11. mellitus , 19. Addmellitus .E. tarda is sensitive to several antibiotic agents, including β-lactams, aminoglycosides, quinolones, and tetracyclines [E. tarda infection, allowing treatment with the appropriate antibiotic agents. Additionally, due to the importance of complete removal of the infected lesion, surgical intervention would be appropriate.Regarding treatment, extraintestinal infections generally require antibiotic therapy. cyclines . HoweverE. tarda infection, fecal culture was performed to reveal intestinal commensal bacterial; however, E. tarda was not detected because culture was performed after antibiotic therapy was started. Although the reported human retention rate is 0.001% [E. tarda sepsis; however, in our case, she had a favorable prognosis. This may be attributed to the patient’s age, early and appropriate surgical intervention to completely remove the infected lesion, and continued systematic administration of antimicrobials based on the culture results, all of which prevented recurrence.Regarding the route of infection in this case, the patient had no history of keeping fish or reptiles as pets, and the possibility of contact infection was considered low. However, because of her habit of eating raw seafood on a daily basis, the possibility of infection by oral ingestion was considered possible. After the diagnosis of s 0.001% , 22. Riss 0.001% , 24. HowE. tarda that was treated with laparoscopic cholecystectomy. Although E. tarda rarely infects humans, it can occasionally cause sepsis, which can be severe, and result in death. Therefore, this infection needs to be recognized, and appropriate therapeutic interventions should be implemented early.We report a case of sepsis secondary to acute cholecystitis caused by


Congenital hyporhinia, also known as partial arhinia, is a very rare congenital abnormality of nasal embryogenesis with unknown etiology. It is commonly associated with other craniofacial anomalies which are thought to be caused by an absent or rudimentary nose. A 3‐h‐old neonate presented to our facility with hypoplastic nasal pyramid, hypertelorism, microcephaly, and micrognathia, a case of congenital hyporhinia with associated anomalies is presented and the embryology and literature review are discussed. Less than 40 cases of congenital arhinia have been reported in the available literatures, most of them defined as complete arhinia and only four cases were congenital hyporhinia.2Attention of otorhinolaryngologist was drawn to review a 2‐h old full‐term female neonate born from 17 years prime gravid, presented with nasal malformation, respiratory distress, and bluish coloration, delivered vaginally with APGAR score 5 and 6 at 1st and 5th minute at a GA 36 weeks. Pregnancy was supervised with reported 3 antenatal visits, screened for malaria, syphilis, and HIV which was negative. She received all important supplements, and no complications or medical conditions were brought into attention throughout pregnancy. Father 22 years and were not consanguineously married, no familial history of congenital malformations. Mother had no history of ingestion of any traditional medicines or exposure to radiation during her pregnancy; she does not smoke or drink alcohol and has never abused drugs.Examination revealed birth weight of 3.2 kg with microcephaly and had single nostril with remnants of alar cartilage barely palpable and a centrally placed single stenotic anterior nasal nare with pinpoint perforation. Columella, nasal septum, and the philtrium were absent. Also, she had microcephaly, high arched palate, and hypotelorism Figure .Initial stabilization was provided by maintenance of oral airway, and oxygenation. Trial to insert nasal gastric tube through the single nostril done which revealed anterior nare leading to 4‐mm‐deep single nasal cavity with atretic posterior choanae. There was ongoing discussion about stent insertion and tracheostomy, since some family members were hesitating for surgical intervention. Echocardiography was done and did not reveal any abnormality, chromosomal analysis to delineate extent and cause of malformation was not done. Non‐contrast computerized tomography scan of the brain Figure  revealed3Congenital hyporhinia is a rare defect of embryogenesis which is associated with other craniofacial abnormalities such as holoprosencephaly and midline defects.The patient had holoprosencephaly with cebocephaly, microcephaly, and high arched palate. Orbital anomalies are frequently associated with this condition,Clinical presentation depends on the severity of nasal hypoplasia, and patient with atretic posterior choanae present with severe respiratory distress at birth.Our index case had respiratory distress due to the presence of atretic posterior choanae where oral airway and oxygenation was initiated, also there was ongoing discussion with the family about tracheotomy.Prenatal diagnostic advances have greatly improved the possibility of early detection of congenital anomalies. This gives not only an opportunity to plan and improve perinatal care but also offers the option to terminate the pregnancy for cases in which the prognosis is likely to be poor,Surgical reconstruction is usually delayed until preschool years around 6 years when facial development is nearly complete but due to associated malformations management controversies regarding timing and surgical techniques.4Congenital hyporhinia or partial arhinia is an extremely uncommon entity with only four cases previously reported in the literature, usually associated with other craniofacial malformations as our case which was associated with holoprosencephaly with cebocephaly which indicate a poor prognostic factor.Nasal reconstruction during childhood is a surgical challenge, due to infrequent of this pathology and associated malformations hence management controversies regarding timing and surgical techniques.KM conceptualized and drafted the manuscript. AM reviewed the patient records. PS, DC, and PM reviewed the final script. All authors have read and approved the script.The author(s) received no financial support for the research, authorship, and/or publication of this article.The author(s) declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.Our institution does not require ethical approval for reporting individual cases or case series.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Gastrojejunocolic fistulas are a rare type of fistulas after a laparascopic Roux-en-Y gastric bypass (LRYGB). They are known as a chronic complication. This case report is the first to describe an acute perforation in a gastrojejunocolic fistula after LRYGB.A 61-year-old woman with a history of a laparascopic gastric bypass was diagnosed with an acute perforation in a gastrojejunocolic fistula. A laparascopic repair was performed by closing the defect in the gastrojejunal anastomosis as well as the defect in the transverse colon. However, 6 weeks later, a dehiscence of the gastrojejunal anastomosis occured. This was reconstructed by an open revision of the gastric pouch and gastrojejunal anastomosis. Long-term follow up showed no recurrence.Combining the findings of our case with other literature, a laparoscopic repair with wide resection of the fistula, a revision of the gastric pouch and gastrojejunal anastomosis as well as closing the defect in the colon seems to be the best approach in case of an acute perforation in a gastrojejunocolic fistula after LRYGB. Fistulas after a laparascopic Roux-en-Y gastric bypass (LRYGB) are described in literature. The most common are the gastro-gastric fistulas, between the gastric pouch and the excluded stomach. An analysis of 1292 consecutive patients shows an incidence of 1.2% [In December 2018, a 61-year-old woman presented herself to the emergency unit with severe epigastric pain since three hours and tachycardia. Physical examination revealed a painfull palpation of the epigastric area and right hypochondrium, as well as a mild rebound tenderness in the epigastric area. A blood test showed a mild raise of the inflammatory markers.Her current daily medication consisted of pantoprazole 20 mg, paroxetine 20 mg, nortriptyline 50 mg and lormetazepam 4 mg.She had a medical history of depression, diabetes type II, obestity, osteoporosis, cholecystectomy, tabacco and alcohol abusus. Furthermore, the medical history mentioned a bulbar ulcer. The bulbar ulcer dated from earlier than the digital medical file (earlier than 2002), probably due to NSAID use after a total hip prosthesis. Starting from 2002, there were no signs of an ulcer with a negative endoscopy in november 2011. She underwent a laparascopic short gastric bypass in 2013. During the surgery in 2013, a biliopancreatic limb length of 40 cm and a alimentary limb length of 150 cm was performed. The gastric pouch was constructed with three staplers of 60 mm. The gastro-enterostomy measured 40 mm and was formed by a linear stapler. Chronic diarrhea was present since 2017. In September 2018, gastroscopy and sigmoidoscopy were performed due to melena. Gastroscopy showed an ulcer at the gastrojejunal anastomosis. Sigmoidoscopy was normal. The dose of pantoprazole was increased temporarily to 40 mg twice a day, followed by a maintenance dose of 40 mg a day. In October 2018, the patient was hospitalised at the department of gastroenterology for iron deficiency anemia. A new gastroscopy showed no ulcers or other lesions and a normal anastomosis was visualised. Pantoprazole was decreased to 20 mg a day. One month later, the patient was hospitalised again due to weight loss and hypoalbuminemia with edema. A coloscopy was planned.Computed tomography at the time of arrival at the emergency unit showed the presence of intra-abdominal free air, including air bubbles around the gastrojejunal anastomosis.A laparascopic exploration revealed turbid fluid in the upper abdomen. The transverse colon was fixated to the dorsal side of the gastrojejunal anastomosis. Further dissection showed a perforation in a gastrojejunocolic fistula. As a result, a defect of 2.5 cm was found in the transverse colon, as well as in the gastrojejunal anastomosis Fig. . The defPostoperatively, prophylactic amoxicillin/clavulanic acid was administered intravenously. However, the patient developed a pneumonia, which was treated with intravenous piperacilline/tazobactam. No other postoperative complications occured. The dose of pantoprazole was increased to 40 mg twice a day. Low molecular weight heparines were administered as thrombosis prophylaxis.However, 6 weeks later, the patient presented herself again to the emergency unit of another hospital with anorexia since 4 days, mild epigastric pain, tachycardia and elevated inflammatory markers. Computed tomography showed free air and fluid in the abdomen and a defect in the gastrojejunal anastomosis.A laparascopy comfirmed a dehiscence of the gastrojejunal anastomosis, partly covered by the large biliopancreatic stump. There were no visible signs of ischemia at the site of dehiscence. The transverse colon which was repaired in December 2018, was still intact. No other lesions were found. In order to restore the anastomosis, a conversion to a laparotomy was performed. The gastric pouch was stapled with a linear stapler to maintain only vital tissue. The large biliopancreatic stump was shortened by using a linear stapler, followed by an additional running suture 3–0 Monocryl. The mesenteric defect was closed using 0 Ethibond. Subsequently, the gastrojejunal anastomosis was revised by performing a circular stapled gastrojejunal anastomosis, followed by additional separate stitches 3–0 Monocryl. The anvil of the stapler was introduced into the gastric pouch through the opened stump of the alimentary limb. Subsequently, the stump of the alimentary limb was closed by a linear stapler, followed by an additional running suture 3–0 Monocryl. Methylene blue test showed no leakage. At the end of the surgery, the alimentary limb length measured 70 cm. A nasogastric tube was left in place. One drain was placed under the left hemidiaphragm and one drain was placed with the tip nearby the gastrojejunal anastomosis.Postoperatively, prophylactic piperacilline/tazobactam was administered intravenously during 7 days. Pantoprazole 40 mg twice a day was continued. Low molecular weight heparines were administered as thrombosis prophylaxis. Upper gastrointestinal tract radiography showed a good passage of contrast fluid. There were no signs of leakage. The postoperative stay was free of complications. Pathology report of the biopsies retrieved during this surgery mentioned following results. The gastric pouch showed mucosal and submucosal ischemia and granulation tissue without signs of malignancy. Biopsies of the biliopancreatic limb length and the alimentary limb showed mucosal and submucosal ischemia without signs of malignancy.The patient was not present at the follow-up consultation abdominal surgery. Nevertheless, during the latest internal medicine consultation in context of osteoporosis in July 2022, no abdominal problems were mentioned by the patient.To the best of our knowledge, this case report is the first to describe an acute perforation in a gastrojejunocolic fistula after LRYGB. Schulman et al. described a chronic gastrocolic fistula after LRYGB without perforation . A chronPossible symptoms in a gastrojejunocolic fistula are fecal eructation, chronic diarrhea, malnutrition and weight loss –5. In ouFistulas after LRYGB are often associated with an ulcer at the gastrojejunal anastomosis or with a chronic leak at the anastomosis , 4. In tThe cause of an ulceration at the gastrojejunal anastomosis is multifactorial. Diminished perfusion can contribute to the occurrence of ulcers. Moreover, excessive acidity and foreign materials like the suturing material can contibute. Furthermore smoking and NSAIDs show association with ulceration. The role of a Helicobacter pylori infection is controversial. The majority of patients show a response to high doses of proton-pump inhibitors –9.In our case, the initial repair of the acute perforation in the gastrojejunocolic fistula was done laparoscopically by closing the defect in the transverse colon and closing the defect in the gastrojejunal anastomosis. 6 weeks later, an open redo of the gastrojejunal anastomosis was performed in context of a dehiscence of the gastrojejunal anastomosis. Follow-up was 3 years and 6 months.Concerning chronic fistula, the case presented by Schulman et al. was treated by a laparascopic removal of the fistula and a revision of the gastric pouch and gastrojejunal anastomosis . HoweverSundeep et al. described the case of an acute perforation in a gastrojejunocolic fistula after a gastroenterostomy performed for recurrent peptic ulcer disease . In thisWhen comparing the report by Sundeep et al. and our case, in both cases, an open surgery with wide excision of the nonvital tissue of the gastric pouch has led to a long term stable result. However, the first repair in our case was possible in a laparoscopic way. Combining these findings, a laparoscopic repair with wide resection of the fistula, a revision of the gastric pouch and gastrojejunal anastomosis as well as closing the defect in the colon seems to be the best approach.This case report is the first to describe an acute perforation in a gastrojejunocolic fistula after LRYGB. Chronic diarrhea, malnutrition and weight loss were present. However, fecal eructation, another typical symptom in a gastrojejunocolic fistula, was not present in this patient. An early reduction of the dose of pantoprazole after healing of an ulcer at the gastrojejunal anastomosis has possibly contributed to the recurrence of the ulcer with fistula formation. Combining the findings,of our case with other literature, a laparoscopic repair with wide resection of the fistula, a revision of the gastric pouch and gastrojejunal anastomosis as well as closing the defect in the colon seems to be the best approach in case of an acute perforation in a gastrojejunocolic fistula after LRYGB.


Chondroid syringoma is a relatively rare benign skin appendageal tumor with an incidence of <0.098%. Malignant chondroid syringoma (MCS) arises from cutaneous sweat glands and occurs on the extremities or trunk more commonly in women with only 51 reported cases. Due to the rarity of the disease and lack of published cases of MCS, the diagnostic criteria and treatment protocols are not clear. Based on available recommendations and histological criteria, MCS was diagnosed in a previously classified elbow lipoma following increased size and pain, and skin color changes in a 65-year-old woman.  Chondroid syringoma is a rare benign skin appendageal tumor with an incidence of <0.098% . Its malMCS have high rates of local, regional/nodal, and distant metastasis. MCS on clinical exams present as firm, subcutaneous nodules that are asymptomatic and stable for several years . On histIn this case report, we present a 65-year-old female who presented with an elbow mass that was initially diagnosed as a lipoma but later identified to be MCS. Originally evaluated a decade earlier, the nodule on the patient's right elbow became increasingly larger, more painful, and red/purple in appearance, raising suspicion of a malignant process. Following imaging and biopsy, the nodule was reclassified as an MCS, and excision, surveillance for metastatic disease, and radiation therapy were performed. This is the 52nd case of MCS described in the literature. This article was previously presented as an abstract at the 2022 ACP Southeastern Regional Posters Day and Doctors Dilemma in Philadelphia, Pennsylvania on October 22, 2022. A 65-year-old female with rheumatoid arthritis presented with a painful right elbow mass that had increased in size and pain over the last four months. She described a 10-year history of elbow pain and indicated that the increase in size and pain of the nodule was accompanied by a purple/red color on the overlying skin. Prior to the skin color changes and increasing size, the mass was previously diagnosed as a lipoma 10 years prior. A magnetic resonance imaging (MRI) scan of the right elbow joint revealed a 4.1 x 2.1 x 4.3 cm solid superficial soft tissue mass over the posterior lateral aspect of the proximal forearm , S‐100, vimentin, carcinoembryonic antigen (CEA), and blood group antigen H, less criteria is available for its malignant counterpart  Unlike cThe 51 cases of MCS described in the literature provide a basis for common themes of presentation and disease progression. Nuclear atypia and pleomorphism is the most common histological finding in 80% of patients, and MCS are often aggressive tumors, 45% of which recur locally and 52% metastasize without recurring locally [Despite 51 other cases, this is an exceedingly rare tumor with no standardized diagnostic criteria or treatment. Definitive treatment requires surgical removal with wide excision, but adjuvant treatment is not clearly defined. Given the rarity, there is no data for potential benefits of radiation or chemotherapy after surgery. However, radiotherapy has been used both to the primary site, as with other adnexal tumors, and for lymphadenopathy. More data would need to be collected to determine the best course of treatment for this malignancy. Although rare, MCS is an important diagnosis to consider in evolving skin masses. This is an exceedingly rare tumor with few case reports in the literature and no standardized diagnostic criteria or treatment. Additional research is needed to determine the best course of treatment for these patients and if routine surveillance, of what are thought to be benign skin masses, is needed. It is an important diagnosis to consider in evolving skin masses. This is the 52nd case of MCS described in the literature.


Malignant struma ovarii (MSO) is a rare and aggressive ovarian tumor that mostly affects adults but can occur in adolescents. Prompt recognition, accurate diagnosis, and multidisciplinary management are essential for favorable outcomes. Herein, we report the youngest case of an 11-year-old girl with a large MSO. First, conventional imaging revealed a large left ovarian mass, leading to a left oophorectomy. Subsequently, histopathological examination confirmed papillary thyroid carcinoma within MSO. Thyroid and fertility-preserving surgery were chosen after multidisciplinary consultation. Despite challenges, the patient had a positive outcome with no recurrence after 36 months. Therefore, the adoption of less invasive surgical approaches and vigilant follow-up can achieve remission, but more research is needed to further enhance our understanding of the disease's risk stratification and optimal treatment strategies. Struma ovarii is an extremely rare ovarian tumor, accounting for less than 1% of all ovarian tumors . DespiteConventional imaging modalities are often carried out during the initial diagnostic workup. These include ultrasound (US), CT, and MRI. To date, there is no consensus about the optimal management plan for patients with MSO. Management is often pursued with a multidisciplinary approach and surgery for suspected ovarian tumors and incidental pathological diagnosis is usually definitive for MSO .In the pediatric population, the management of MSO is even more challenging since thyroid and fertility-sparing surgical approaches must be prioritized in adolescent patients. In addition, many of these patients would require lengthy and diligent follow-up.An 11-year-old female presented with left lower quadrant abdominal pain, which progressively worsened over a seven-month period, particularly during the last month of her presentation. The pain experienced was colicky in nature. It was aggravated by her menstrual cycle and radiated to her back. After seeking medical consultation, she underwent a gynecological evaluation. Upon physical examination, the patient was found to have left lower abdominal swelling and tenderness. Her laboratory results showed a hemoglobin level of 13.6 g/dL and a white blood cell count of 6,600/μL. In addition, the levels of beta-human chorionic gonadotropin and cancer antigen 125 (CA 125) were within the normal range. Therefore, conventional imaging modalities were performed  staging system . Based oMore recently, [18F]fluorodeoxyglucose positron emission tomography/CT ([18F]FDG PET/CT) was performed upon patient request in an outside cancer center for surveillance purposes and was unremarkably normal Figure -3D.Pediatric MSO has been acknowledged in pediatric populations in the last three decades. To date, fewer than five cases of pediatric MSO have been reported -5. ThereMost cases of pediatric MSO typically present with pelvic pain -5. OtherConventional imaging modalities are helpful in detecting the MSO mass, depicting its extent, as well as for follow-up . The usuIn the pediatric population, the management of MSO is even more challenging as it must take into account fertility preservation for childbearing. However, this means that routine and diligent follow-up should be pursued. Disease recurrence has been confirmed over a decade after the initial management , and thePhysicians need to be aware of the possibility of MSO when assessing ovarian masses in pediatrics. When suspected, surgical and MDC consultation should be advocated for timely and optimal interventions. For locally confined diseases, our reported case proves that a thyroid and fertility-preserving approach is feasible. Through this approach, fertility preservation can be maintained for childbearing while pursuing routine and regular follow-up. However, such evidence is singular and short-term. Therefore, further knowledge of pediatric MSO is eagerly anticipated in the near future to better understand disease patterns and survival for such a challenging age group.


Portal vein thrombosis (PVT) has been usually diagnosed as a complication secondary to cardiac, hepatic, and malignant etiologies, but it has rarely been described in the setting of blunt abdominal trauma. This case depicts an older male who presented to the emergency department with progressive ascites and lower extremity edema within two weeks after a motor vehicle accident (MVA). Ascitic fluid analysis indicated the presence of portal hypertension, which prompted extensive evaluation to determine the etiology. Further workup, including hypercoagulable and malignancy screening, unveiled the diagnosis of acute PVT secondary to abdominal blunt force trauma, showing a rather rare presentation. Portal vein thrombosis (PVT) is the narrowing or total occlusion of the portal vein secondary to a thrombus and accounts for approximately 5-20% of the cases of portal hypertension ,2. CommoThis case portrays an acute portal venous thrombosis as a rare complication following blunt abdominal trauma. We present a case of a patient with new-onset ascites and abdominal pain associated with PVT two weeks after a motor vehicle accident (MVA).A 62-year-old male with hypertension, diabetes mellitus type II, and chronic kidney disease presented to the emergency department with sharp right upper quadrant (RUQ) abdominal pain radiating to the right lower quadrant associated with bilateral lower extremity edema. Symptoms started two weeks prior to an MVA and had progressed since onset. The patient was hemodynamically stable and a febrile. Physical examination was remarkable for mild RUQ abdominal tenderness, distended abdomen with fluid wave present, and grade IV bilateral lower extremity edema. Remarkable laboratories are demonstrated in Table Laboratories were unremarkable for leukocytosis, thrombocytopenia, abnormal coagulation studies, electrolyte abnormalities, negative smooth muscle antibodies, and mitochondrial antibodies. D-dimer was not obtained in the initial presentation. Computed tomography (CT) of the abdomen and pelvis without contrast was remarkable for bilateral pleural effusions, the right being greater than the left; gallbladder thickening and pericholecystic edema; thickening and edema in the region of descending duodenum wall; and abdominal ascites Figure . AbdomenThe most common symptoms among non-malignant and non-cirrhotic acute PVT cases are abdominal pain up to 91%), followed by fever 53%) and ascites 38%) 3% and as,7. The c%, follow% 3% and PVT is a rare occurrence in a rather healthy person without risk factors. Oftentimes, symptoms are broad and non-specific, which makes its diagnosis even more challenging. This case depicts a rare presentation of ascites in a non-cirrhotic patient with acute PVT in the setting of blunt abdominal trauma without acute complications. We aim to highlight the importance of accurate diagnosis, treatment, and management of atypical acute cases, such as our patient in a multi-disciplinary approach that will decrease the risk of long-term complications, improve survival rate, and optimize their quality of life.


The diagnosis of Sneddon Syndrome should be considered in adults with young‐onset dementia accompanied by neuropsychiatric signs and livedo racemosa. Magnetic resonance imaging and cerebral angiography are essential. A cutaneous biopsy may help in the diagnosis.Sneddon syndrome (SS) is a clinical entity corresponding to a noninflammatory thrombotic vasculopathy that typically includes livedo racemosa and cerebrovascular ischemia. Psychiatric symptoms with cognitive impairment often occur but are rarely the inaugural symptoms. We present a case of secondary SS in a 45‐year‐old man in whom dementia and psychosis revealed the disease. Brain MRI showed multiple ischemic lesions on T2‐weighted, some Gadolinium‐enhanced cortical–subcortical regions and on the left occipital lobe and left and right parietal lobes, and diffuse brain atrophy. The family also described a loss of autonomy for routine tasks, disordered sleep, and labile mood. The initial diagnosis was a major depressive episode with psychotic features, according to the diagnostic and statistical manual of mental disorders: DSM‐5 criteria.Brain MRI Figure  showed mCerebral angiography Figure  revealedThe patient was discharged on acetylsalicylic acid (100 mg/day), oral corticosteroids (prednisolone 60 mg/d), and oral anticoagulants (acenocoumarol 4 mg/day) with a diagnosis of SS. Clinical stability was recorded during 12 months of follow‐up. In particular, there was no recurrence of stroke. No deterioration in autonomy or cognitive functions was observed.3The analysis of the data and the presentation of the results were performed according to the Declaration of Helsinki statement of ethical principles.SS is a rare entity, with an annual incidence of four cases per million.Clinically, dementia is rarely inaugural in SS. It may simulate the Alzheimer's type of dementia, making the diagnosis more difficult.The course of dementia in SS is progressive. It is preceded in half of all cases by a transient cerebral accident.Cases of other psychiatric symptoms in patients who were diagnosed with SS have been reported in the literature. We found two case reports regarding suicide attempts in patients with SS. In the first case, it was a suicide attempt in a patient with bipolar II disorder for whom oral olanzapine treatment was not effective; this episode ultimately led to a diagnosis of SS.Psycho‐cognitive signs generally occur after years, but cases of dementia and mood disorder secondary to subclinical recurrent strokes have been reported without preceding episodes of a focal neurological deficit.Radiologically, cerebral angiography is the gold standard for diagnosing SS.In terms of histology, a cutaneous biopsy may show occlusion of the arterioles with intimal proliferation.4When encountering an adult with young‐onset cognitive dysfunction or psychiatric symptoms and dermatological abnormalities, the diagnosis of SS should not be overlooked. If strokes are found, especially in light of the unusual livedo racemosa skin rash, further workup should be performed to detect this autoimmune disease. MRI and cerebral angiography are essential. A cutaneous biopsy may help in the diagnosis.Mehdi Karoui: Conceptualization; investigation; project administration; validation; writing – review and editing. Emna Baklouti: Writing – original draft; writing – review and editing. Dina Ben Mohamed: Writing – original draft. Hend Riahi: Resources; supervision; validation; writing – original draft. Mouna Chelli‐Bouaziz: Software; validation; visualization.None.The authors report no conflicts of interest.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Rosai Dorfman disease is a rare but benign and self-limiting disorder. A case of Rosai Dorfman disease in a 16-year-old female with classic radiological and pathological findings is presented. T2W hypointense signal of the soft tissue masses was a distinguishing MRI feature.Rosai Dorfman disease is often overlooked in the differentials of lymphadenopathy and soft tissue masses on account of its rarity. This case report comprehensively discusses the imaging approach to this rare disorder. It commonly presents as massive lymphadenopathy in children and adolescents. However, extranodal manifestations involving virtually any organ of the body may be seen in approximately half of the patients. Nevertheless, it remains a benign and self-limiting disease with management focused mainly on removing any compressive effects of massive lymphadenopathy.A 16-year-old female presented to the Otorhinolaryngology department with multiple cheek and neck swellings over 9 years. The swellings were insidious in onset and progressive in nature, with subsequent bilateral upper eyelid swelling. She had a focal swelling in her left thigh for 2 years. She also had recurrent episodes of nasal obstruction for about 7 years. There was no associated pain, fever or weight loss present. No history of any immune compromise, prior medical event or similar findings in family members was noted.On examination, the patient had smooth, firm swellings involving both eyelids with normal vision and no limitation of eye movements. Diffuse enlargement of both parotid and submandibular glands was noted along with cervical lymphadenopathy. The swellings were not associated with tenderness, redness or heat. The patient had a normal complete blood count with a mildly raised erythrocyte sedimentation rate (ESR). Lactate dehydrogenase (LDH) levels and viral markers were within normal limits.Initial investigation was with ultrasonography (USG) of the cheek and neck , which revealed diffuse enlargement of both parotid and submandibular glands. Multiple enlarged hypoechoic lymph nodes with a lobulated outline, increased vascularity and loss of fatty hila were noted at the parotid, submental and submandibular stations bilaterally. On ultrasound elastography, the lymph nodes showed an intermediate elasticity score . Ocular A contrast-enhanced (CE) CT scan of the face and neck (Philips Ingenuity Core 64 slice CT) was performed. Homogeneously enhancing soft tissue masses were seen in the preseptal regions of the eyelids . MultiplAssessing for the disease extent in the face and orbit and for any intracranial involvement, contrast enhanced MRI of the face, orbit and brain  was acquired. The enlarged lymph nodes and salivary glands showed T2W hypointense signal and homogeneous post-contrast enhancement . HomogenPansinusitis was noted with homogeneously enhancing nodular thickening seen in the frontal, ethmoidal and maxillary sinuses bilaterally, along the nasal septum and involving the nasal turbinates. The corresponding CT scan showed no erosions of the sinus walls .Focused ultrasound of the right thigh swelling revealed a hypoechoic soft tissue lesion in the subcutaneous plane with mild to moderate internal vascularity on colour doppler . AbdominThe patient underwent an excision biopsy of the submental lymph nodes under general anaesthesia. Histopathological examination showed multiple partially encapsulated lymph nodes with loss of normal architecture and markedly widened sinuses. The sinuses of the lymph nodes were distended with lymphocytes, plasma cells and histiocytes. Marked ‘emperipolesis’ was seen. The histiocytes were positive for CD68 and S100 and negative for CD1a . These pThe main imaging differential diagnosis included lymphoproliferative disorders like lymphoma and infection. Lack of restricted diffusion and lack of organomegaly were not in favour of lymphoma. Lack of fever, local tenderness, normal leukocyte count and non-necrotic lymph nodes made the possibility of infection less likely. The long period of evolution of the pathological process also favoured the benign nature of the disease rather than lymphoma or infection.The benign and indolent course of the disease was explained to the patient. She was started on prednisolone therapy and was followed up regularly. There was no need for surgery given the lack of any significant complications. Follow-up after 6 months showed only a mild reduction in the size of the parotid and cervical lymph nodes. No significant increase or decrease was noted in the size of eyelid masses or subcutaneous thigh swelling. However, because of associated side effects and reduced serum calcium levels, the steroids were discontinued. After explaining all the risks and benefits of chemotherapy in RDD, the patient’s family refused consent for a trial of chemotherapy. The patient was further advised regular follow-up and was asked to report immediately in case of any suspected complications.3 It is also known as Rosai Dorfman Destombes disease. The term RDD is now preferred as few cases may present solely as extranodal disease.2 The paranasal sinuses (PNS) are a common site of involvement but the term sinus histiocytosis, as described originally, refers to histiocytic infiltration of the medullary sinus of lymph nodes.4Rosai Dorfman disease is a well-established but rare disease entity that involves the proliferation of histiocytes. It was first described by Rosai and Dorfman in 1969 and was originally termed Sinus Histiocytosis with massive lymphadenopathy (SHML).5 Some authors have mentioned it as a disorder of the mononuclear phagocyte and immunoregulatory effort (M-PIRE) system. Association with Ebstein-Barr virus was also sought6; however, no single cause has been validated.The aetiopathogenesis of RDD is not known. Immune-mediated dysfunction is one of the proposed theories. Other causes may include infectious or neoplastic processes.6 A slight male preponderance is seen with a greater incidence of the disease in African and Western Indian populations.4Children and adolescents are predominantly affected by the disease with 80% of patients being less than 20 years of age. Isolated extranodal disease is more common in the elderly population.7 Other lymph nodes, including the axillary, mediastinal, retroperitoneal and inguinal regions, can also be involved.1 The lymph nodes may become very large in size and cause mass effect on vital structures. The ultrasound features of the involved lymph nodes can appear similar to malignant infiltration.8 However, no case of malignant transformation of RDD has been reported in the literature.4 The involved lymph nodes have been shown to be Gallium and18 FDG avid.4Painless cervical lymphadenopathy is the most common presentation. There may be associated fever, leukocytosis, raised ESR and hypergammaglobulinaemia.9 while isolated extranodal disease without nodal involvement has been reported in approximately 23% of cases.2 Any organ can be affected by RDD.1 The head and neck is the most common extranodal region with the commonest site being the skin, followed by the nasal cavity and PNS, subcutaneous tissue, orbits, eyelids and bones.4 Extranodal head and neck involvement tends to occur more frequently in patients with immunological disturbances.10Extranodal involvement has been reported in approximately 43% of patients4 The PNS involvement in the presented case also had similar imaging features with enhancing T2WI hypointense polypoidal thickening and pansinusitis but no osseous erosion. Salivary gland lymphoid hyperplasia seen in the current case is another common presenting feature of RDD.1Nose and PNS involvement can present as nasal obstruction, epistaxis or olfactory abnormalities. Cross-sectional imaging can show enhancing polypoidal masses, thickening of the mucosa or opacification of the involved sinuses or nasal cavity. The lesions are usually hypointense on T2-weighted MRI. Bone erosion and adjacent soft tissue involvement are usually not seen. This in contrast to destructive diseases like granulomatosis with polyangiitis and lymphoproliferative disorders that form close differentials of the nose and PNS involvement.4 It can be isolated or may be associated with skin or lymph node disease.11 Unlike the presented case, unilateral involvement of the orbit is more common. Patients can present with proptosis, limitation in the range of eye movements, swelling of the eyelids or decreased vision.2 An extraconal variably enhancing soft tissue mass with infiltration of the surrounding structures is the commonest manifestation on imaging.4 Involvement of the eyelids can be in the form of large preseptal (as in this case) or postseptal masses.2 Involvement of the lacrimal gland in RDD is a known entity and was seen in this case as bulky enhancing lacrimal glands. Involvement of the eye globe can also be rarely seen. Several cases of intracranial extension of the orbital masses have also been reported in RDD, though this is rare.1 A myriad of diseases that can mimic orbital involvement of RDD include lymphoma, orbital pseudotumor, sarcoidosis, haemangioma or lymphatic malformation like lymphangioma.2Involvement of the orbit and eyelid can be seen in 7% – 10% of cases of RDD.12 Another feature of meningioma, which is lacking in RDD, is hypervascularity on angiography. About 70% of RDD patients with intracranial involvement have no associated lymphadenopathy.4Intracranial involvement in RDD is a rare but known manifestation. Typically, extra axial dural-based enhancing masses are seen, which have a characteristic ‘markedly T2WI hypointense’ signal on MRI. This feature helps to distinguish it from meningioma, which is typically T2WI hyperintense, unless calcified.7 Multicentric lytic lesions within the medulla of long bones like the tibia or fibula or lytic skull lesions are the typical imaging features on radiographs and CT. Langerhans cell histiocytosis (LCH) is the main imaging differential of osseous involvement in RDD.1 One of the differentiating features is the ill-defined fuzzy margins of the lytic lesions in the healing phase of RDD rather than well-defined sclerotic margins seen in LCH.4Osseous involvement is rare (<10%) in RDD but usually occurs in association with nodal disease. Isolated osseous involvement is reported in the literature but is extremely rare.13Subcutaneous involvement is known and was seen in this case as a subcutaneous thigh lesion. Thoracic involvement has been reported in a few cases. These cases included RDD presenting as a lung mass in one report and epicardial involvement in another case.10 All these features were seen in the presented case and helped clinch the final diagnosis.The imaging manifestations of RDD (summarised in 14Rosai Dorfman disease is a benign disorder with an indolent course, good prognosis and often does not require any therapy. Treatment is needed in cases showing involvement or compression of vital organs or the ones causing life-threatening complications. Therapy in such cases is limited to surgical resection and/or debulking. Radiation and steroid therapy have been tried with variable results. Chemotherapy is considered largely ineffective.This case was a typical case of RDD affecting an adolescent female with nodal and extranodal involvement. However, lymphoma was still the main differential on imaging. This highlights the rarity of the disease that is often missed in the differential diagnosis even in cases with classic features. Knowledge of the disorder can help guide optimal management and avoid unnecessary treatment in this self-limiting disease. Histopathology remains the gold standard and is necessary for a definitive diagnosis.


Here we describe a rare post-traumatic lesion and discuss its management.Lumbar Morel-Lavallée is a rarely reported lesion. The cause is usually post-traumatic in a polytraumatic context, and care is often focused elsewhere. This leads to misdiagnosis with a risk of chronic pain and infection. In addition, there is no consensus for the management as few cases have been reported so far.A 35-year-old African woman was involved in a motor accident. Physical examination at the emergency department revealed moderate head trauma, a lumbar inflammatory mass, and a closed leg fracture. She underwent a whole-body computed tomography scan, which revealed a left frontal brain contusion and a large left paraspinal mass in favor of a lumbar Morel-Lavallée lesion. She benefited from osteosynthesis and conservative management of the cerebral and lumbar lesions. After 4 days, she complained of headaches and vomiting. Magnetic resonance imaging was requested. There was resorption of the cerebral contusion, and the lumbar mass was heterogeneous. She was discharged 10 days later without lower back pain and fully recovered from the headaches. Ultrasound of the lumbar soft tissue performed a month later showed no more collection.More frequent in young men, lumbar Morel-Lavallée lesion is underdiagnosed. Thus, there is no consensus on its treatment. However, conservative management followed by close monitoring is advisable in the acute phase. Other therapy includes surgery with or without the use of sclerosing agents. Early diagnosis prevents infections. Although the diagnosis is clinical, magnetic resonance imaging is the critical paraclinical examination for its assessment. Our case is interesting because it occurs in a woman following polytrauma, and to the best of our knowledge, it is an extremely rare lesion, especially in women. Lumbar Morel-Lavallée is a rarely reported lesion. The etiology is post-traumatic due to the shear force that separates the underlying fascia from the subcutaneous tissue. The space created is filled with blood, lymph, and necrotic fat. It generally occurs in the context of polytrauma, and care is often directed elsewhere. It is, therefore, underdiagnosed with a risk of chronic pain and infection. Although rare, it is an unusual cause of hemorrhagic shock.A 35-year-old African woman without medical or surgical history was involved in a motor accident. She complained of pain in her lower back and left leg. She was initially admitted to a hospital with no neurosurgery department, underwent a full body scan, and was then transferred to our center. Physical examination at the emergency department 6 hours after the accident revealed normal vital signs with respiratory rates of 16 breaths per minute, 100% oxygen saturation on ambient air, heart rate of 86 beats per minute, blood pressure of 122/78 mmHg, and temperature of 36 °C. The Glasgow Coma Scale was 14 , and the pupils were symmetric and reactive to light. Neurologic examination showed no deficit except on the left leg due to a closed fracture. A back examination revealed a large swelling on the lower back without a skin lesion. The rest of the physical examination was unremarkable. Whole-body computed tomography (CT) scan showed a left frontal contusion with no mass effect. However, a voluminous left hyperdense paraspinal mass indicated a possible lumbar Morel-Lavallée lesion  was conducted in the hospital. Unfortunately, our hospital has no access to CT scans; only MRI is available. MRI revealed resorption of the cerebral contusion, and the lumbar mass appeared heterogeneous in both T1 and T2 sequences (Fig. Morel-Lavallée lesion is rarely reported, especially in lumbar localization, where the incidence is 3.4% . There iThe etiology is post-traumatic, with shear forces that separate the underlying fascia from the subcutaneous tissue. The result is an injury of the trans-aponeurotic capillaries and lymphatics, leading to the collection of a hemolymphatic mass in the space created , 13. ThePatients usually present within hours to days after the trauma, but up to one-third after months or years . Pain anMorel-Lavallée can occur in isolation but is usually associated with an underlying fracture . UltrasoIn 2005, a classification of Morel-Lavallée lesion was established according to the delay of trauma, amount of blood fat and lymph, contrast enhancement, and presence of a capsule. Other than giving a detailed characterization of the lesion, this classification does not provide guidance or the outcome of each class .There are currently no guidelines for managing this lesion due to its rarity. Conservative management is advisable in the acute phase but is not always achievable, especially when faced with polytrauma. It consists of compression bandaging, pain killer, and bed rest. Bed rest allows spontaneous tamponade of the bleeding due to compression from the patient’s body weight. This therapeutic option usually minimizes the localizations outside the knee and must be associated with another approach . Other oComplications are mainly infectious with tissue necrosis, and data regarding bacterial colonization are inconclusive . In addiTable Lumbar Morel-Lavallée lesion is a rare lesion with a clinical diagnosis, but MRI is the gold standard for its assessment. Conservative management in the acute phase is advisable with a good outcome. Physicians should consider this diagnosis when a patient presents with high-velocity, blunt trauma injury with persistent pain.


Gastritis cystica profunda (GCP) has been defined as a rare submucosal benign gastric lesion with cystic gland growth. Due to its unclear etiopathogenesis, this lesion is often misdiagnosed and mistaken for other gastric masses. Currently, a standardized treatment for GCP lesions is still missing. Here, we illustrate a case of a patient admitted to our general surgery department for melena and general discomfort. No history of peptic ulcer or gastric surgery was present. Upper GI endoscopy was performed, showing a distal gastric lesion with a small ulceration on the top. CT-scan and endoscopic ultrasound confirmed the presence of the lesion, compatible with a gastric stromal tumor, without showing any eventual metastasis. Surgical gastric resection was performed. Histological findings were diagnostic for GCP, with cistically ectasic submucosal glands, chronic inflammation, eosinophilic infiltration and foveal hyperplasia. GCP is a very exceptional cause of upper-GI bleeding with specific histological features. Its diagnosis as well as its therapy are challenging, resulting in several pitfalls. Even though it is a rare entity, GCP should always be considered in the differential diagnosis of gastric submucosal lesions.  In 1947, Scott and Payne reported a case of a tumor-like gastric lesion presenting as diffuse cystic hyperplasia in the submucosa of the stomach, which they were the first to describe as Gastritis Cystica Profunda (GCP) . They reThe definition of GCP proposed by Scott and Payne was then reintroduced by Franzin and Novelli in 1982, due to histological features being similar to a condition of the colon—colitis cystica profunda .GCP is a rare condition and only a limited number of case reports have been published on the topic, mainly regarding the Eastern population. Different hypotheses have been made on the etiology of this lesion, but at present it has yet to be fully clarified. GCP is more commonly found in patients with previous gastric surgery or endoscopic procedures such as polypectomies or biopsies ,5. HenceThe clinical presentation of GCP is vague, and in most cases, it is an incidental finding . More coMany authors ,12 consiIn this paper, we report a case of a patient presenting with upper gastrointestinal bleeding in the absence of previous gastric surgery. The clinical presentation and the diagnostic workup are analyzed, as well as the therapeutic choice, that led to the histological definitive diagnosis of GCP. Due to its rare occurrence and the lack of robust data, especially in the Western population, we did not take into consideration GCP among the differential diagnoses and a gastric stromal tumor was hypothesized. The pathological examination of the surgical specimen was paramount for the diagnosis. To our knowledge, this is one of the limited cases of GCP occurring in unoperated stomachs in the Western population, and more data are needed in order to standardize the diagnostic and therapeutic process.A 61-year-old male was admitted to the General Surgery Department due to general discomfort and multiple episodes of melena in the previous 24 h. His medical history was positive for arterial hypertension undergoing therapy with Amlodipine 10 mg/daily, previous major trauma with multiple bone fractures and diaphragmatic laceration treated with explorative laparotomy and suturing of the diaphragm, as well as deep venous thrombosis undergoing anticoagulant oral therapy with a dose of Warfarin adjusted according to INR values. No previous gastrointestinal disorders were reported. Physical examination was unspecific, revealing a diffusely tender abdomen without palpable masses or signs of peritonism. The blood tests at arrival revealed anemia with a hemoglobin value of 8.8 g/dL, a hematocrit value of 27.2% and an international normalized ratio (INR) increased to 3.00, due to the patient’s therapy. The anticoagulant oral therapy was replaced with low molecular weight heparin (LMWH) and a blood transfusion was administered. After a hemotransfusion of two units of packed red blood cells, the patient’s hemoglobin levels increased up to 10.5 g/dL the day after admission.The patient underwent a diagnostic upper GI endoscopy for melena. The endoscopic examination revealed a 25 mm submucosal lesion at the posterior wall of the antrum , with a An upper GI endoscopy also revealed a thickening of the folds in the gastric body. Biopsies of the submucosal lesion were performed, and the histological examination showed foveolar hyperplasia without evidence of Helicobacter Pylori infection.A 50 × 20 mm irregular lesion of the gastric antrum without evidence of metastasis was confirmed with contrast-enhanced computed tomography CE-CT; .To better characterize the lesion and its extension through the gastric wall, an upper endoscopic ultrasound (EUS) with radial echoendoscope was performed. The EUS showed a 5.0 × 2.8 cm submucosal antral mass with a heterogeneous echo, penetrating the muscolaris propriae with no involvement of the subserosa .TM administration, the septa of the lesion were hyperechoic while the holes remained anechoic  with a 22-Gauge needle were performed. However, the FNB results were inconclusive for a definitive diagnosis. Despite the undiagnostic FNB, the endoscopic, radiological and EUS findings were indicative of a gastrointestinal stromal tumor (GIST). After a multidisciplinary discussion including surgeons, oncologists, endoscopists and radiologists, resection of the lesion was indicated to obtain a definitive diagnosis and to prevent further gastric bleeding in the patient, which would result in long-term anticoagulant therapy. Due to the location and dimension of the lesion, endoscopic resection was not performed, and the patient underwent distal gastric resection with Billroth II-type reconstruction. The surgery had no short-term complications, and the patient was discharged on the eight post-operative day. On the 18th postoperative day, the patient was readmitted to the Surgical Department for sudden onset of abdominal pain and vomiting. The clinical presentation was indicative of bowel obstruction and the CT scan confirmed an incarcerated loop of the proximal ileum secondary to post-operative adhesions. A relaparotomy was performed with adhesiolysis and there was no need for bowel resection due to the vitality of the ileal loop. The residual postoperative period was uneventful, and the patient was discharged after one week.Macroscopic pathologic examination of the surgical specimen showed a multiloculated cystic lesion of 2 cm covered by normal mucosa, without serous membrane invasion, at the gastric antrum. Microscopic histological findings presented cystically dilated glands, diffuse in the submucosa a–c and fThese features were consistent with a diagnosis of GCP. The lymph-nodes examined were microscopically free of neoplastic cells.The multidisciplinary team suggested no adjuvant treatment and the patient was examined at 18-months follow-up, testing negative.Gastritis cystica profunda is a rare pathological lesion of the stomach characterized by elongation and hyperplasia of the gastric foveolae, disruption of the muscolaris mucosae and deep epithelial migration and proliferation, with many cystically dilatated glands in the submucosa. In the literature, several terms have been proposed to describe this entity, such as gastritis cystica polyposa, multiple polypoid cystic gastritis, heterotopic cystic malformation of the stomach and diffuse submucosal cysts of the stomach ,3,7. GCPThe pathophysiology of GCP is yet to be totally clarified. In the literature, prior gastric surgery is described in 65% of cases. In 1981, Franzin and Novelli pointed out that dilated cystic glands in the submucosa were consequent to the post-surgical disruption of the gastric mucosa . IschemiRecently, Du et al. published an updated literature review on this topic. Between 1972 and 2014, a total of 52 cases of GCP have been published. Most of the patients were male, older than 50 years old, and no significant difference was highlighted between the operated and unoperated-on patients, with 52% of them having received previous gastric surgery [Symptoms are unspecific and uncommon. When they occur, patients typically present with abdominal pain, fullness, loss of weight, upper-GI bleeding and anemia. The lack of specific symptoms may contribute to the low rate of GCP diagnosis .In the presented case, the patient was admitted to our department for upper-GI bleeding and anemia. GCP is often underdiagnosed because of unspecific clinical presentation and imaging manifestation; therefore, no standardized algorithm for its diagnostic process has been identified yet. In our experience, the first exam performed was an upper-GI endoscopy to identify the cause of the melena and upper-GI bleeding, which revealed a submucosal broad-based lesion of the antrum. Different authors agree on the endoscopic features of GCP, which usually manifests as a submucosal tumor-like lesion or polypoid or similar to early gastric cancer ,22. BeinAs suggested by Okada et al. , EUS is Regardless of the vague indicative findings, the preoperative diagnosis of GCP is challenging and histological examination is necessary to provide a definitive diagnosis. Therefore, pathological examination of the resected specimen is the gold standard for the diagnosis of GCP ,22,27. ADifferent resection techniques have been proposed for GCP—both endoscopic procedures and surgery. Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD) are the preferred methods to treat GCP if the patient is asymptomatic and the dimension of the gastric lesion is compatible with endoscopic resection ,25,28,30The differential diagnosis of submucosal gastric lesions should include leiomyoma, lipoma, gastrointestinal stromal tumor, lymphoma, leiomyosarcoma, neuroendocrine cell tumors, schwannomas, Menetrier’s disease and GCP ,21,28,32In conclusion, GCP is a rare submucosal lesion of the stomach whose preoperative diagnosis may be challenging due to its unspecific symptoms and presentation.It is important to consider GCP in the differential diagnosis of gastric submucosal lesions—not only when the lesion occurs at anastomotic site of operated stomach, but also in case of gastric submucosal lesions in patients without history of gastric surgery.No standardized diagnostic algorithm is available in the literature, but EUS may contribute to its identification, detecting anechoic lacunae within the lesion.With histopathological examination being the gold standard for GCP diagnosis, endoscopic or surgical resection are indicated. An adequate endoscopic follow-up after total excision is advisable, considering the risk of GCP local recurrence.To date, no consensus has yet been reached on the management strategy for GCP, and further studies are needed to clarify pathological mechanisms of GCP and its role as a precancerous lesion in the development of gastric adenocarcinoma.Here, we reported a case of GCP that was preoperatively misdiagnosed and then successfully identified at histology in a patient without previous gastric surgery. To our knowledge, this is one of the few cases of GCP in the Western population. Finally, we conducted a review of the literature to highlight GCP’s etiological and clinical features, aiming at increasing scientific knowledge on the topic.


Liposarcomas are neoplasms of mesodermal origin representing less than 1% of all malignant tumors and 1 to 2% of urogenital lesions. Primary retroperitoneal liposarcomas extending into the inguinal canal are rare. We present the case of a large retroperitoneal liposarcoma invading the left testicle and its spermatic cord. It was diagnosed by imaging as a large mass that compresses surrounding abdominal structures and communicating with the inguinal canal. A surgical intervention consisting of en bloc resection of the tumor and the left testicle with its cord was performed by 2 routes, intercostal and inguinal. Histology showed a dedifferentiated liposarcoma, which is a rare entity with a high rate of malignancy and a poor prognosis. The treatment of choice is wide surgical resection with clear margins; chemotherapy and radiotherapy are less sensitive. The patient did not manifest any particular complaints during the first six months after surgery. Retroperitoneal liposarcomas (RPLPS) are rare mesenchymal tumors. They account for 7.5–25% of all soft tissue sarcomas and 1–2% of urogenital lesions . We repoA 58-year-old man presented with an abdominal mass and swelling of the left scrotum that had been evolving for approximately three months. The patient had a good clinical appearance at the time of consultation, with no urinary or digestive complaints reported. Physical examination revealed a large, firm and painless mass occupying the entire left flank. A thoraco-abdomino-pelvic CT scan showed a voluminous retroperitoneal mass of fatty density measuring 20 × 18 × 21 cm simulating a liposarcoma, which communicates with the left inguinal canal and responsible for a left pyelocaliceal dilation . ComplemRetroperitoneal liposarcoma (RPLPS) is a rare and primary tumor. Its physiopathology is poorly understood. The liposarcoma (LPS) is a malignant soft tissue tumor of mesenchymal origin, developed from immature lipocytes at different stages of differentiation. It accounts for 14–18% of all malignant soft tissue tumors [The disease affects, without a clear predominance of sex, the adult population of about fifty years , 5. The Inguino-scrotal invasion of the RPLPS is rarely reported in the literature. Scrotal involvement is more common with inguinal LPS than with RPLPS because the latter less often extends into the inguinal canal. In their study, Rhu et al.  listed oImaging, in this case scanner and MRI, helps in diagnosis but the reference examination remains the pathological anatomy. The World Health Organization WHO, in its fifth edition 2020 of classification of soft tissue and bone tumors, classifies LPS into four subtypes, which can be compiled into three groups: myxoid LPS (56.2%), atypical LPS  and pleomorphic LPS 17.8%) [.8% 7, 8. The preSurgical resection remains the mainstay of treatment for LPS and local recurrences , 2. In tExtension of retroperitoneal liposarcoma through the inguinal canal is an extremely rare situation. Its clinical manifestation is delayed due to the compliance of the retroperitoneal space. Dedifferentiated liposarcoma has a very poor prognosis; only surgical treatment with negative margins can reduce the recurrence rate.