Eosinophilic angiocentric fibrosis (EAF) is an infrequent and slowly progressive disease, represented by fibroinflammatory lesions of unknown origin, which mainly involves the sinonasal structures and upper respiratory tract. Occasionally, it can affect the orbit and ocular adnexa causing symptoms such as proptosis, globe displacement and periorbital edema. In very rare cases, ocular manifestation as an orbital inflammatory pseudotumor can be the primary localization of the disease. Current literature proposes a relation between EAF and immunoglobulin G4-related disease spectrum.We describe the case of a 69-year-old man presented with antecedents of left periorbital edema, epiphora and retroocular pain. Examination showed a nonaxial proptosis, severe limitation in left eye adduction and lateral globe displacement. Orbital imaging revealed a left medial orbital mass with involvement of the inferior rectus and the medial rectus muscles. An orbital biopsy of the mass illustrated an inflammatory infiltrate with a notable eosinophilic component, “onion-skin appearance” of vessels and surrounding concentric fibrosis, highly suggestive of EAF. Further investigations showed a high expression of IgG4 and excluded other possible diseases. There was a favorable evolution of the orbital inflammatory pseudotumor following a 4-month treatment course with oral glucocorticoids.Abbreviations: EAF = Eosinophilic angiocentric fibrosis, CT = Computed tomography, MRI = Magnetic resonance imaging, GPA = Granulomatosis with polyangiitis, EGP = eosinophilic granulomatosis with polyangiitis, MPA = microscopic polyangiitis, ANCA = Anti-neutrophil cytoplasmic antibodies, Ig = Immunoglobulin  The inflammatory infiltrate within this lesion is an admixture of predominantly eosinophils along with lymphocytes and plasma cells. The characteristic histologic feature of EAF is the appearance of small-caliber arteries surrounded by concentric layers of fibrosis, also reported as “onion-skin” appearance. Little has been discovered about the etiology of EAF since its first description in 1985 [2]. This benign disease is represented by a gradually progressive process imitating a tumor, with many recurrences after surgical extirpation and glucocorticoid therapy. The typical histology is made up of fibro-inflammatory lesion with several eosinophils, organized in a perivascular pattern. As the lesion evolves, inflammation becomes not so much intense and the fibrosis appears like “onion-skin” type perivascular fibrosis.It predominantly affects the sinonasal tract, the larynx and the gums and infrequently the orbit and ocular adnexa. In limited cases, ocular manifestation can be the primary localization of the disease [3].Deshpande et al. found a patient with EAF with a significant increase of serum IgG4. This unintentional finding led to a retrospective analysis of 5 EAF cases and proposed the probability that EAF would be a manifestation of IgG4-related disorder .Not too many EAF cases with nasolacrimal duct obstruction and orbital involvement have been described in literature. These cases described patients with periorbital edema, globe displacement, painless proptosis, epiphora, diplopia and limitation in ocular movements, on physical examination . In 2011, EAF was described as being component of the immunoglobulin G4-related condition spectrum [3]. IgG4-related diseases are a group of inflammatory conditions that affect many organs of the body, including the pancreas, lungs, kidneys, and salivary glands. Serum IgG4 is only elevated in 50% of patients. The diagnosis is generally based on histology. A high expression of IgG4-related plasma cells and an IgG4:IgG ratio > 0.4 in the biopsy sample support the diagnosis [6].The term “EAF of the upper respiratory tract” was used by Roberts and McCann to describe a condition characterized by inflammatory cell infiltration, mainly with eosinophils and gradual perivascular fibrosis .EAF symptoms are nonspecific. The most common symptoms are related to the sinonasal region consisting of progressive nasal obstruction, sinusitis, swelling, nasal tenderness, facial pain, and shortness of breath [6]. EAF is a progressive disorder, but there is some proof that the lesion stabilizes over time, and no EAF-associated mortalities have been documented. Imaging, both CT and MRI, is nonspecific and usually describes a well-circumscribed submucosal tissue density mass with sinus opacification .Histopathological examination shows both early and late lesions. The early lesion is a vasculitis with inflammatory infiltrate containing lymphocytes, plasma cells, scattered neutrophils and with numerous eosinophils. The late lesions consist of heavy fibrosis with angiocentric pattern and combined inflammatory cells. The fibrous component has a concentric stratified “onion-skin” type perivascular layout, which is typical for EAF and is useful for establishing the histologic diagnosis of EAF .The differential diagnosis of EAF is extensive and includes the ANCA-associated vasculitis spectrum with its three major entities , two neoplastic conditions represented by NK/ T cell lymphoma and lymphomatoid granulomatosis, infectious granulomatous diseases, sarcoidosis, Sjogren’s syndrome, etc. . In both entities, ANCA tests can be negative, and considerable numbers of eosinophils may be seen in the histopathology report. Our patient did not have the classic necrotizing granulomatous vasculitis of typical GPA, but did have striking lamellar “onion-skin” angiocentric fibrosis with a low-grade vasculitis. The advanced angiocentric fibrosis suggests a well-established chronic lesion. Eosinophils and fibrosis can be seen in early cases of orbital GPA, but rarely in chronic lesions. Moreover, the lack of typical histologic lesions of GPA makes this diagnosis unlikely [14].The limited form of GPA is an important entity, with heterogenous clinical and pathological manifestations and should be considered in the differential diagnosis of EAF [9]. All patients should undergo a thorough blood examination . In addition, the patients should be referred to a rheumatologist to exclude any rheumatologic diseases and to an ear, nose, and throat specialist to exclude any nasal or sinus involvement. Once the diagnosis of EAF is established, the possible treatments are medical or surgical. Surgical resection seems to be the treatment of choice in most previously reported cases. However, recurrences are very frequent and repeated excisions are usually required to control the sometimes-slow evolution of the disease .The initial step in managing patients who have an orbital inflammatory pseudotumor is to exclude alternate inflammatory and neoplastic diseases based on the clinical and histological findings [Glucocorticoids had beneficial effect in our case over a 4-month treatment course.EAF is a benign fibrosing lesion affecting the sinonasal tract and infrequently extends to the orbit. The clinical manifestations of EAF with orbital involvement often mimic other more common ophthalmological diseases. The physical, laboratory and radiological findings of these patients are commonly nonspecific, thus requiring more extensive investigations. In this circumstance, biopsies of the involved lesions can be revelatory in the process of finding the diagnosis. Also, the response to glucocorticoids depends on the histological stage (inflammatory or fibrotic) of the lesion. In our case, we expected a slowly favorable progression of the disease due to the predominantly fibrotic histological phase of the orbital inflammatory pseudotumor. Even if EAF is very uncommon in the upper airway tract, nasal cavity, and orbit it should be taken into consideration in the differential diagnosis of lesions of these regions.Conflict of Interest statementAuthors state no conflict of interest.Informed Consent and Human and Animal Rights statementInformed consent has been obtained from all individuals included in this study.Authorization for the use of human subjectsEthical approval: The research related to human use complies with all the relevant national regulations, institutional policies, is in accordance with the tenets of the Helsinki Declaration, and has been approved by the review board of “Sfânta Maria” Clinical Hospital, Bucharest, Romania.AcknowledgementsNone.Sources of FundingNone.DisclosuresNone.


Trichobezoars are indigestible masses of ingested hair commonly found in the stomach, often presenting with symptoms related to gastric outlet obstruction and severity related to the mass’s size and location. Gastrointestinal complications include ulceration, perforation, peritonitis, pancreatitis, obstructive jaundice, pneumatosis intestinalis, and intussusception. Management of trichobezoars differs from that of other forms of bezoars, which can often be addressed with chemical dissolution. Trichobezoars are high-density structures that are also resistant to enzymatic and pharmacotherapy degradation, and as such, they require endoscopic, or more commonly, surgical removal. Here, we present the diagnosis and surgical management of a 12-year-old female with a large trichobezoar causing gastric outlet obstruction, with an associated Rapunzel syndrome manifesting as multiple small intestinal intussusceptions. The locbezoars) . Patientbezoars) -8. Earlybezoars) ,9-12. WeA 12-year-old female with no significant past medical or psychiatric history presented with sharp, crampy abdominal pain of three weeks duration associated with nausea and non-bloody, non-bilious emesis. Physical exam was notable for mild tachycardia and hypertension, abdominal tenderness, and voluntary guarding in the right upper and lower quadrants without peritonitis. No hematologic or metabolic derangements were noted on initial labs. Initial abdominal radiographs and a right upper quadrant ultrasound performed at our institution similarly demonstrated no acute abnormalities. Computerized tomography revealed a large gastric bezoar distending the stomach, likely resulting in partial gastric outlet obstruction. Multiple prominent short segments small bowel-small bowel intussusceptions were also noted Figures , 1B. TheAn upper midline laparotomy with an oblique gastrotomy was performed. Intraoperatively, a large gastric trichobezoar was found with extension past the ligament of Treitz into the mid-jejunum. A long braided synthetic cord measuring about 50 cm was also present and intertwined with the hair, serving as a lead point for multiple small bowel-small bowel intussusceptions Figures , 2B. TheOn further questioning, the patient and her parents endorsed hair chewing throughout her life, but denied overt hair pulling or ingestion. She was also found to have stressors concerning schoolwork with several prior episodes of self-harm behavior. Ultimately, she was diagnosed with a social anxiety disorder with trichophagia and was referred for outpatient psychological therapy to further evaluate possible trichotillomania. The remainder of her hospital course was unremarkable, and she was discharged on postoperative day 3.Bezoars in and of themselves are not dangerous, yet the potential for obstruction of the gastrointestinal tract warrants urgent diagnosis and treatment. We present a case of a trichobezoar with Rapunzel syndrome leading to seven small bowel-small bowel intussusceptions. Trichobezoars are distinct from other bezoars in that hair can generate highly dense masses that are resistant to enzymatic digestion. Furthermore, the smooth surface is thought to prevent hair from passing with peristaltic waves and to be retained within the gastric folds ,13,14. TThe diagnosis of trichobezoars is often delayed, as they are not often recognized on initial presentation due to non-specific abdominal symptoms . The iniRapunzel Syndrome was first described by Vaughan et al. in 1968 and has since been reported with varying features . We suppThe treatment of bezoars largely falls into three categories: medical dissolution, endoscopy, and surgery . TrichobTrichobezoars are indigestible masses of ingested hair that can cause gastric outlet obstruction and even in our case intussusception as they serve as a lead point. They can be complicated with ulceration, perforation, pancreatitis, obstructive jaundice, and pneumatosis intestinalis. For this reason, early diagnosis and treatment are vital. They are usually resistant to enzymatic degradation and endoscopic treatment for which laparotomy should be always considered. Our case demonstrates the safety and efficacy of an up-front surgical approach with subsequent psychiatric evaluation and treatment in the management of trichobezoars with associated Rapunzel syndrome.


A comprehensive literature search revealed 48 cases of extremely giant ovarian tumor in these 20 years. Six out of 48 cases are solid. Twelve out of 48 cases are malignant or borderline malignant, and patients' age and tumor size/weight were not related to the frequency of malignancy/borderline malignancy. As many as 4 out of 48 patients died before their first hospital visit or early after surgery. Clinicians should consider a considerable high mortality and frequency of severe surgical complications when planning the treatment strategy for extremely giant ovarian tumors.Ovarian tumors can get extremely giant to occupy the whole abdominal cavity. We report a case of 36 kg solid ovarian tumor, which was the largest ovarian solid tumor that have been ever reported. A 54-year-old woman presented to our hospital with a chief complaint of markedly distended abdominal wall. Preoperative imaging examinations revealed that most of the tumor was uniform and its density was like that of subcutaneous fat. Pleural effusion was detected in the right thoracic region. We organized a multidisciplinary team and successfully resected the right adnexa. The patient had an uneventful postoperative course, and she was discharged on the 7 Various kinds of tumors can develop in the ovaries, and they can become extremely large, occupying the whole abdominal cavity. However, since extremely giant ovarian tumors (ExG-OvTs) are rare, most of relevant reports are just case reports and there are few reports that investigated a certain number of ExG-OvTs . As for Herein, we report a case of a patient with a giant ovarian fibroma with pleural effusion due to Meigs syndrome. To our best knowledge, our case is the largest solid ovarian tumor that has ever been reported. In addition, we performed a literature review to investigate the clinicopathological backgrounds, mortality, and the frequency of severe complication during postoperative period of ExG-OvTs in these 20 years. Our review is the first review that investigates a certain number of ExG-OvTs including solid tumors.A 54-year-old woman  was transferred to our department with an extensively distended abdominal wall and leg pain. Regular menstruation started at age 14, and she experienced menopause at age 48. She had no history of regular hospitalizations. Over the past few years, she had noticed a gradual progression of abdominal bloating, but she had not decided to go to the hospital. Finally, when it became difficult for her to walk by herself, she went to a nearby hospital and was transferred to our department.Her vital signs were stable; however, her abdomen was markedly distended from the cardiac fossa to the lower abdomen, making it difficult for her to stand by herself . Marked Contrast-enhanced computed tomography showed that the tumor occupied the whole abdominal cavity (38 cm × 40 cm × 48 cm), and both kidneys were being pressed significantly dorsally . Most ofBlood test results showed that the CA125 value was slightly elevated, and there was a marked increase of estradiol and a marked suppression of luteinizing hormone and follicle-stimulating hormone levels , which iWe planned to surgically remove the right adnexa, but because of concerns about potentially severe complications, we organized a multidisciplinary team of general surgeons, anesthetists, radiation oncologists, and plastic surgeons to plan the treatment course.We placed two surgical beds side by side for the operation. During the laparotomy, the patient was placed in the left lateral decubitus position to maintain hemodynamic stability and because the tumor was assumed to be of right ovarian origin . With thst postoperative day. A chest radiograph on the fourth postoperative day showed a marked decrease in the right pleural effusion  tumors with a maximum diameter > 30 cm in imaging or (2) tumors weighing more than 20 kg. These criteria narrowed our results to 47 cases, to which we added our case for all further analyses, for a total of 48 cases . DetailsThe resulting reports showed that ExG-OvTs have been found in patients of a wide age range, from 12 to 74 years. The frequency of solid ExG-OvTs was low  were of malignant or borderline malignant tumors. There were no significant differences about the frequency of malignant or borderline malignant tumors between the cystic and solid ExG-OvTs  deceased  are pathologically benign, they are still strongly associated with a high mortality and fatal postoperative complications, and we have to take that into account when planning the treatment.


Testicular torsion is a urologic emergency that requires surgical intervention. Its diagnosis is rarely made in elderly men especially the subset of men on urethral catheter. As a result, delayed diagnosis and surgical exploration occur leading to testicular infarction with necrosis, abscess formation and ultimately orchidectomy. We report a 73-year-old urologic patient referred with a 2-month history of transurethral catheterization to relieve retention of urine with subsequent scrotal pains and fever. Physical examination showed left hemi-scrotal swelling and normal right hemi-scrotal findings. A Doppler scan done showed an intratesticular fluid collection with no blood flow in the left testes. This case illustrates the need to include testicular torsion when diagnosing geriatric men with transurethral catheter presenting with any acute scrotal pains. We, therefore, recommend a detailed history and physical examination in addition to a colour Doppler ultrasound scan in making a diagnosis. One of the rarely seen urological emergencies in the adult and elderly male population is spermatic cord torsion (SCT) with fewer than 10 cases reported in literature among urological patients aged 70 years and above . SCT occA decrease in intratesticular perfusion starts with obstruction of venous outflow when the degree of spermatic cord twist is <360° and cessation of arterial flow when the testis twists 360° or greater, leading to the testicular ischaemia . TesticuUnfortunately, the early diagnosis of testicular torsion may be missed, if it occurs in a rare situation such as in geriatric patients or conditions such as a patient with an indwelling urethral catheter. Complications due to chronic indwelling urethral catheter such as infectious–cystitis, prostatitis, epididymitis, urethritis and periurethral abscess  may be mWe present a 73-year-old man who was referred to a hospital after 9 days of management as acute epididymo-orchitis by a primary caregiver.He presented with sudden onset of left hemi-scrotal pains. This was his first episode of experiencing such pains that were so severe that he could not continue with his usual activities. He had been very well after a transurethral catheterization 2 months prior, on account of acute retention of urine from clinically suspected benign prostatic hyperplasia and had since been regularly changing the catheter. There was no prior history of any urethritis, urethral discharges, scrotum swelling, fever, chills, rigours, a feeling of malaise, haematuria, lower urinary tract discomfort, suprapubic pains or trauma. He had no co-morbidities like diabetes. He was empirically treated with oral ciprofloxacin and analgesia and discharged. Even though he noticed an improvement in the pains, he developed a progressively worsening left hemi-scrotal swelling associated with generalized malaise.Physical examination on the patient revealed a swollen left hemi-scrotum  with difA CDU scan was done, and it showed an intratesticular fluid collection with no blood flow into the left testis and normal right hemi-scrotal findings .Other investigations showed mild leucocytosis but no pus cells in the urine. He had scrotal exploration done, and the findings were an intravaginal torsion, oedematous left scrotum with a swollen and necrotic testis and a normal right testicle . There win situ.Testicular torsion is much common among adolescents and neonates with few reported cases in the geriatric population , 11. Thein situ [Most scrotal pain in the elderly is often attributed to infective causes such as epididymitis or orchitis especially in inpatient with transurethral catheters in situ . Other cin situ , 12 withThe majority of other pathologies are diagnosed clinically through history and physical examination. However, delayed diagnosis is noted among elderly men reporting with testicular torsion and very often this is through Doppler ultrasound scan , 14. OurThe management of this case illustrates how a low index of suspicion continues to delay the diagnosis of testicular torsion and impact poor testes salvage despite classical presentations. Testicular torsion must be included as a differential diagnosis in the evaluation of men with transurethral catheters presenting with acute scrotal pain. We recommend a detailed history and physical examination in cases of this nature.


Background: Metastases to the pituitary gland are extremely rare with an incidence rate reported from an autopsy series of 1.8%–12%, and only 20% was diagnosed clinically. Tumors that commonly metastasize are breast and lung tumors.Case series: We present a series of five cases, including four female patients and one male patient with metastatic cancer. Two women had metastatic small lung cancer and presented with diabetes insipidus (DI). Two women had metastatic breast cancer, of which one presented with DI and the other with panhypopituitarism. The male patient had bronchogenic adenocarcinoma and presented with DI.Conclusion: Our case series confirmed earlier reports that DI is the most common presentation of metastases to the pituitary gland. She underwent staging by positron emission tomography (PET) which revealed bilateral axillary, supraclavicular, hilar, and mediastinal lymph node metastasis and uptake in the left breast, bone, and several liver metastases with intense uptake in the pituitary. She was started with goserlin, letrazole, and denosumab.In June 2016, she started complaining of polydipsia. She was drinking more than 5 L of water per day. Magnetic resonance imaging (MRI) of the pituitary gland confirmed pituitary metastasis, and she exhibited signs and symptoms of pituitary insufficiency and diabetes insipidus. She was treated with suprasellar radiation therapy to the pituitary in July 2016 and maintained on replacement therapy mainly with levothyroxine, hydrocortisone, and desmopressin. She also had a small metastasis to the brain detected on MRI and was treated with gamma knife radiotherapy.In September 2016, follow-up PET showed marked improvement with near resolution of bone uptake, resolution of hepatic uptake, and decrease uptake in both breast lesions.In December 2016, repeated MRI of the brain showed re-demonstration of the previously depicted asymmetry of the pituitary gland being relatively and mildly more prominent on the right side with mild inclination of the pituitary stalk to the right. These findings are stable since the latest MRI. The previously depicted hyperintense small foci on tbl2 and fluid-attenuated inversion recovery sequences demonstrated a stationary course with no related edema, restricted diffusion, or abnormal enhancement.Moreover, in December 2016, PET showed hypermetabolic lesion in the right thyroid lobe for further correlation. Moderate hypermetabolic soft tissue lesion was noted in the right breast and required further evaluation. Nonfluorodeoxyglucose-avid multiple sclerotic lesions were observed at multiple levels of the thoracic and lumbar vertebrae.She maintained the same management, and follow-up imaging continued to show improvement. During this time, the patient was clinically well.In January 2018, follow-up PET showed clear progression of the disease with progressing neck and mediastinal lymph nodes, as well as right breast lesion and new bone lesions. At this time, the oncologist decided to start second-line treatment for premenopause as ribociclib plus fulvestrant and to continue gosrelin and denosumab. She continued to receive replacement therapy for panhypopituitarism.She responded well to treatment. In September 2018, the latest PET showed complete metabolic resolution of the disease .An 80-year-old man was referred to the endocrinology clinic for headache, thirst, and polyuria of 4 months duration. He was known to have hypertension, diverticulosis, and vitamin B12 deficiency. He drank at least 5 L of fluids per day. He also lost 6 kg of weight. He had no other systemic or alarming symptoms.2. Clinical examination was unremarkable, with no features suggestive of acromegaly, Cushing's, or any other endocrinopathies.On examination, he had normal visual fields and absence of cranial nerve palsy. He weighed 83.9 kg, and his body mass index was 28.4 kg/mResults of baseline investigations were as follows: sodium of 147 mEq/L, plasma osmolality of 301 mosm/kg, prolactin of 1062 mU/L, and normal levels of other pituitary hormones.The water deprivation test showed results consistent with cranial diabetes insipidus. At baseline, his urine osmolality was 65 mosm/kg; after 2 h of water deprivation, it was 319 mosm/kg; and after subcutaneous administration of desmopressin, it increased to 416 mosm/kg. He was started with desmopressin and demonstrated good therapeutic response.MRI of the pituitary gland showed a 10-mm mixed cystic/soft tissue mass lesion filling the posterior aspect of the pituitary sella, with infiltration of the pituitary stalk . He contComputed tomography (CT) of the chest, abdomen, and pelvis showed a central tumor of the right lung (CT stage tbl4), prominent para-aortic and left hilar lymph nodes, and metastatic deposit in tbl11.His general condition deteriorated very quickly, so he was not fit for palliative chemotherapy. He was referred to the palliative care team for symptom management. He died within 1 month of his diagnosis.A 42-year-old woman with a history of stage 4 breast cancer was referred from the oncology department for management of abnormal thyroid functions. In 2011, she was diagnosed with breast cancer, for which she underwent mastectomy, received chemotherapy, and discharged on tamoxifen. However, in 2016, she had recurrence of breast cancer and further received chemotherapy. Owing to severe back pain and headache, she had radiological imaging that showed spinal metastasis, and MRI of the pituitary gland detected a metastatic lesion . She alsIn 2017, during clinic follow-up, she was taking hydrocortisone 25 mg daily, levothyroxine 75 mcg daily, and desmopressin 60 mcg once daily. She was very keen to reduce the dose and then stop hydrocortisone because she was gaining weight. Clinical examination on her first visit revealed a blood pressure of 115/76 and heart rate of 90 beats per min. She reported feeling tired at the end of the day.Her biochemistry showed the following: serum cortisol (9:00) am of < 22 nmol/L, thyroid stimulating hormone (TSH) of 0.03 mU/L, free thyroxine of 9.93 pmol/L, and spot urine osmolality of 146 mosm/kg (50–1200) normal range.A repeat MRI of the pituitary gland after 8 months showed no metastasis or mass lesion but an empty pituitary sella .Steroid replacement was optimized, and she maintained hydrocortisone 10 mg/5 mg/5 mg. She was also taking levothyroxine 150-mcg and desmopressin 60-mg tablets once daily. She is doing very well and still having denosumab injections six times weekly.A 70-year-old woman with metastatic right breast cancer  and autoimmune hypothyroidism was referred to the endocrine clinic for thirst and polyuria. She was on prednisolone 10 mg to enhance weight and well-being and letrozole. The oncologist ruled out diabetes mellitus and hypercalcemia. Clinical examination was unremarkable.Blood investigations revealed the following: normal sodium level, plasma osmolality of 296 mosm/kg, urine osmolality of 161 with low normal urine sodium, and elevated prolactin at 1051 mU/L. Cortisol was checked; however, it cannot be interpreted given her treatment with prednisolone. TSH was suppressed as she was on tbl3 replacement.The water deprivation tests confirmed the diagnosis of cranial diabetes insipidus. At baseline, her urine osmolality was 161 mosm/kg; after 4 h of water deprivation, it was 288 mosm/kg; and after subcutaneous injection of desmopressin, it further increased to 609 mosm/kg.She was started on Desmospray which immediately resolved her symptoms.MRI of the pituitary gland showed a 9-mm enhancing round lesion originating from the pituitary stalk impinging on the optic chiasm and optic tracts suggestive of metastasis .She received radiotherapy to tbl9 and the whole brain but developed sepsis during her hospital stay. She died 8 months later.A 50-year-old man presented to the hospital with a 3-week history of excessive thirst, urinary frequency, and right loin pain. He had felt generally unwell for the previous 8 weeks and had lost approximately 6 kg of weight over this time. He felt nauseous and had vomited several times. He urinated 4–5 times at night and had recorded a urine output of 3 L in 24 h at home. He had dull, right loin pain that did not radiate, was constant in nature, but exacerbated by movement. His appetite was grossly reduced. He was an ex-smoker [30 pack years].On clinical examination, he was afebrile and normotensive. His heart rate was 70 beats per minute and regular.Results on admission were as follows: plasma osmolality of 289 mosmol/kg, urine osmolality (random) of 396 mosmol/kg, and urine sodium of 23 mmol/L. He was admitted into the hospital, and during hospital stay, he underwent an endocrine profile, with results shown in His results were consistent with panhypopituitarism. He was commenced on hydrocortisone and subsequently felt much better. The nausea and vomiting stopped, and his 24-h urine output remained at 3 L.He presented again to the emergency department 4 days after discharge with worsening nausea and vomiting. He was unable to eat and could not tolerate his prescribed medications. He was given fluids, hydrocortisone, and antiemetic intravenously. Within 48 h, he felt well and was able to eat and drink normally; therefore, IV fluids were stopped. The dose of hydrocortisone was doubled for another 48 h and given orally. Levothyroxine and testosterone were also started.With further history assessment, he reported being unwell for more than a year, with excessive lethargy. He had decreased libido and was unable to maintain an erection.Examination revealed cervical lymphadenopathy that had not been present or recorded on previous examination. An in-patient MRI of the head was performed and showed “multiple ring enhancing lesions [>50], including a lesion in relation to the pituitary stalk measuring 8 mm. There was no associated mass effect or significant edema” .Chest X-ray imaging was performed and showed a left hilar mass. Urgent CT of the chest, abdomen, and pelvis was then arranged, which showed a large left upper lobe mass consistent with bronchogenic carcinoma. Lung, nodal, hepatic, and adrenal metastases were identified . Lymph node biopsy of a left cervical node was performed under ultrasound guidance. Histology confirmed a diagnosis of small cell carcinoma of the lung.He was commenced on dexamethasone (hydrocortisone was stopped) along with thyroid hormone and testosterone, but he died 2 weeks later.The five patients with pituitary metastasis presented herein are patients recalled from the clinics of each of the authors. Each patient comes from a different center; thus, the treatment approach for each case might be different.10 However, metastasis rates are as high as 27% in autopsy series that evaluated both the pituitary and surrounding sella turcica.11 Metastatic disease accounts for approximately 1% of all transphenoidal surgeries.12Pituitary metastases are a relatively rare clinical condition. They occur in 1%–3.6% of patients with advanced cancer at autopsy.3 Teears and Sliverman reported that two-thirds of the lesions localized to the posterior pituitary, 13% to the anterior pituitary, and 12% to both lobes,13 and the remaining to the capsule or stalk.14Metastases are commonly caused by tumors in the posterior lobe of the pituitary, which is affected approximately twice as often as the anterior lobe.15The mechanism of pituitary metastases is considered hematogenous, and the incidence of metastases is dominant in neurohypophysis in comparison with adenohypophysis. The most likely reason is that the posterior lobe receives blood directly from the systemic circulation, whereas the anterior part receives blood indirectly from the hypophysial portal system.4 followed by prostate, renal, gastrointestinal, hematological, and thyroid malignancies. Our case series included two patients with breast cancer and three patients with lung cancer. Occasionally, no primary tumor can be identified.16 In some patients, symptoms due to pituitary metastases may be the first presenting feature of cancer.17 Actually, two of the patients presented with diabetes insipidus that led to pituitary metastasis diagnosis and then identification of the primary tumor.Pituitary metastases appear to occur more frequently with certain types of tumors, such as breast and lung cancers that account for 50% and 20% of the cases, respectively,14 Higher prevalence rate of headache, diabetes insipidus, visual field defect, and cranial nerve palsy as presenting symptoms is reported in patients with a large metastatic sellar mass.8 In most case series, diabetes insipidus is reported as the most common symptom; its presence should cause a high clinical suspension to rule out metastatic sellar lesions.18 Treatment of anterior pituitary deficiency may unmask underlying diabetes Insipidus.14 Thyroid and adrenal deficiencies were the most common anterior pituitary manifestations of metastatic sellar lesions.19Symptoms such as tiredness, fatigue, headache, weight loss, and vomiting, which are very common in advanced primary metastatic neoplasm, will mask anterior pituitary deficiency states.20 In our case series, four of five patients presented with diabetes insipidus and one patient had hypopituitarism.Pituitary metastasis presenting with hormonal hyperfunction, i.e., acromegaly and Cushing's syndrome, is very rare.21 Radiological evaluation of pituitary metastasis by CT or MRI showed that majority of the lesions are sellar or suprasellar enhancing mass in approximately 50% of the cases, followed by stalk enhancing or thickening lesions in 30%, and loss of high intensity signal in posterior lobe in approximately 15%.20The challenge lies in distinguishing a pituitary adenoma from a metastatic pituitary mass; this is important to avoid unnecessary therapeutic intervention. The presence of abducens nerve palsy, rapidity of clinical presentation, and diabetes insipidus, and a history of underlying primary neoplasm will point toward a metastatic pituitary lesion.Metastatic pituitary has poor prognosis and will depend on the nature of primary neoplasia and its response to treatment. Endocrinologists should promptly recognize the hormone deficiency state and provide adequate hormone replacement therapy. A multidisciplinary approach is necessary in the management of metastatic pituitary lesions, involving an endocrinologist, oncologist, and neurosurgeon.11 However, early detection and appropriate treatment may improve the quality of life and even the prognosis.The vast majority of pituitary metastases remain undiagnosed, found incidentally or at autopsy, and are asymptomatic because the patients usually die from the complications of the primary disseminated cancer.Our case series confirmed earlier reports that diabetes insipidus is the most common presentation of metastases to the pituitary gland. Herein, four of our five patients presented with such syndrome. Recent reports have shown that metastases may have a diverse source, including renal cell, follicular thyroid, and hepatocellular cancers, but lung and breast cancer are the leading ones.No fundingNone declared.None declared.The abstract was presented as a poster in the Endocrine Society Meeting 2019.


Hydroxyapatite deposition disease (HADD) is a mostly uniarticular, self-limiting condition caused by deposition of hydroxyapatite (HA) crystals in tendons or in the peritendinous soft tissues. Commonly, the glenohumeral joint is affected. More rarely, the HA depot can be cause of a carpal tunnel syndrome due to an acute inflammatory reaction and space-occupying soft tissue oedema. We report a case of acute HA depot located at the volar site of the right wrist with affection of the deep flexor tendons and intraosseous migration into the lunate bone in a 50-year-old female. There are two main goals of this case report: First, to remind the diagnosis of HADD as a cause of wrist pain and also of carpal tunnel syndrome, as this entity being often misdiagnosed clinically, and second, to report a rare case of intraosseous migration of HA crystals into the lunate bone. HADD is a cell-mediated inflammatory condition and characterized by periarticular depots of HA crystals within or around a tendon . The patBy far, the most common manifestation of acute HADD is the glenohumeral joint, with HA depots in or around the supraspinatus tendon in about two-thirds of cases , 5. In tWhile there are several previous case reports presenting HADD as a cause of carpal tunnel syndrome , 13, 14,A 50-year-old female presented with a 4-month history of right wrist pain. The patient denied any history of fever, trauma or previous surgery. Physical examination showed slight swelling and warmth, while skin appearance was normal. Range of passive and active motion was painful, but not restricted. However, palpation of the wrist revealed a local pressure pain above the lunate bone. In addition, she presented mild symptoms of carpal tunnel syndrome like slight tingling and numbness, but no weakness. Bottle sign was positive. Plain radiographs revealed a solitary, oval-shaped, amorphous calcification within the volar soft tissues adjacent to the proximal carpal row Fig. . The lunFor further evaluation, CT was performed to better locate the HA calcifications within the carpal tunnel and to assess bony changes of the lunate Fig. . CT scanSecond, there was a small, smooth-edged, very dense calcification depot located at the ulnar site of the lunate bone, which was consistent with a HA depot in the calcific stage Fig. . The lunAdditionally, MRI was performed Fig.  visualizBased on clinical and radiological findings, the diagnosis of HADD-associated carpal tunnel syndrome was made and treatment with non-steroidal, anti-inflammatory drugs (NSAID) was started. The patient’s symptoms decreased within 2 weeks. Surgical release of the retinaculum flexorum was therefore not necessary.To our best knowledge, this is the first report describing a case of HADD-associated carpal tunnel syndrome with intraosseous invasion of HA depots at the wrist. Carpal tunnel syndrome is either caused by a volume increase of its content or by a decrease of the tunnel volume itself . In rareIn the majority of cases, the diagnosis of HADD is made by physical examination as well as by radiographs, which demonstrate the more or less dense calcifications at the site of involvement . HADD usAs HADD in the acute inflammatory phase goes along with soft tissue inflammation and oedema, it might be misdiagnosed, e.g. as cellulitis, infectious arthritis or gout . In addiIn our case, we did not perform a biopsy procedure with crystal analysis for the following reasons. First, the patient did neither have elevated leukocytes or uric acid levels, nor did she have a history of gout. Second, all imaging features were HADD-typical and other crystal-associated arthropathies could be excluded by means of imaging due to different morphology of calcifications. Unlike with CPPD, a HA depot usually presents as solitary calcification spot with an amorphous structure and is found in the course of tendons, but not in cartilage tissues. HA depots are thus in contrast to the linear, granular or crumbly CPPD depots . Third, This report describes a rare case of HADD of the deep flexor tendons in the carpal tunnel and intraosseous HA migration into the lunate bone with intense bone marrow oedema. From our point of view, the HA crystals have migrated into the lunate via a small cortical erosion located at the anterior horn of the lunate 3 mm radial to the nutritial canal at the level of the radiolunate ligaments. Most likely, the long radiolunate ligament is the anatomical structure along which the HA crystals migrated, as this ligament originates at the palmar side of the scaphoid fossa at the distal radius, runs to the anterior horn of the lunate, where it has an attachment, and then continues to the triquetrum. The short radiolunate ligament is much less likely to be assumed in our case, as its attachment site at the anterior horn of the lunate is located more proximal .In a previous study, inflammatory response with focal hypervascularity at the site of tendinous involvement was discussed being responsible for local bone resorption at the osseous junctions with consecutive intraosseous migration of HA crystals in different manifestations . AccordiOral NSAIDs are usually the first-line treatment to alleviate pain and shorten the acute inflammatory phase. Other therapeutic options include oral corticosteroids or ultrasound-guided calcific lavage, in cases of calcifications over 1 cm . The ima


Case Report. Here, we report a 10-month-old infant presented with a right thigh mass with an otherwise benign physical exam and medical history. MRI of the lower extremities suggested tumoral infiltration in the soft tissue of both thighs, predominantly on the right side. Surgical pathology of the lesion confirmed neuroblastoma. A large subhepatic mass and paraaortic lymphadenopathy in the abdominal CT scan and metaiodobenzylguanidine scan findings favored primary abdominal neuroblastoma that had spread to lower extremities. The patient has been in remission since the completion of chemotherapy.  Neuroblastoma is a solid tumor that occurs more frequently in pediatric populations. It may originate from any part of the sympathetic nervous system, but it most commonly arises from the paraspinal sympathetic ganglia in the abdomen or mediastinum. Local lymphadenopathy and distant metastasis to the central nervous system, orbit, and liver might be detected; however, it rarely includes soft tissue or musculoskeletal involvement.  Neuroblastoma should be considered in infants with an abnormal mass in extremities. Due to its aggressive nature, most patients struggle with distant and local tumor spread at diagnosis. Therefore, any abnormal signs and symptoms, especially in younger pediatrics, warrant immediate evaluation to avoid tumor expansion. Neuroblastoma originates from neural crest cells of the sympathetic nervous system. More specifically, it develops from the paraspinal sympathetic ganglia in the abdomen or mediastinum. Neural crest cells migrate to form the adrenal medulla and paraspinal mediastinal or abdominal sympathetic ganglia . As the Like other malignancies, staging and risk stratification are essential to design an appropriate treatment plan , 11. As In December 2019, a 10-month-old infant with no significant medical history presented with a mass in the anterior aspect of the right thigh found by his parents three months prior. No other symptoms were reported. Magnetic resonance imaging (MRI) of both thighs without contrast with axial, sagittal, coronal T1W, PD, and PDFS sequences showed several fusiform intramuscular and intermuscular lesions up to 15 × 14 mm in size at both thighs, more prominent on the right side, suggestive of neurofibroma. The bone and bone marrow each appeared normal and devoid of any lytic or sclerotic lesion Figures . One weeDuring a follow-up appointment, a right upper quadrant abdominal mass was noted. Abdominopelvic ultrasound displayed an ill-defined hypoechoic lesion measuring 115 × 68 × 67 mm with calcification and vascularity. It was located between the liver and the right kidney and seemed to cross the midline, highly suggestive of malignancy. Subsequently, an abdominopelvic CT scan with contrast demonstrated a large heterogeneous mass in 74 × 70 mm in the subhepatic area with paraaortic and pelvic calcification centers suggesting lymphadenopathy Figures .To identify any undetected neoplastic lesion, the patient underwent Metaiodobenzylguanidine (MIBG) scan, which showed the increased uptake of the primary soft tissue mass in the subhepatic region. In contrast to MRI findings, it revealed metastasis to the superior part of the right femur and its adjacent soft tissue. Our patient was classified as intermediate-risk despite having distant metastases because the fluorescence in situ hybridization (FISH) test was negative for MYCN gene amplification. The abdominal tumor was managed without surgical removal, and the patient only received VAC chemotherapy regimen . After two years, he has been doing well and has not shown any signs of tumor relapse.As a high-grade solid malignancy, the clinical presentation of neuroblastoma depends on the location of the primary and metastatic lesions . This neIn histopathological assessments, primary or metastatic lesions appear as small round blue cells that require IHC staining to confirm the diagnosis. Homer Wright pseudorosettes, an eosinophilic neuritic process (neuropil) of neuroblasts, might be seen in some cases . IHC staThe primary tumor and metastatic lesions of neuroblastoma may present as specific signs and symptoms that can be mistaken for another malignancy. In patients with an abdominal mass, Wilms tumor, hepatoblastoma, and rhabdomyosarcoma must be ruled out . The mosBone metastasis in neuroblastoma should be distinguished from primary bone tumors including Ewing sarcoma, osteosarcoma, and chondrosarcoma through imaging features. Ewing sarcoma, a neuroectodermal derivative consisting of poorly differentiated small round or spindle cells, is seen in adults and children older than five. It often arises from the pelvic area, chest wall, and tissues surrounding the spinal cord and bones of the extremities. Systemic symptoms, including fever, weight loss, and elevated erythrocyte sedimentation rate (ESR), are likely in both malignancies . DespiteFactors that impact the prognosis and outcome of neuroblastoma, including histopathologic differentiation, tumor stage, age, and MYCN mutation status, categorize patients into low, intermediate, and high-risk groups . DespiteNeuroblastoma often originates from the abdominal organs and rarely spreads to musculoskeletal tissues. Any abnormal mass in a child, significantly less than two years old, warrants thorough clinical and paraclinical evaluations, and the differential should include neuroblastoma.


Background: Glioblastoma is the most frequent and aggressive malignant brain tumor among adults. Unfortunately, its symptoms can vary considerably depending on the size, location and the anatomic structures of the involved brain. Case report: A 58-year-old male amateur cyclist who suffered from sharp arm pain was examined for a thoracic outlet syndrome due to a previous clavicle fracture. Because of ambiguous results of the neck and nerve plexus imaging, he was referred to a neurosurgeon who properly suspected a brain tumor. The neuroimaging of the brain shown a 3 cm disploriferative mass with a blood enhancement within the left parietal lobe. The mass was urgently removed, and its histologic analysis stated a grade 4 glioblastoma. Conclusion: This case report highlights the differential diagnosis process and the teamwork approach needed to diagnose a rare presentation of a brain glioblastoma, which started its symptoms mimicking a thoracic outlet syndrome caused by a previous bone fracture. Shoulder pain is one of the most prevalent complaints seen both in outpatient clinics and emergency departments ,2. UnforA 58-year-old male amateur cyclist, manager in a company consulting firm, presented to outpatient physiotherapy clinic complaining of a tingling, numbness and burning pain wrapping all the right upper limb, from the hand to the supraclavicular region  of the right side that were managed conservatively, as suggested by his orthopedic surgeon. Moreover, he denied any unexplained weight loss, history of malignancy, smoking and drinking habits, sleep disturbances or constitutional symptoms. After careful history-taking, a thorough MSK evaluation of neck, shoulder and scapular movements was performed. The diagnostic criteria of specific  and non-As stated by Povlsen et al. ,20, the The MRI reported a straightening of the cervical lordosis, widespread spondyloarthrosis of the cervical zygapophyseal joint, wide bulging disks at C5-C6 and C6-C7 level and signal hyperintensity on the right primary brachial plexus trunks, for the detailed imaging, see However, the episodes of quick and burning pain became more frequent, even during light normal activities, such as washing the dishes, and further worsened  during the physical therapy program. For this reason, after the MRI and EMG examination, the PT, in accordance with the GP, referred the patient to his orthopedic surgeon for a detailed evaluation of the clavicle movements as a possible cause of the neural symptoms. The orthopedic surgeon stated that the clavicle was likely not the cause of the worsening of the symptoms, while the latter was probably related to the cervical spine bulging disks of C5-C6 and C6-C7 levels. Moreover, the day after the orthopedic examination the patient experienced a tonic-clonic seizure over his forearm and IV/V° finger muscles, under PT’s supervision. The seizure started while the patient was performing a Serratus Punch exercise  for scapTwo days after, during the neurosurgeon assessment, the patient also reported experiencing a 30 s epileptic tonic-clonic seizure episode, which occurred the evening before, while he was watching TV, which was recorded using the phone by the patient itself  and losAt the second postoperative month, the patient has completed the first cycle of chemotherapy and radiotherapy without major side-effects and restored the physiological gait pattern and balance control, while the loss of sensitivity in the right lower limb and hand was still present.To the best of the authors’ knowledge, this is the first case report that highlights the differential diagnosis process of a brain glioblastoma in which symptoms were mimicking the symptoms of a neurogenic TOS. As clearly reported in the scientific literature, the diagnosis of TOS is challenging ,20, becaIn this regard, to improve the clinical reasoning in the case of differential diagnosis, more attention should be paid to the differentiation between peripheral and central neurological symptoms. In the present case, notwithstanding the careful patient history-taking, and even though both the PT and GP performed a thorough examination of the neck and upper limb movements  and a coGlioblastoma is a deeply aggressive and infiltrative malignant tumor that has the characteristics of a unique site of origin, the brain . FurtherIt is noteworthy, glioblastoma shows wide variability in its presentation, location, and patient demographics, overlapping in many ways with a wide variety of neoplastic or non-neoplastic lesions . This ovIn contrast, these other entities should not be mistaken for a glioblastoma, treatment of which in most patients, as well as in the present case, starts with neurosurgery, either resection or biopsy, which are fundamental both for histological diagnosis and to reduce the tumor mass . Due to For this reason, it is essential for healthcare professionals to be aware of the clinical meaning of particular and atypical clinical manifestations ,56,57,58Unfortunately, the substantial absence of clear reference standards related to the diagnosis of TOS make this case report an attention-grabbing paper toward the need of a thorough differential diagnosis process in those patients with suspicious and doubtful symptoms, rather than a detailed description of how to manage properly patients with TOS symptoms.Differential diagnosis is a key element of any healthcare professionals’ clinical reasoning, especially if the supposed disease is challenging to diagnose, as with TOS. In fact, framing each sign and symptom in the case of TOS is difficult given that the diagnosis often requires several professionals. Therefore, applying a teamwork diagnostic process, PTs, GPs and medical specialists are able to carry out a comprehensive clinical evaluation of different MSK affections and to screen doubtful conditions that could require an appropriate pathway of care.


BackgroundThe common benign surgical lesions of skin and subcutaneous tissues like lipoma and sebaceous cysts are diagnosed clinically and treated by surgical excision under local anesthesia. The occurrence of malignancy in these lesions is extremely low, and routine histopathological examination (HPE) adds to increased costs and workload on pathologists. This study was undertaken to estimate the clinical concordance and the frequency of malignancy in these lesions.MethodsA total of 1,815 HPE reports of clinically benign skin and subcutaneous lesions excised under local anesthesia from January 2014 to December 2018 were studied.ResultsLipoma (31.3%) and sebaceous cyst (29.9%) were the common clinical diagnosis in our study. The clinical accuracy in the diagnosis of lipoma was 88.6%, and for sebaceous cyst, it was 72.7%. There were six reports of malignancy in our study from the clinically diagnosed benign skin and subcutaneous lesions (0.33%). None of the cases of lipoma and the sebaceous cyst had a malignancy in the final histopathology report. The frequency of malignancy in the rest of the lesions is 0.85% (six out of 699 cases); .DiscussionIn the absence of red flag signs, lesions like lipoma, sebaceous cyst, corn, and callus can be discarded without an HPE. We advocate routine HPE of other solid lesions, cystic lesions with solid areas, and pigmented or ulcerated lesions, as the clinical concordance is low and there is a significant occurrence of malignancy in these lesions. Lesions like lipoma, sebaceous cysts, and dermoid cysts are commonly occurring benign lesions of skin and subcutaneous tissues. These lesions are often diagnosed based on clinical examination findings. The treatment of these benign conditions is surgical excision done under local anesthesia. After complete excision, the specimens are routinely sent for histopathological examination (HPE) to confirm whether it is a benign or malignant lesion. However, the rate of malignancy in these lesions is extremely low. The incidence of malignancy in some conditions like callus and corns is virtually nil.Moreover, in our experience, a few patients do not follow up after surgical excision of these lesions, and the HPE reports are not studied by the surgeons subsequently. The “send all the excised” practice is historic surgical teaching where surgeons were encouraged to routinely send all excised specimens for histological examination, irrespective of clinical certainty for definitive documentation, and thus avoid potential medico-legal action . There aThough some surgeons send every specimen for histopathological review, others advise sending specimens for HPE only if an unusual finding was encountered . The rolTherefore, this retrospective study was done to study the concordance between clinical diagnosis and histopathology report to address this controversial topic and estimate the malignancy frequency reported in clinically diagnosed benign skin and subcutaneous lesions.This is a retrospective descriptive study conducted in the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry. Institute ethics clearance was obtained (JIP/IEC/2019/0107). All patients diagnosed with benign skin and subcutaneous lesions treated by excision under local anesthesia in the minor operation theatre from January 2014 to December 2018 were included. The lesions were diagnosed as benign by their indolent nature, without fixation to surrounding structures, and with a smaller size that can be safely excised under local anesthesia as a daycare procedure. Patients who presented with skin lesions that were excised as a part of a diagnostic evaluation, like lymph node swellings and breast lumps, were excluded.We retrieved the details, such as the clinical diagnosis of benign skin and subcutaneous lesions, from the minor operation theatre register. The hospital information system (HIS) portal of our institute was used to access the HPE reports of all these cases. All the pertinent information was entered in Microsoft Excel. The hospital case sheets of those cases that were reported as malignant were collected from our institute's medical records department for a detailed study of the clinical picture.Statistical analysis was performed using STATA/MP 14.0. The distribution of continuous data was expressed in mean and standard deviation. The distribution of categorical data was expressed in frequencies and percentages. The comparison of the percentage of malignancy between categorical variables was carried out using Fischer exact test. All statistical analyses were carried out at a 5% significance level, and p-value <0.05 was considered significant.A total of 3,800 clinically diagnosed benign skin and subcutaneous lesions were excised under local anesthesia in the Surgery Minor OT in the study period, January 2014-December 2018. Out of these, 1815 lesions were sent for histopathological examination; therefore, only 1815 were included in the study. The mean age of the study group is 40±14 years. In our study, 1020 (56.2%) were male patients. Table The most common lesion sent for histopathology in the study period was lipoma in 568 (31.3%) cases, followed by the sebaceous cyst and dermoid cyst in 542 (29.86%) and 269 (14.83%) cases, respectively. Other common clinically diagnosed lesions are ganglion in 98 (5.4%) cases, papilloma in78 (4.3%) cases, corn in51 (2.8%) cases, and neurofibroma in 38 (2%) cases. Less commonly lesions sent for histopathological examination include fibroma, corn, callus, granuloma, angiokeratoma, keloid, and calcinosis cutis. A total of six malignancies were reported in our study, with an incidence of 0.33% in clinically diagnosed benign skin and subcutaneous lesions. There are no reports of malignancies reported in cases with the clinical diagnosis of lipoma and sebaceous cyst. Excluding lipoma and sebaceous cyst, the frequency of malignancy in the rest of the lesions is 0.85% . The clinically diagnosed benign lesions that turned out to be malignant on HPE are listed in Table The frequency of malignancy in the final histopathology report compared to the clinical diagnosis is presented in Table The concordance between the clinical diagnosis and histopathology report among the common lesions is the highest for lipoma with a concordance of 88.6% and the least for dermoid cyst at 16% clinical concordance. The clinical concordances of the lesions are shown in Figures Various studies have shown that about 25%-40% of all laboratory tests are unnecessary and are done mainly for completion of diagnosis, meeting the patients' expectations, and fear of medico-legal consequences . The cosThis was a retrospective study of 1,815 histopathological reports of clinically diagnosed benign skin and subcutaneous lesions that were excised under local anesthesia. The common lesions examined in this study include lipoma, sebaceous cysts, dermoid cysts, and ganglion. Lipoma and sebaceous cysts are the common benign skin and subcutaneous lesions excised under local anesthesia in various studies .The clinical diagnosis was concordant with the final histopathological report in 88.6% of cases of lipoma. For sebaceous cyst, the concordance was 72.7%, which was less compared to the clinical accuracy of 81.9% by the assessing surgeons in the study by Apollos et al. . In thisThree malignancies were reported from clinically diagnosed dermoid cysts (1.12%) and one malignancy each from ganglion (1.02%), neurofibroma (2.63%), and pyogenic granuloma (2.78%). The malignancies identified in our study are mucoepidermoid carcinoma, soft tissue sarcoma, and malignant trichilemmal cyst, all three diagnosed clinically as a dermoid cyst; a malignant melanoma diagnosed as ganglion of the ankle, a verrucous carcinoma diagnosed clinically as pyogenic granuloma, and a synovial sarcoma with a clinical diagnosis of benign neurofibroma.For other clinically diagnosed benign lesions like papilloma, corn, callus, calcinosis cutis, and hemangioma, the histopathology did not show any malignant condition that requires further management. Histopathological diagnosis of the phaeohyphomycotic cyst was reported in 41 (2.25%) cases in our study. Dermoid cyst and ganglion were the commonly used clinical diagnosis for these fungal cysts. All the phaeohyphomycotic cysts were excised in total and did not require further treatment.The incidence of malignancy from the clinically diagnosed benign skin and subcutaneous lesions becomes significant only when lipoma and sebaceous cysts have been excluded clinically, six malignancies out of 699 lesions . Morritt et al. described red flag features like rapid growth and ulceration that raise the suspicion of malignancy in a sebaceous cyst . FurtherRoutine HPE of lesions like lipoma, sebaceous cyst, corn, and callus can be deferred if no pathognomic signs of malignancy are present both pre-operatively and intra-operatively. Based on this study, we advocate the routine use of histological examination in all other solid lesions, cystic lesions with solid areas within it, pigmented lesions, ulcerated lesions, and other lesions where there is a strong suspicion of malignancy intra-operatively. Healthcare resources are limited, especially in developing countries, and therefore must be used wisely. This approach can lessen the workload on pathologists, may indirectly facilitate faster reporting of important malignant samples, and considerable expenditure on processing these samples can be curtailed.


Pediatric-type follicular lymphoma is a disease that affects the lymph nodes of the head and neck in the adult and pediatric patient groups. Ocular involvement is exceedingly rare, especially in the pediatrics age group; therefore, keeping a high clinical suspicion is warranted.Here, we report a rare conjunctival pediatric-type follicular lymphoma in a 15-year-old boy presenting with progressive swelling over the medial aspect of the left bulbar conjunctiva for two months. On examination, the mass was firm, mobile, well encapsulated, wide-based, and had a negative transillumination. An excisional biopsy was performed, and histopathological examination and immunohistochemistry studies revealed lymphoid tissue that was positive for CD20, CD79a, BCL6, and CD10; and negative for BCL2 and MUM1. The CD21 and CD23 positivity highlighted the presence of an expanded follicular dendritic cell meshwork. The patient was diagnosed with conjunctival pediatric-type follicular lymphoma and referred to an oncology center for further examination and treatment.This lymphoma is rare, requiring high clinical suspicion, and thus, reporting the case detail is important and valuable for ophthalmologists and general pediatrics practitioners alike.  Lymphoma is one of the most prevalent adult orbital malignancies, representing 10% of all orbital tumors, and around 2% of all nodal and extra-nodal lymphomas ; this tyThis report was approved by the appropriate institutional review board (IRB), and the work was carried out in accordance with the code of ethics of the world medical association (Declaration of Helsinki).A 15-year-old otherwise healthy boy presented to the emergency department in Dhahran Eye Specialist hospital with a two-month history of progressive swelling over the medial canthus of the left eye. On examination, a pink conjunctival mass over the medial aspect of the left eye was seen. The mass was firm, well encapsulated, mobile, wide-based, and had negative transillumination Figure . The rigAnterior segment optical coherence tomography (OCT) was performed and revealed no retinal extension. An excisional biopsy of the lesion in the left eye was performed, and histopathological examination revealed lymphoid tissue with expanded and irregular serpiginous follicles, minimal mantle cell zone, and reduced interfollicular space. The germinal centers were predominantly composed of blastoid cells with numerous mitotic figures and multiple tingible body macrophages, giving the germinal centers a "starry sky" appearance. The blastoid cells were intermediate in size and had nuclear pleomorphism and multiple nucleoli. A few centrocytes and plasma cells were also present within the germinal centers. Reactive follicles were present at the periphery of the specimen Figure .Immunohistochemistry (IHC) examination was positive for CD20, CD79a, BCL6, and CD10 Figure , and negConjunctival pediatric-type follicular lymphoma is a rare entity. Only seven cases have been reported in the literature summarized in Table It is important to consider benign reactive lymphoid hyperplasia in the differential diagnosis. Microscopic examination of reactive lymphoid hyperplasia lesions reveals large interfollicular zones of various sizes and shapes, while in pediatric-type follicular lymphoma, the follicles are similar in configuration and arranged close to each other ,12.Histopathological evaluation and IHC studies are essential to diagnose lymphoma. IHC markers were positive for CD20 in all eight cases, for CD10 in seven of eight cases, and for BCL6 in six of eight cases; however, almost all the cases were negative for BCL2, which is predominantly seen in the adult population -11. All A case of follicular lymphoma in a pediatric patient is documented in this report. Follicular lymphoma of the conjunctiva and sub conjunctiva in the pediatrics age group is rare and could be easily mistaken for a more common entity such as reactive lymphoid hyperplasia. High suspicion of such tumors in children is warranted to provide necessary early treatment. Failing to do so will have a detrimental effect on the morbidity and mortality of the child. Especially given the improved life expectancy when prompt treatment is provided, as evident by this case where treatment was provided at the time of diagnosis leading to preventing recurrence at one year. Immunohistochemistry has an important role to play in the differential diagnosis of the disease, and unique characteristics can be identified, thus aiding in the diagnosis and assessment in selecting the proper treatment regimen for the patient.


A 77‐year‐old man presented with a spinal cord tumor at the cervical 7/thoracic 1 level and pain and weakness in the right hand. Blood tests revealed anemia, renal dysfunction, and hyperproteinemia. Immunoelectrophoresis revealed the M‐protein component of immunoglobulin G gamma globulin. Bone marrow aspirate contained an increased number of atypical plasma cells. He was diagnosed with symptomatic myeloma and treated with radiation therapy, chemotherapy, and extradural tumor resection. Upper gastrointestinal endoscopy, performed because of anemia progression, revealed a 5‐mm submucosal tumor‐like elevated lesion in the upper thoracic esophagus. On white light observation, the lesion appeared whitish with a central redness. Our patient was diagnosed with extramedullary multiple myeloma. Extramedullary lesions are rare in the gastrointestinal tract. To our knowledge, this case is the first of multiple myeloma with esophageal involvement. Multiple myeloma is a disease in which neoplastic plasma cells proliferate mainly in the bone marrow and produce M‐protein, resulting in hematopoietic disorders, renal disorders, and osteolytic lesions. Approximately 13% of patients with multiple myeloma have extramedullary lesions at the time of diagnosis or during follow‐up,A 77‐year‐old man presented to our hospital with a spinal cord tumor and spinous process destruction at the cervical (C) 7/thoracic (T) 1 level. He had a more than 10‐year history of cervical spondylosis with ongoing treatment at an orthopedic clinic. He recently visited another hospital because of right‐hand pain and weakness. On presentation, blood tests indicated multiple myeloma, and he was admitted to the Department of Hematology at our hospital.Laboratory findings on admission revealed anemia, renal dysfunction, and hyperproteinemia Table . ImmunoeSymptomatic myeloma was diagnosed according to the International Myeloma Working Group diagnostic criteria.Radiation at C7/T8 at 30 Gy for 10 sessions was performed from Day 3 to Day 17 to improve neurologic symptoms. Treatment with bortezomib, melphalan, and prednisolone was also started on Day 7. Initially, the treatment course progressed without adverse effects; however, low back pain and nausea developed by Day 34, and neuropathy due to bortezomib was suspected. To reduce the dose of bortezomib as a key treatment drug, we changed the therapy to bortezomib plus dexamethasone starting on Day 43. The melphalan was discontinued because it is not included in this regimen.On Day 68 day, lower limb weakness developed, and thoracic spine magnetic resonance imaging showed spinal cord compression due to an epidural tumor at the T10–11 level, for which the patient underwent laminectomy and partial tumor resection. Pathologic findings revealed that the tumor was a plasmacytoma. Radiation therapy  1 at 30 Gy for 10 sessions) was performed again on Days 84–98 to relieve the pain caused by the mass.On Day 103, therapy with Revlimid plus dexamethasone was started. Anemia gradually progressed, and the hemoglobin concentration decreased to 6 g/dl.On Day 114, upper GI endoscopy revealed a 5‐mm submucosal tumor‐like elevated lesion in the upper thoracic esophagus. On white light observation, the lesion appeared whitish with a central redness Figure . On iodiIt is necessary to distinguish between primary and extramedullary lesions of multiple myeloma in plasmacytoma in the GI tract; however, it has been reported that extramedullary lesions often occur in stage‐3 cancer.After this diagnosis, on Day 121, the second course of Revlimid plus dexamethasone therapy was started. The right‐back pain appeared, and computed tomography showed a mass around the kidney and lymphadenopathy at the bifurcation of the trachea. Chemotherapy was ineffective, and re‐irradiation (T5–11 at 30 Gy for 10 sessions) was performed, but no sufficient effect was obtained. A blood test showed an increase in lactate dehydrogenase and plasma cells in the peripheral blood. The patient's general condition gradually deteriorated, and he died about 5 months after the diagnosis.Myeloma is a disease in which plasma cells, which are the final differentiation stage of B lymphoid cells, show neoplastic proliferation. The disease is classified into five types based on the infiltration mode: multiple myeloma, solitary myeloma, extramedullary plasmacytoma, and plasma cell leukemia. Of these types, multiple myeloma is the most common.Extramedullary lesions of multiple myeloma are reported to occur in approximately 13% of patients, 7% at diagnosis and 6% during the course of the disease,Most stomach cases were submucosal tumor‐likeIn the cases of small and large intestine lesions, abdominal pain and GI bleeding are common,In this case, esophagus involvement by multiple myeloma, submucosal tumor, and cancer was considered as differential diagnoses. However, diagnosis based on endoscopic findings alone was difficult because the typical findings of esophagus involvement by multiple myeloma were not reported. We think that endoscopic ultrasonography can be used for detailed observation. However, in this case, we performed only a biopsy because the patient's condition was poor and we were focused on investigating the source of bleeding that was causing the anemia.Several other reports have documented bleeding and perforation in the stomach and intestinal lesions, but our patient did not present with these signs.Extramedullary lesions in the esophagus are extremely rare and have not been reported to date. The mechanism for extramedullary lesions is attributed to blood and lymphatic vessels. In this case, the cervical and thoracic spine myeloma were irradiated and partially resected. It is possible that myeloma cells settled in the esophagus through the vessels due to therapeutic invasion. However, even after confirming in past reports, the relationship between extramedullary lesions of the GI tract and the myeloma site remains unclear. Regarding the formation of extramedullary lesions, fulminant multiple myelomaThe authors declare that they have no conflict of interest.None.All procedures followed have been performed in accordance with the ethical standards laid down Declaration of Helsinki and its later amendments. Since it is difficult to obtain written consent from the person regarding the presentation, the ethics committee of this hospital approved the presentation.


We report a unique case of synchronous sacrococcygeal chordoma in association with rectal invasive adenocarcinoma. Retrorectal tumors are a rare disease caused by a variety of pathologies. To our knowledge, no prior cases of such a coincidental finding of both cancers have been reported in the literature.This is the case of a 74-year-old white middle eastern man, with known hypertension under treatment, who presented with complaints of progressive lower back pain associated with urinary incontinence over the past 12 months. Magnetic resonance imaging (MRI) of the pelvis showed a large midline, well-defined, oval-shaped lesion replacing the sacrococcygeal portion of the spine, with extension to the presacral region. Computed tomography (CT)-guided Tru-Cut biopsy revealed features suggestive of chordoma. At surgery, we performed excision of the entire mass en bloc, sacrectomy with rectus abdominis myocutaneous flap reconstruction and end sigmoid colostomy. Surgical histopathology proved it to be sacral dedifferentiated chordoma and rectal invasive adenocarcinoma. Overall, the patient recovered well postoperatively, was discharged home with functional stoma and on permanent Foley catheter use.To the best of our knowledge, this is the only reported case of such a presentation, and sheds light on the approach and management. We hope that reporting such a case will add value to the medical literature.The online version contains supplementary material available at 10.1186/s13256-021-02728-2. Chordoma is a low-grade, slow-growing tumor which originates from the notochord, the basis for the axial skeleton . The incOur patient was a 74-year-old white middle eastern man, with known hypertension under treatment, who presented with complaints of back pain for the past 12 months which was progressive and localized at the lower back. The pain improved after receiving analgesia and was associated with episodes of urinary incontinence. The patient’s family history for cancers was unremarkable. He underwent investigations at a local hospital; the computed tomography (CT) scan showed a sacrococcygeal mass suggestive of chordoma. Therefore, the patient was referred to our center for further evaluation and management. He was seen in January 2020 in the outpatient orthopedic clinic at our hospital. The examination revealed localized tenderness at the coccygeal bone. Neurological tests  were all normal. Blood test results were within normal limits. A lumbar CT indicated a large midline, destructive, osseous, sacrococcygeal mass with a large presacral mass with soft tissue components and linear calcification measuring 12.5 × 10.4 × 10.6 cm  Escherichia coli; hence, the patient was treated with the appropriate intravenous antibiotic for an entire course of 14 days. In addition, upper cuts of the abdominal CT showed incidental findings of a left posterior segmental artery filling defect representative of pulmonary embolism despite the patient’s stable and asymptomatic status. Therefore, the anticoagulation team advised switching to rivaroxaban 20 mg daily. The patient was subsequently discharged home in good clinical condition, with functional stoma, all drains removed, healthy surgical wound, and on permanent Foley catheter, as his urinary incontinence did not improve. On follow-up 4 months after surgery, he remained stable, and his lab tests and investigations were unremarkable.During the postoperative period, the patient was kept on a Foley catheter and prophylactic enoxaparin 40 mg. However, abdominal drains were slightly turbid in color and the patient had mild leukocytosis of 11.0 × 10Chordoma is a rare malignant bone tumor that emerges from notochordal remnants and occurs in the axial skeleton, with a tendency for the sacrum, base of the skull and mobile spine . ChordomGrossly, sacrococcygeal chordomas are mostly well demarcated by a pseudocapsule and involve the bone and surrounding tissues. The surface of the tumor is soft, gelatinous, mucoid and hemorrhagic. Chordomas are classified as classical, chondroid and dedifferentiated types. The most common is the classical type, and in terms of prognosis, the worst is the dedifferentiated type. Histologically, it consists of chords of tumor cells and lobules with a mucoid matrix and extensive fibrous tissue in between .Chordoma is best seen on T2-weighted MRI. MRI of the entire spine should be performed to check for any metastasis. CT is recommended in addition to MRI if the diagnosis of chordoma is vague. Furthermore, CT scans of the chest, abdomen and pelvis are recommended to check for any tumor spread .Typically, such major surgery involving a large retrorectal tumor with locoregional invasion is expected to carry a risk of a wide range of neurological defects, for instance, incontinence and sexual dysfunction due to extensive sacral nerve root excision . TherefoChemotherapy was not necessary for our patient for the rectal cancer because we had negative margins, and 16 lymph nodes were negative for metastasis (T2N0M0). However, the effects of adjuvant therapies such as chemotherapy and radiation therapy for chordoma are debatable and not as effective as surgery. There have been some indications for radiotherapy mentioned in the literature, as it may be helpful in prolonging the disease-free interval. Such indications include inoperable masses, no free surgical margins or incomplete excision of the mass. Also, radiation can be used after resection of the primary tumor or if recurrence is visible on follow-up imaging , 7.Prognosis depends on the surgical resection of the tumor and postoperative treatment. However, the possibility of metastasis cannot be ruled out, and local recurrence usually has a devastating outcome. The five-year survival rate is 51%, and the 10-year survival rate is 35% .In conclusion, we experienced a unique and rare case of synchronous sacral chordoma associated with rectal adenocarcinoma. To the best of our knowledge, this is the only case of such a presentation in the medical literature. Approaching such a major case through a multidisciplinary team approach was a crucial step in its successful outcome, which was reflected in the patient’s overall recovery.Additional file 1: Surgical specimen side view. courtesy King Faisal Specialist Hospital and Research Center.Additional file 2: Surgical specimen top view. courtesy King Faisal Specialist Hospital and Research Center.


Tenosynovial giant cell tumor (TSGCT) is a slow-growing soft tissue tumor that develops from the synovial tissue of tendon sheaths, joints, or bursae. In the knee, this type of tumor is uncommon. Giant cell tumors of the cruciate ligaments' tendon sheath are far more infrequent. Only 16 localized TSGCTs of the cruciate ligaments have been recorded in the literature to our knowledge, with 9 involving the anterior cruciate ligament (ACL) and 7 involving the posterior cruciate ligament (PCL).We present a rare case of localized TSGCT arising from the PCL's femoral insertion in a 44-year-old male, as well as a literature review on localized TSGCT of cruciate ligaments in the knee. The diagnosis of tumor's presence was made using MRI while the definitive diagnosis was obtained through intraoperative evaluation and postoperative pathology.Arthroscopic tumor resection was an effective and safe treatment option based on the available data. •Giant cell tumors of the cruciate ligaments are extremely uncommon.•The most typical clinical presentations are pain and decreased range of motion of the knee without a history of trauma.•MRI helps confirm the presence of a tumor but not its original location or type.•Based on available data, arthroscopic tumor removal is an effective and safe treatment option. This type of tumor is quite uncommon in the knee . TSGCT t2A 44-year-old male patient complained of discomfort in the left knee while extending for two months. The pain began spontaneously and was vague. The patient previously underwent conservative treatment for a grade II PCL injury ten years ago. Clinical examination revealed that the range of motion of the knee was normal. Prior to the onset of the pain, the patient was able to participate in amateur basketball without incident. The patient's MRI revealed a 1.8 × 1.2 × 1.0 cm mass in the intercondylar area, located anterior to the ACL but originating from the PCL's femoral insertion. Additionally, the MRI showed an earlier PCL injury with a synovial cyst behind it .Fig. 1ThAt first, we believed that the mass was fibrous tissue caused by PCL injury. However, endoscopic examination revealed a yellowish, pinkish, and partially gleaming white tumor that was continuous with the synovial membrane at the PCL's femoral origin. The tumor became trapped between the ACL and the intercondylar notch during extension . The PCL3TSGCTs are benign, slow-growing tumors that account for approximately 1.6% of soft tissue tumors. They are most frequently seen in the hands (76% of cases), followed by the feet (12%). Only 4% of cases occur in the knee. TSGCTs occur from 4 to 80 years old but are most prevalent between the ages of 30 and 40, with a female/male ratio of around 2:1  reportedTSGCTs of the hand or foot are often asymptomatic . HoweverAccording to the literature, MRI is the primary approach for confirming the diagnosis of a tumor in the knee joint. TSGCT of the cruciate ligaments could only be definitively diagnosed based on intraoperative evaluation and postoperative pathology. Except for three cases for which data were unavailable, all the remaining cases were undetected on knee X-rays and regular laboratory tests . In all Arthroscopic tumor removal is the favorite treatment option for TSGCTs located in the cruciate ligament. According to previous reports, 13/16 patients had endoscopic tumor removal, while only three cases underwent open surgery, including two cases of PCL adjacent to the posterior capsule ,11 and o4Localized TSGCT of the cruciate ligaments of the knee are extremely uncommon and have received insufficient attention. The primary signs are pain and limited range of motion. The diagnosis of the tumor's presence is made using MRI while a definitive diagnosis is obtained through intraoperative evaluation and postoperative pathology. Based on the available data, arthroscopic tumor resection is an effective and safe treatment option.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.The procedures used in this study inhere to the tenets of the Declarations of Helsinki.We declare no funding for this study.Professor Dung Tran Trung MD, PhD.This is a case report, so I do not have to register.-NVT contributed to perform the operation-DTT contributed to revising, and approval for publishing.-NVSQ contributed to manuscript drafting.-MHN, HPT contributed to assist the operation, data collection, analysis and interpretation, manuscript drafting.We declare that we have no known competing financial interests or personal relationships with anyone that could have appeared to influence the work reported in this paper.


Congenital mature teratomas of the umbilical cord are extremely rare. We report on a girl who presented with a ruptured omphalocele and a 7 cm mass connected to the umbilicus, which we resected on the first day of life. Histology revealed mature umbilical cord teratoma . On the 29th day of life, a secondary laparotomy was necessary to address the associated intestinal malformations . After a prolonged hospital stay, we discharged the patient in age-appropriate conditions. Antenatal diagnosis of an umbilical cord tumor can be challenging in the presence of an omphalocele. Given the high prevalence of associated malformations, the finding of umbilical cord teratoma should be followed by a detailed and comprehensive neonatal workup for additional abnormalities. Teratomas can be subgrouped into extragonadal and gonadal. Two-thirds of these tumors are extragonadal and one-third is of gonadal origin.A non-smoking 34-year-old, first gravida, was referred to our hospital due to an antenatal ultrasound finding suggesting gastroschisis. The past medical history revealed osteogenesis imperfecta of the child's mother and maternal grandmother. After 36 + 6 weeks of gestation, a preterm newborn of 2,735 g (30th percentile) was delivered via C-section.At birth a ruptured omphalocele with a large cystic, solid tumor connected to the umbilicus was seen . The maDuring this procedure, the mass was carefully separated from the adherent small bowel and resected . The duOn histology, the resected mass contained skin, respiratory epithelia, muscle tissue, adipose tissue, bone and cartilage without immature elements corresponding to a mature teratoma .Upper gastrointestinal series were taken on the 29th day of life. These showed an obstruction at the level of the duodenum. During the following relaparotomy, the megaduodenum was tubularized andB. At this time, the length of the small bowel was 80 cm. Parenteral nutrition was given until 5 months of age. After 8 months, the patient was discharged from the hospital on full enteral feeds. After a follow-up of 23 months, the girl has no developmental deficits and no signs of a tumor recurrence on MRI or elevated tumor markers (AFP or β-hCG).Teratoma of the umbilical cord is extremely rare. At present, there are only 18 other cases reported.A teratoma derives from more than one germ cell layer. Most of UCTs comprise mature elements comparable to our case.UCT can reach significant sizes. The mean diameter of all described UCT is 8.8 cm.Associated malformations are frequently described as nine of the 18 other cases had multiple malformations.Like in our child, the most prevalent additional anomaly is an abdominal wall defect in 46% of cases mostly omphalocele.At the age of 2 years, our patient is thriving and developing appropriately to her age. There is neither recurrent tumor on MRI nor indicated by serologic markers. In 8 of the 18 other reported cases (44%), the outcome was favorable without developmental deficits. Conversely, eight of the newborns (44%) did not survive the first year of life. Among those were three patients of intrauterine demise,If prenatal imaging suggests an abdominal wall defect especially in a female fetus, the rare differential diagnosis of an UCT should be taken into consideration and associated malformations expected. As seen in our case, the surgical treatment may be complex.


In this report, we present the case of a rare tumor in the sphenoclival region and discuss the potential pitfalls in its diagnosis and management. Intraosseous lipoma is a rare benign tumor, mostly accounting for 0.1% of all bone tumors. The disease is usually asymptomatic and mainly involves the hips, vertebrae, ribs, and metaphysis of the long bones. However, the intraosseous lipoma of the skull is less common, especially with few cases having been reported to involve the sphenoid bone in the literature. We present a rare case of sphenoclival intraosseous lipoma in a 28-year-old female who presented with a history of chronic headache. A non-contrast computed tomography (NCCT) was ordered, which revealed a deviated nasal septum with thickening of bilateral ethmoidal sinuses with mastoiditis and a well-defined fat-containing intraosseous lesion in the clivus with a mean HU~ of -32 with few septations within. The risk of malignant transformation in intraosseous lipoma is very low. The differential diagnosis of intraosseous lipoma includes end stage of infection, infarct lesions, intraosseous meningioma, angiolipoma, and myxofibrous tumors. Intraosseous lipoma is a very rare and usually benign tumor of flat bones. However, the localization in skull bones is described in sporadic cases. Identification of fat-containing lesions as well as dystrophic calcification and cyst formation is now facilitated with the advent of computed tomography (CT) and magnetic resonance imaging (MRI) ,2. LipomA 28-year-old female presented with a history of chronic headache. A non-contrast computed tomography (NCCT) of the head was ordered due to ongoing symptoms. On NCCT, we found deviated nasal septum with convexity toward the left side with a nasal spur measuring approximately 4 mm, as well as contralateral inferior turbinate hypertrophy, mastoiditis (opacification of the right mastoid air cell was noted), ethmoidal sinusitis , and an osteolytic lesion in the clivus with a mean HU~ of -32 with few septations within Figures -3. A subIntraosseous lipoma is a rare benign tumor, accounting for approximately 0.1% of all primary bone tumors. It usually occurs in the calcaneus, inter-trochanteric, and sub-trochanteric regions of the femur, pelvis, and flat bones. Campbell et al.  concludeRecent reports revealed that sphenoid localization of intraosseous lipoma is rare . Skull lOur patient has non-specific symptoms such as headache and elevated cerebrospinal fluid (CSF) protein levels. However, the relation of these symptoms to lipoma seems to be coincidental.Intracranial intraosseous lipomas are mostly diagnosed incidentally. Treatment of intraosseous lipoma is usually conservative with observation and scanning of the lesion being recommended every six to eight months.Intracranial intraosseous lipomas are very rare bone tumors, specifically in the sphenoclival region. The differential diagnosis of intraosseous lipoma is broad and includes end stage of infection, infarct lesions, intraosseous meningioma, angiolipoma, and myxofibrous tumors. A direct diagnosis can be made using essential features such as measuring the attenuation of the lesion on CT and by fat saturation pulses on MRI. In addition to the accurate diagnosis of intraosseous lipomas, cross-sectional imaging can also be used to accurately and consistently stage these lesions.


Figure 1A). Film array respiratory panel was negative, and pulmonary aspergillosis was diagnosed after bronchoscopy. Cardiac magnetic resonance corroborated the huge left atrial appendage . No other structural or functional heart abnormalities were diagnosed.A 52-year-old female was admitted to our hospital in April 2021 with dyspnea. She was discharged from the hospital 3 weeks ago due to the diagnosis of pneumonia caused by coronavirus disease 2019 (COVID-19). Physical examination revealed an oxygen desaturation of 82%. The patient underwent computed tomography angiography (CTA) that showed a ground-glass pattern and a giant left atrial appendage (1 Patients can be asymptomatic or present with symptoms such as palpitations, chest pain, or dyspnea. A number of recent cases in the literature have highlighted the diagnostic utility of CTA.2 While there is no standard treatment for this condition, surgical resection is the most frequent therapy. Another option reported in the literature is anticoagulant treatment for select cases.3 Closure of the left atrial appendage is a more recent and emerging intervention that can be considered.A giant left atrial appendage is a rare cardiac anomaly that can be congenital or acquired. In the literature, it is called a left atrial appendage aneurysm. The dilatation can be generalized or focused. Although it can occur in all age groups, it is predominant in patients in their 30s to 50s and most common in females.In our patient, we initiated anticoagulant therapy to reduce the risk of thromboembolic events; however, we recommended left atrial appendage occlusion or surgical resection after completing the treatment for pulmonary aspergillosis. The corresponding author had a written consent of the patient to use the data for publication.


Intestinal ischemia commonly occurs after arterial thrombosis or embolism. Thrombosis of the mesenteric vein accounts for less than 10% of cases of intestinal ischemia. Superior mesenteric vein thrombosis (SMVT) in its chronic form is less culpable to produce intestinal ischemia as it forms sufficient collateral drainage. Intestinal obstruction due to mesenteric venous thrombosis is rare, and so far, only 12 cases have been reported. The majority of them had a distinct episode of acute abdominal pain due to ischemia and later developed bowel stricture and intestinal obstruction. Here we report a case of a 44-year-old male who presented with intestinal obstruction as an initial presentation of SMVT. The patient required surgical resection and anastomosis, and he was started on anticoagulation therapy. This case report reiterates the fact that persistent low-grade mesenteric venous ischemia may lead to bowel stricture formation at a later stage. Therefore, etiological workup and early anticoagulant therapy can be useful to improve recurrence. Mesenteric venous thrombosis (MVT) is an uncommon cause of intestinal ischemia. The usual presentation is abdominal pain out of proportion to abdominal signs. In its severe form, it may lead to perforation peritonitis. Rarely the persistence of ischemia may lead to bowel stricture and intestinal obstruction in a patient with superior mesenteric vein thrombosis (SMVT). Intestinal obstruction in SMVT results from persistent ischemia and presents in the later part of the clinical course . The majA 44-year-old male presented to the emergency department with worsening periumbilical pain and bilious vomiting for four days. He did not have a fever, diarrhea, or gastrointestinal bleed, and his past medical history was unremarkable. He was neither an alcoholic nor a smoker. There was no history of inherited thrombophilic disorders in any of the family members. On examination, the patient had tachycardia and tachypnea. Abdominal examination showed a distended gaseous abdomen with mild diffuse tenderness. X-ray abdomen erect revealed dilated bowel loops with multiple air-fluid levels. His blood sugar, amylase, renal, and liver function tests were normal. Contrast-enhanced CT (CECT) abdomen showed stricture in proximal jejunum with dilated edematous proximal jejunal loops and thrombosis of portomesenteric confluence with extension into the superior mesenteric vein (SMV), and that was replaced by multiple collaterals Figure . The patMesenteric artery embolism and thrombosis are common causes of bowel ischemia. In 1895, it was first reported that bowel ischemia could also result from venous thrombosis . MVT is Here we have enlisted all the reported cases of MVT with intestinal obstruction in the available English literature till this date Table . All of A high index of suspicion is required for early diagnosis and management of mesenteric vascular thrombosis. Persistent low-grade mesenteric venous ischemia may lead to bowel stricture formation. Patients who did not manifest in the acute phase may still require surgical resection later due to intestine stricture. Etiological workup and early anticoagulant therapy are crucial to avoid postoperative recurrence.