The complete absence of limbs is a rare occurrence. Though the causes are various, it is hard to elicit most of the time. They are usually diagnosed via anomaly scan but the lack of access to the same can often lead to a term presentation. It is still not uncommon to receive pregnant patients at term to the hospital or in labour as the first antenatal visit. Increasing the feasibility of the scan can help in the early diagnosis and management. Here, we report a rare combination of limb defects that we managed in a district-level hospital and highlight the difficulties in the management and referral of the patients while working in rural areas. The incidence of the complete absence of one or more limbs is 1.41 per 100,000.3 Given the rarity of the incidence of the case, we have reported a case of congenital limb deficiency that presented in a rural district hospital.The majority of congenital limb deficiencies are sporadic with no risk of recurrence while some are associated with syndromes.3 weeks of gestation as per the calculation based on the ultrasonography done in the first trimester. The mother had a total of 2 Antenatal Care (ANC) visits, skipped an anomaly scan, and had not taken folic acid. She did not recall any history of exposure to drugs or specific teratogens during pregnancy. The mother had been healthy throughout her life and was a nonsmoker and didn’t drink alcohol. She had no history of any infections during the pregnancy. There was no family history of congenital birth defects. There was no history of consanguinity. The father had three children, all born normally and living healthy from his previous marriage. The parents were counseled about the risks of breech delivery and methods of delivery. A male baby was born at 38+3 weeks of gestation by emergency lower segment cesarean section. The baby had an Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score of 6/10 and 8/10 at 1 and 5 minutes of birth. On examination, the baby had a right upper limb bud but there was no bud in the left upper limb. The 3 lateral digits were fused in the bilateral foot and club foot deformity was present on the left side (A 20-year-old primigravida presented to our centre in labour pain. Ultrasound screening revealed a fetus in breech presentation. The baby was estimated to be at 38+eft side , 2.On examination, there was tenderness in the movement of the right hip. A head and neck examination revealed no obvious abnormalities. There was equal air entry in bilateral lungs and the heart sounds were normal. The abdomen was soft and non-distended, and external genitalia showed well-formed scrotal rugae and bilaterally descended testes. The baby breast-fed normally after birth and passed urine and stool within the first 24 hours of birth.rd day of birth (A complete X-ray of the baby was done after birth and showed a complete absence of the left upper limb and the presence of a limb bud in the right. The right femur was hypoplastic and club foot deformity was present in the left foot. Apart from it, the lungs and heart of the child appeared normal. Complete blood count and renal function tests were done immediately after birth which were reported normal. The parents were counselled regarding the prognosis of the condition and for the early management of clubfoot deformity. The immediate referral was not possible for financial difficulties and the patient had to be referred only on the 3of birth .4 The combination of limb defects in isolated limb deficiencies shows individual variations. The combination we encountered, in this case, is unique and to our best knowledge, the individual combination of all these defects might be the rarest of the rare.Though limb defects are some of the most common birth defects, amelia, the complete absence of limbs is a rare congenital finding.th day of gestation.5 Various insults during the developmental period can lead to congenital malformations. A population-based case-control study from Finland showed the association between pregestational diabetes, male sex, and primiparity.6 The aetiology of limb deficiencies is difficult to identify. The asymmetry in the findings of limb defects in our case puts amniotic band syndrome as a potential cause.7 However, chromosomal abnormalities or various syndromes could also be the cause. A study in an attempt to classify the causes showed that, in more than a third of the cases, the cause was not immediately clear and it was not possible to identify even after autopsy examination.2Limb buds start developing in the ventrolateral body wall around the 26th and 22nd weeks.8 Scans in the first trimester are routinely done for dating and maternal complaints of vaginal bleedings. However, trans-abdominal and transvaginal scans may also be used to diagnose congenital limb defects even in the first trimester.9 In the context of Nepal, women in rural areas are less likely to receive proper antenatal care compared to women in urban areas.10Our case reflects the importance of antenatal ultrasound scans in the diagnosis of congenital malformations. The routine anomaly scan is best done in the second trimester between the 18The case was managed in a district-level hospital with no advanced facilities. The lack of genetic studies and neonatologists limited our study. Similarly, the lack of orthopaedic surgeon facilities in our centre limited the management of the case for which the patient was referred to a higher centre.This case highlights the importance of antenatal checkups and anomaly scans in the early diagnosis and counseling of congenital anomalies. Making antenatal checkups and anomaly scans feasible in rural areas can help identify birth defects earlier and help in the management.


A 6-year-old, female spayed Bengal cat with a bodyweight of 6.4 kg was presented with swelling of the bilateral calcaneal region and weight-bearing hindlimb lameness with a 4-month history of unsuccessful conservative therapy. On orthopedic examination, a cyst-like mass around the calcaneal tendon was palpated. Palpating the mass and flexing the tarsal joint triggered pain. Through ultrasonography and magnetic resonance imaging, an inflamed or fluid-accumulated lesion was suspected around the calcaneal tendon, but there was no evidence of calcaneal tendonitis. Swollen calcaneal bursae were removed surgically. Histopathologic examination revealed fibrosis and an edematous feature. The cat was diagnosed with bilateral chronic primary calcaneal bursitis based on history, clinical signs, and diagnostic results. Hence, subtotal bursectomy was performed. At 4 weeks postoperatively, the cat had no pain around the tarsal joints and was ambulating normally. Radiographic and ultrasonographic exams revealed no recurrence of swelling or inflammation in the calcaneal region. Thirteen-month follow-up confirmed acceptable function and no relapse of clinical signs. The inflammation of calcaneal bursa alone can be the primary cause of hindlimb lameness in cats. A cat with hindlimb lameness and swelling on the calcaneal region should be assessed with the possibility of primary calcaneal bursitis. Subtotal calcaneal bursectomy can be considered as an effective treatment for primary chronic bursitis. Synovial bursa is a small, flattened sac of synovial membrane located between the tendons, muscle, or skin at points of friction or stress. Bursa helps to reduce friction and provides freedom of movement over a short distance . BursitiIn small animals, bursitis has rarely been reported. One case of chronic olecranon bursitis in a dog has been described. Conservative therapy such as aspiration and intralesional administration of dexamethasone and hyaluronidase were tried, but there was no effect. The dog was treated with resection of the bursa, and the outcome was successful . There hHowever, primary calcaneal bursitis has not been reported in small animals. Therefore, we present the first case of bilateral chronic primary calcaneal bursitis eliciting hindlimb lameness in a cat. This case report describes the successful surgical management of primary calcaneal bursitis with subtotal bursectomy in a cat.A 6-year-old, female spayed Bengal cat weighing 6.4 kg was presented for evaluation of the swollen left calcaneal region and weight-bearing hindlimb lameness. The patient showed left hindlimb limping and had difficulty jumping or going up stairs. There was no history of trauma. A cyst-like mass and swelling around the calcaneal tendon were revealed on physical examination . ManipulMediolateral and craniocaudal radiographic images revealed increased opacity between the distal tibia and calcaneal tendon. On ultrasonography , hypoechConservative therapy was initiated; the fluid was aspirated and followed by meloxicam oral suspension  and prophylaxis antibiotics, including amoxicillin-clavulanate  and clindamycin  for 7 days. Microscopic examination of the aspirated fluid revealed low nucleated cell density (<3 cells/hpf) and most of them were mononuclear cells (90%) with a small number of neutrophils (10%). There was no sufficient amount of fluid to perform quantitative cell counts. The fluid was incubated aerobically and anaerobically for 3 days, and no organisms (fungus included) were isolated. The patient was able to ambulate without limping, and jump upstairs after the aspiration. Meloxicam was replaced by PDS  after the washout period of 7 days. Tramadol  was added as an analgesic, and both the medications were tapered for 1 month. Despite the conservative treatment, 1 month after the first visit, the same clinical conditions occurred contralaterally . Aspiration of the fluid was repeated, and the patient showed improvement of the clinical signs. However, recurrence of swelling of the bilateral calcaneal bursa occurred 2 months after the last aspiration.For further investigation, magnetic resonance imaging (MRI) was performed –H. InflaA tentative diagnosis of chronic calcaneal bursitis was made. Bilateral subtotal bursectomies were planned for removal of inflamed chronic lesions including gastrocnemius and intertendinious calcaneal bursae. After following general anesthesia, a caudomedial incision was made through the skin over the right calcaneus for approximately 4 cm. The medial retinaculum was dissected for approaching the lesions. The calcaneal tendon was surrounded by distended bursa tissue, and the gastrocnemius calcaneal bursa was especially enlarged . The burPostoperative medical management was initiated with meloxicam suspension , tramadol (2 mg/kg IV twice daily), and cefazolin (22 mg/kg IV twice daily). The patient recovered uneventfully and was discharged 9 days postoperatively with the medications. Tramadol  and gabapentin  were prescribed for 2 weeks and tapered for 2 weeks as pain management medication. Silymarin  was added as hepatic supplement. The patient's owner was educated regarding postoperative care including restricted activity for 4 weeks and rehabilitation once a week for 8 weeks.Histopathologic examination revealed that the specimens consisted of synovium with connective tissue with mild to moderate fibrosis . There wThis report described diagnosis and surgical treatment of bilateral primary calcaneal bursitis in a cat. We ruled out the known causes of calcaneal bursitis, including trauma, superficial digital flexor tendon luxation, and calcaneal tendonitis through an orthopedic exam and diagnostic imaging, including radiography, ultrasonography, and MRI –9. FurthIn human medicine, inflammatory disease of the bursa tendinis calcanea is termed retrocalcaneal bursitis. An abnormal enlargement of the bone where the Achilles tendon is inserted is called Haglund's deformity, which is known to be a predisposing factor for retrocalcaneal bursitis . HaglundThe treatment of retrocalcaneal bursitis starts with the conservative method. It includes oral anti-inflammatory medications, antibiotics, aspiration, topical lidocaine, local steroid injection and physiotherapy such as exercise and electric shock wave therapy , 13, 14.In large animals, traumatic events with or without infection have been reported as a common cause of calcaneal bursitis –11. CalcThis case report has some limitations. First, we reported only a single case. Although an excellent clinical outcome was obtained from our case without any complications, an extended long-term follow-up with large case series is needed to evaluate the benefits of subtotal bursectomy . SecondlThis case report describes for the first time the clinical features, diagnosis and therapeutic management of a chronic primary calcaneal bursitis in a cat. We propose that the subtotal bursectomy could be an effective treatment in cases unresponsive to conservative treatment. Further clinical studies are necessary to investigate the etiology and clinical outcome of calcaneal bursitis treated with subtotal bursectomy.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because this study is a case report of examination, surgery, and biopsy performed for the purpose of treatment of the patient, and no action contrary to treatment was performed. Written informed consent was obtained from the owners for the participation of their animals in this study.YJ, JJ, and HL actively involved in managing the case and writing and editing the manuscript. HL performed the surgery. JJ reviewed the article critically and revised the manuscript. YR, DK, and SJ supervised the clinical management of the case. All authors contributed to preparation and final approval of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pure androgen-secreting adrenocortical tumors (PASATs) are rare entities. Their clinical presentations include virilizing features that vary based on age and gender. The pathogenesis of this tumor is still unclear, with around 50% of such tumors being malignant. Imaging characteristics of the tumor on CT/MRI including size, heterogenicity, and contrast wash-out time are used to predict malignancy. Surgical excision is recommended for all functional adrenal tumors. In this report, we discuss a case of a 68-year-old postmenopausal female presenting with hyperandrogenism and was found to have a 7-cm, PASAT that raised suspicion for malignancy on CT scan, but was determined to be benign on surgical pathology. Adrenal incidentalomas are estimated to be present in about 2% of the population, with a peak incidence between the fifth to seventh decades of life, and adrenocortical carcinomas make up about 2% of these cases . Adrenoc2, blood pressure of 126/80 mmHg, a few coarse thickened hair on the chin, and clitoral enlargement. She did not have acne or a deepening of the voice. There were no physical examination findings suggestive of hypercholesterolemia, overt Cushing syndrome, or acromegaly.A 68-year-old postmenopausal female presented with excess facial hair around the chin for 18 months. She did not have excess hair in other areas of her body. She endorsed thinning of hair on the crown of her head. She did not report a change in her voice. She had no prior history of polycystic ovarian syndrome or long-term glucocorticoid use. At the age of 51 years, she had breast cancer managed with lumpectomy followed by radiation therapy and had no evidence of recurrence on follow-up imaging. At age 52, she had undergone a hysterectomy with bilateral oophorectomy for cervical intraepithelial neoplasia. She was not using any medications or supplements containing androgen. Her husband never used topical androgen replacement. She reported no family history of adrenal tumors or related genetic syndrome. Physical examination revealed a BMI of 22.3 kg/mLaboratory investigations revealed normal serum electrolytes, elevated testosterone, dehydroepiandrosterone sulfate (DHEA-S), and estradiol while luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were on the lower side of the postmenopausal reference range Table .Plasma metanephrines, aldosterone, renin activity, and 24-hour urine free cortisol were within the reference range. An abdominal CT scan with adrenal protocol revealed a 7.0 x 7.3 x 7.5-cm left adrenal mass with heterogeneous enhancement with small areas of central calcification. There was no wash-out, rather “wash-in” with HU increasing from 35 to 70 at eight minutes and no evidence of abdominal metastasis Figure .The adrenal mass had displaced the left kidney and pancreas without evidence of infiltration of surrounding structures. The 18F FDG PET/CT confirmed the above findings and did not reveal any abdominal metastasis.The patient underwent laparoscopic left adrenalectomy. A 7-cm well-encapsulated adrenal tumor not adherent to any structures was visualized intraoperatively. Pathology showed a pleomorphic population of cells with rare mitotic figures, areas of hemorrhage, and fibrin deposition without necrosis surrounded by a thick fibrous capsule without lymphovascular or capsular invasion favoring a benign adenoma Figure .Postoperatively, the patient reported improvement in clinical symptoms. Levels of androgens and estrogen normalized and remained so seven years after surgery. Follow-up CT abdomen did not show any evidence of recurrence seven years postoperatively.Features of hyperandrogenism in a postmenopausal female, as seen in our patient, is a diagnostic challenge and a malignant etiology is always a concern. Determining the source to be ovarian or adrenal is an important initial step. A thorough clinical history and physical examination in a postmenopausal woman are important in distinguishing the functional causes of hyperandrogenism from ovarian/adrenal tumors . An abseThe majority of the adrenal tumors are non-functional and are diagnosed incidentally on imaging. Excess hormone production is seen in about 10% of patients . Of thesDHEA-S is exclusively produced by the adrenal glands under the regulation of adrenocorticotropic hormone (ACTH). Testosterone, the most potent androgen, is produced by the adrenal cortex (25%) and ovarian stroma (25%). The remaining 50% is produced by the peripheral conversion from its precursors . Measuring elevated levels of serum testosterone or DHEA-S has a sensitivity of 100% and specificity of 50% for detecting virilizing adrenal tumors . A recenAbdominal CT with adrenal protocol is the preferred initial method of imaging for adrenal glands in adults . Szolar Steroid metabolite profiling using either 24-hour urine or serum is another method that is currently being used to evaluate adrenal tumors. A prospective test validation study showed that urine metabolite measurement had a higher positive predictive value compared to tumor size or imaging characteristics . ElevateA biopsy is not recommended in an adrenal tumor suspicious for cancer due to poor diagnostic accuracy and the risk of needle track seeding . SurgeryA malignant etiology is always a concern when postmenopausal patients present with clinical hyperandrogenism. Once biochemical hyperandrogenism is confirmed, imaging of the abdomen/pelvis leads us to either an adrenal or ovarian etiology. Large adrenal tumors with suspicious radiological features are considered malignant unless proven otherwise. It is challenging to differentiate benign PASATs from malignant ones based on imaging characteristics alone. A combination of imaging features and serum or urine steroid profile should be utilized to better characterize PASATs preoperatively, which will help guide surgical management. Our 68-year-old postmenopausal female patient presented with virilization and biochemical hyperandrogenism suggestive of a PASAT and a 7-cm adrenal mass with radiological characteristics suggestive of malignancy, which was surprisingly found to be benign on surgical pathology. This case is an exception to the general clinical rule for adrenal malignancy based on the size and radiological features.


Leiomyosarcomas (LMS) involving the inferior vena cava (IVC) is a clinically rare entity, accounting for approximately 0.5% of all adult sarcomas.ex vivo back-table resection of the retro-hepatic LMS, replacement of the retro-hepatic vena cava with a ringed Gore-Tex graft, liver re-implantation, and hepatic vein-atrial reconstruction under cardiopulmonary bypass. There were no intraoperative or post-op complications.A 67-year-old male presented to the emergency department with mild back and lower abdominal pain. During the workup, a computed tomography scan without contrast showed an area of decreased attenuation within the liver adjacent to the intrahepatic IVC. Magnetic resonance imaging confirmed the involvement of the retro-hepatic IVC; biopsy confirmed the diagnosis of LMS. Given the location of the involvement of the retro-hepatic IVC, liver explantation was deemed necessary for adequate tumor resection. The superior extension of the tumor toward the heart necessitated Cardio-Pulmonary (CPB). The patient successfully underwent a complex surgical procedure involving liver explantation with The role of vascular reconstruction of the IVC varies depending on the level and extent of the tumor, with options ranging from primary repair, ligation, or reconstruction dictated. Surgical resection with negative margins remains the treatment of choice due to the lack of efficacy of adjuvant therapies. Importantly, liver explantation offers a chance for complete surgical resection and reconstruction. Similarly, the complex nature of the tumor necessitated a pioneering approach involving direct hepato-atrial venous anastomosis.To the best of our knowledge, this is the first reported case in which the hepatic veins were anastomosed directly to the right atrium while also replacing the native vena cava with a separate graft. Case reports detailing successful tumor removal are few (in the hundreds), speaking to the condition’s rarity and the expertise required to perform a successful resection , 2. The  benefit . We descA 67-year-old male patient presented to his local emergency department for evaluation of lower abdominal pain. He was prescribed antibiotics with minimal relief. Upon return for re-evaluation, a CT scan found him to have a large retro-hepatic mass involving the IVC. An abdomen MRI then uncovered findings concerning sarcoma of the retro-hepatic IVC . A biopsThe patient was referred to our surgical oncology clinic, where he received a physical exam, which resulted in unremarkable showings; he denied any lower extremity swelling and was found without signs or symptoms of IVC compression. The consulted cardiac surgeons obtained a negative cardiac catheterization. A CT of the chest did not show metastatic disease. The clinic offered total liver explantation with back-table resection of the retro-hepatic IVC and tumor with a subsequent liver re-implantation on cardiopulmonary bypass.The surgeons performed a sternal incision, isolated the intrapericardial IVC, and then extended the incision to below the umbilicus. After liver mobilization and gallbladder removal, the common duct, cystic artery and duct were ligated and divided. Dissection of the hepatic artery followed in the operation and moved to ligation and division of the gastroduodenal artery. The portal vein was then dissected in preparation for veno-venous bypass. For explantation, the IVC was mobilized completely out of the retroperitoneum.in situ native vena reconstruction during back-table work.The patient was then placed on full cardiopulmonary bypass to excise the liver and vena cava. Each was excised from above the renal veins to below the atrium, before being taken to the back-table for tumor resection. At that point, the patient was placed on portal venous bypass, which was connected to the cardiopulmonary bypass circuit. The leiomyosarcoma was circumferentially dissected en-bloc with the IVC, leaving only the origins of the right hepatic vein and the confluence of the middle and left hepatic veins . The carAfter completing the IVC tumor resection, two separate, non-ringed 20 mm GTX grafts were utilized to reconstruct the hepatic veins before re-implantation. One graft was sewn to the origin of the right hepatic vein, and a separate graft was sewn to the confluence of the middle and left hepatic veins. These two grafts were then joined together to allow a single anastomosis directly to the right atrium anterior to the previously placed vena cava ringed GTX graft. Next, the surgeons removed the patient from the portal venous bypass. They re-anastomosed the portal vein end-to-end and perfused the liver thereafter. The patient was able to be weaned from cardiopulmonary bypass at this time.The procedure moved to hepatic artery anastomosis in another end-to-end fashion at the level of the gastroduodenal artery. Protamine was administered, and the patient was decannulated. After achieving meticulous hemostasis, the biliary anastomosis was performed end-to-end over a biliary stent. A segment of the patient’s pericardium was harvested and utilized to patch the diaphragmatic opening triangularly, preventing compression of the GTX venous grafts. Last, the surgeons placed bilateral chest tubes along with an abdominal Blake drain in the patient prior to closing the pericardium, chest, and abdomen. The transesophageal echocardiogram revealed normal biventricular function. A total of one unit of packed red blood cells and one unit of cryoprecipitate were administered throughout the procedure.The patient was extubated on the first post-operative day. His chest tubes were removed on the third post-operative day, and the intra-abdominal drain was removed on day 4. He was discharged home in stable condition on day 5. Other than intractable singultus, the hospital stay was usual. The patient’s 3-month follow-up visit was unremarkable, as well as his 3-month post-operative abdominal and chest CT scans .Leiomyosarcomas (LMS) are classified as malignant neoplasms involving mesenchymal smooth muscle cells found within the vasculature, gastrointestinal tract, and portions of the genitourinary system. LMS originating from the IVC is extremely rare, representing 0.5% of all diagnosed sarcomas  . Accordi•Segment I involves the IVC inferior to the renal veins; lesions can cause nephrotic syndrome due to compression or occlusion of the renal vein(s).•Segment II involves the IVC from the renal veins to the hepatic veins; lesions are typically asymptomatic and are the most common.•Segment III involves the IVC superior to the hepatic veins. Segment III leiomyosarcoma can present with cardiac arrhythmia and Budd-Chiari syndrome , 9. . The native vena cava between the renal veins and the atrium also required resection; this was subsequently reconstructed with a GTX graft in the heterotopic position. To reimplant the joined hepatic vein grafts into the vena, the caval graft would have required lengthy extensions to the hepatic vein grafts. To reach the vena caval grafts, the hepatic vein grafts would have to have been angled significantly posteriorly and would have been in danger of kinking with subsequent thrombosis. The atrial anastomosis was a straight shot for this anastomosis which allowed a much shorter length of hepatic vein GTX grafts and eliminated the risk of kinking/thrombosis. Intraoperative images shown in In our case, the lack of radiographically significant local invasion of the patient’s segment II tumor made the MYH11 also emerged as a potential diagnostic marker (Chemotherapy, which was previously thought to be of limited benefit in the treatment of cava leiomyosarcoma, has now been shown to have increased efficacy in the modern area of chemotherapeutics. Squires et al. performed a single-center experience evaluating neoadjuvant and adjuvant chemotherapy in patients diagnosed with cava leiomyosarcoma. They found that out of 11 patients evaluated, two were able to convert from an unresectable disease to an R1 resection with the addition of neoadjuvant tyrosine kinase inhibitor-based chemotherapy. Additionally, through proteomic analysis, c marker . Hines ec marker . The rolThe patient remains grateful for the procedure and continues to do well following surgery. Recently, he started showing radiological signs of metastatic disease following the discovery of a lung mass, but appreciates that the surgical resection and reconstruction have not only enhanced his quality of life, but have also potentially helped increase his overall survival. In his words, “The surgical team helped me enjoy a memorable Christmas with my family, that is what it’s all about!”The challenging anatomic considerations involved in treating IVC LMS have led to numerous techniques for resection and reconstruction. However, no significant difference in disease-free survival has been noted based on excision or reconstruction techniques, allowing the surgeon to tailor the treatment with considerations for disease progression, local invasion, and surgeon expertise.


Choroid plexus tumors are commonly described as intraventricular mass lesions and account for 7–10% of intracranial, primary tumors in dogs. This paper reports about an unusual case of a choroid plexus carcinoma in a 3-year-old Shetland sheepdog that presented for slowly progressive lethargy, vision impairment and cognitive deficits. On magnetic resonance imaging, a subdural fluid accumulation overlying and compressing the left parietotemporal lobe as well as multifocal changes consisting of cyst-like lesions, supposed intra-axial brain lesions and generalized meningeal changes were identified. Cerebrospinal fluid analysis showed a mononuclear pleocytosis with negative results for infectious agents. The dog was treated with prednisolone followed by burr hole craniotomy with puncture of the subdural fluid accumulation and subsequent chemotherapy that resulted in temporary improvement. The dog deteriorated again and was therefore euthanized. Post-mortem examination revealed a diffuse, highly invasive choroid plexus carcinoma that involved the entire central nervous system. In conclusion, a choroid plexus carcinoma should be considered as a possible cause of a subdural fluid accumulation even in the absence of an intraventricular mass lesion. Choroid plexus tumors are commonly described as intraventricular mass lesions and account for 7–10% of intracranial, primary tumors in dogs. A 3-year-old Shetland sheepdog was presented with a history of slowly progressive lethargy, vision impairment and cognitive deficits. On magnetic resonance imaging, a subdural fluid accumulation (SFA) overlying and compressing the left parietotemporal lobe as well as multifocal changes consisting of cyst-like lesions, supposed intra-axial brain lesions and mild, multifocal meningeal thickening and generalized contrast enhancement were identified. Cerebrospinal fluid (CSF) analysis showed a mononuclear pleocytosis with negative results for infectious agents. The dog was treated with prednisolone followed by burr hole craniotomy with puncture of the SFA, which macroscopically appeared to be CSF-like fluid. After initial improvement, the dog deteriorated despite continuation of prednisolone and cytarabine therapy and was euthanized four weeks after surgery. Histopathology was consistent with a disseminated, neuroinvasive choroid plexus carcinoma (CPC) that involved the entire neuroaxis including the meninges of the brain and spinal cord. Immunohistochemical examination showed a strong Kir7.1 and a heterogenous cytokeratin-immunoreactivity in neoplastic cells. In conclusion, a CPC should be considered as a possible cause of a SFA even in the absence of an intraventricular mass lesion. Choroid plexus tumors (CPTs) account for 7–10% of intracranial, primary tumors in dogs  and are The classification of CPTs in veterinary medicine based on the International World Health Organization histological grading of tumors of the central nervous system (CNS) for humans  subdividCPTs are one of the most important differential diagnoses for an intraventricular neoplasia in dogs and typical neuroimaging features include a strongly contrast-enhancing mass mostly within the fourth ventricle accompanied by hydrocephalus internus and periventricular edema . HoweverA 3.5-year-old, female neutered Shetland sheepdog presented with a 6-month history of slowly progressive lethargy, disorientation and vision impairment that was suspected by the owner. Physical examination was unremarkable except for a body condition score of 8/9. Ophthalmological examination confirmed that the dog was blind in the left eye (OS), but no ophthalmological cause could be identified and therefore a neurological examination was recommended. On neurological examination, the dog was mildly obtunded; ran into obstacles when blindfolding the right eye; and had a normal gait, postural reactions and spinal reflexes. Anisocoria with a mydriatic pupil OS was noted as well as an absent menace response, dazzle reflex and pupillary light reflex OS, positional horizontal nystagmus with the fast phase to the right side and discomfort on palpation of the head and cervical spine. Based on these findings, the neuroanatomical localization was multifocal central nervous system (CNS) including forebrain, left-sided vestibular and left-sided retina or optic nerve. The main differential diagnoses were inflammatory and neoplastic disease or less likely a degenerative disease or intracranial malformation.®, Dechra, Raamsdonksveer, The Netherlands) and butorphanol 0.2 mg/kg IV , the anesthesia was induced with an IV bolus of propofol  and maintained with isoflurane and oxygen mixture for magnetic resonance imaging (MRI). MRI was performed using the Aperto Lucent 0.4 T scanner  and sagittal and transvere T2-weighted (T2W), dorsal fluid-attenuated inversion recovery (FLAIR), dorsal 3-dimensional T1-weighted (3DT1W) before and after IV contrast administration ) including transverse and sagittal reconstructions, dorsal balanced steady-state gradient echo sequence (BASG) and transverse T2* images were obtained. MRI revealed a T2W hyperintense, crescent-shaped lesion within the subdural space overlying the left parietotemporal lobe and causing compression of the adjacent cerebral hemisphere with attenuation of the left lateral ventricle. The lesion was 3DT1W hypointense, incompletely suppressed on FLAIR; had no signal void on T2*; and showed a mild contrast enhancement of the adjacent dura mater, while there was no leptomeningeal pattern or contrast enhancement of the content of the subdural lesion  for tick-borne encephalitis virus were negative. Based on these further diagnostic findings, meningoencephalitis or multifocal intracranial neoplasia were suspected to be the most likely differential diagnoses. CSF analysis showed a mononuclear pleocytosis with a total cell count of 110 cells/μL (reference range 0–5) and an elevated protein of 0.83 g/L (reference < 0.3). The CSF infectious disease panel including polymerase chain reactions (PCRs) for canine distemper virus, ®, MSD Animal Health, Unterschleißheim, Germany), clindamycin 20 mg/kg IV twice daily  while awaiting CSF results and until a toxoplasma gondii or neospora caninum infection could be excluded, pantoprazole 1 mg/kg IV twice daily , buprenorphine 0.005 mg/kg IV three times daily  and with a continuous rate infusion of lactated Ringer’s solution  during the time of hospitalization. After four days the dog was discharged and PO treatment was continued consisting of prednisolone 2 mg/kg once daily , clindamycin 20 mg/kg twice daily , omeprazole 1 mg/kg once daily  for its potential to decrease CSF production [®, GeriSan, Heppenheim, Germany) and metamizole 40 mg/kg three times daily . Surgical evacuation of the compressive SFA was recommended but declined by the owner. The dog was treated with dexamethasone 0.4 mg/kg IV once daily  and methadone 0.3 mg/kg IV , anesthesia was induced with an IV bolus of propofol  and maintained with isoflurane and oxygen mixture. Cefazoline  was administered perioperatively at 20 mg/kg IV once. The dog was positioned in sternal recumbency and burr hole craniotomy was performed via a left-sided rostrotentorial approach with puncture of the SFA using a 20-gauge IV catheter, which macroscopically was consistent with CSF-like fluid. Postoperative MRI, obtaining transverse T2W and dorsal 3DT1W images including transverse and sagittal reconstructions, confirmed a resolution of the SFA  and pantoprazole 1 mg/kg IV twice daily . Prednisolone was reduced to 1 mg/kg once daily to reduce the risk of post-operative wound infection and otitis externa was topically treated using silver sulfadiazine suspension  and hypochlorous acid . The dog improved and was discharged three days after surgery with intermittent spontaneous knuckling in the right thoracic limb, improvement of head and cervical pain and persistent bilateral vision loss. Ten days after surgery, prednisolone was increased again to an immunosuppressive dose of 2 mg/kg once daily and a standard cytarabine protocol  was started with a dose of 50 mg/m2 SC every 12 h for two days. Postoperative management included continuous rate infusion of lactated Ringer’s solution, buprenorphine 0.005 mg/kg IV four times daily , and finally developed cognitive decline and non-ambulatory tetraparesis and was therefore euthanized four weeks after surgery. The dog remained stable for two weeks after surgery, then started to have generalized epileptic seizures that were treated with phenobarbital 3 mg/kg PO twice daily . There was neoplastic invasion of the sphenoid bone and the adjacent brain parenchyma at multiple sites including the cerebral cortex, cerebellum and brainstem. Neoplastic cells displayed a strong immunoreactivity against the CPT marker Kir7.1 [Subsequently, a full post-mortem examination with pathologic-anatomical inspection of a broad spectrum of different organs and tissues was performed . Necropsy confirmed the hydrocephalus internus and revealed multiple, focally extended dural hemorrhages at the level of the left parietotemporal (corresponding to the previous SFA and craniotomy-site) and olfactory lobes as well as osteolytic lesions of the sphenoid bone. On transverse sections of the unfixed brain multiple, moderately demarcated, tan-opaque tissue masses of soft consistency arising from the subarachnoid space at the level of the midbrain B, thalamr Kir7.1  (Figure r Kir7.1 ,18 and sUnusual CPTs that lack the typical MRI features of intraventricular neoplastic mass lesions rarely have been reported in dogs. In two of those cases, multifocal cyst-like lesions and meningeal changes consistent with disseminated meningeal metastasis caused by a CPC have been described as unusual MRI features ,14. MRI The most unusual finding in our case was a compressive SFA, a MRI feature that is commonly associated with subdural empyema , traumatCystic neoplasia, SFA secondary to meningitis, which has been commonly described as a complication of bacterial meningitis in infants , parasitCSF analysis in this dog provided no additional information to favor either an inflammatory or neoplastic disease, as the marked mononuclear pleocytosis and increased protein could have been also related to meningoencephalitis. The total cell count in CPTs has been described as variable, ranging from 1 to 260 cells/µL . In termMRI of the whole spine was not performed in our dog. At first presentation, the dog only demonstrated mild cervical and head pain that was explainable by the mass effect caused by the SFA or by the meningeal involvement that is known to be painful, e.g., in terms of meningitis . It therThe large extent of the disease in this dog was not identified until histopathology was performed, which revealed a diffuse, invasive CPC that involved the entire CNS including the ventricular system, the meninges of the brain and the spinal cord with infiltration of the adjacent neuroparenchyma. The extensive meningeal involvement in our dog might have been crucial for the development of the SFA in this patient. Meningeal changes caused by metastasis can impair the mechanism of CSF absorption in the same way as it is described in post-meningitis SFAs in humans, and therefore, the same pathomechanism might have caused the SFA in our dog. Impaired CSF production and absorption have also been suspected as an underlying cause in the development of cyst-like lesions in CPTs  that havPost-mortem examination was also able to identify the real origin of the midbrain and thalamic lesions noted on MRI that were believed to be intra-axial in origin due to the absence of characteristic extra-axial signs but appeared to be multifocal macroscopic mass-like tumor foci arising from the subarachnoid space. It has to be mentioned that diagnostic imaging in this dog was performed with a low-field MRI and interpretation of these lesions could have been more straightforward when using high-field MRI. Different immunohistochemical markers have been described for CPT in dogs, including cytokeratins, glial fibrillary acidic protein, vimentin, E- and N-cadherin, and β-catenin, but immunoreactivity can be inconsistent ,16. ReceTreatment guidelines for primary brain tumors in dogs including CPTs are lacking. Therapeutic options applied in veterinary medicine are often non-specific for tumor types and include palliative treatment, consisting of corticosteroids, analgetic and antiepileptic drugs, chemotherapy, irradiation and surgery . SurgeryAdjuvant treatment with radiation- or chemotherapy has been shown to improve the overall survival rate in human patients, especially if GTR cannot be achieved, e.g., due to brain infiltration or the presence of disseminated leptomeningeal metastasis ,10,36. AThe medical treatment in our dog consisted of corticosteroids, analgetic and antiepileptic drugs after seizure onset, with an adjuvant cytosine arabinoside therapy, which is routinely used for adjuvant treatment in meningoencephalitis in dogs  but alsoIn conclusion, this is the first report of a SFA that was associated with a CPC in a dog that demonstrated extensive, diffuse lesions throughout the entire CNS including disseminated meningeal involvement in the absence of an intraventricular mass lesion. The clinician should be aware of rare variants of unusual CPCs that can be associated with a SFA, cyst-like lesions, generalized meningeal changes and lack the presence of an intraventricular mass.


Soft-tissue lesions in the oral cavity, one of the most common sites for tumors and tumor-like lesions, can be challenging to diagnose and treat due to the wide spectrum from benign indolent to invasive malignant lesions. We report an abnormally large, rapidly growing hyperplastic lesion originating from the buccal mucosa in a 28-year-old male patient. Clinical examination revealed a well-circumscribed, smooth-surfaced, pinkish nodular lesion measuring 2.3 × 2 cm, which suggested the differential diagnosis of irritation fibroma, pyogenic granuloma, oral lipoma, and other benign or malignant neoplasms such as hemangioma, non-Hodgkin’s lymphoma, or metastases to the oral cavity. Dental MRI using a 15-channel mandibular coil was performed to improve perioperative radiological and surgical management, avoiding adverse intraoperative events and misdiagnosis of vascular malformations, especially hemangiomas. Black bone MRI protocols such as STIR (short-tau inversion recovery) and DESS (double-echo steady-state) were used for high-resolution radiation-free imaging. Radiologic findings supported the suspected diagnosis of an irritation fibroma and ruled out any further head and neck lesions, therefore complete surgical resection was performed. Histology confirmed the tentative diagnosis. This article evaluates the use of this novel technique for MR diagnosis in the perioperative management of soft-tissue tumors in oral and maxillofacial surgery. The oral cavity is considered one of the most common sites for tumors and tumor-like lesions, which may be odontogenic or nonodontogenic in origin. These oral mucosa disorders can be difficult to diagnose and treat, as they include a broad spectrum from benign indolent to invasive malignant lesions of various etiologies. Many of these oral soft-tissue lesions tend to become chronic and affect the patient’s quality of life ,2,3.Oral fibromas, benign lesions originating from connective tissue, are the most common tumors of the oral cavity . In dailRecent developments in dentomaxillofacial imaging and state-of-the-art computer technologies reveal that the basis for oral and maxillofacial radiological assessment and preoperative surgical planning is constantly evolving. Thus, cross-sectional imaging is considered an advanced and indispensable support tool in modern medical diagnostics that complements the clinical examination . While cMRI has evolved rapidly over the past decades with various technical novelties and advanced imaging protocols, providing a broad spectrum of new diagnostic capabilities for the dental field . Dental This article reports an abnormally large hyperplastic lesion originating from the buccal mucosa of a 28-year-old male patient with relatively rapid growth and displacement of the maxillary second molar. Dental MRI with a 15-channel mandibular coil was performed to improve perioperative management. Specific black bone MRI protocols such as STIR (short-tau inversion recovery) and DESS (double-echo steady-state) were used to image soft-tissue lesions in the oral cavity with high resolution. In addition, the current literature is reviewed and evaluated for evidence-based perioperative clinical and radiological case management.A 28-year-old male patient presented to the Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich (Switzerland), complaining of pain and swelling of the left cheek. He reported rapid, uncomfortable growth of a lesion originating from the buccal mucosa over the past 6 months. He had initially noticed the lesion three years earlier after removing braces. Recently, the lesion started to occasionally impair his masticatory function, causing him to bite himself accidentally.The dental history revealed no abnormalities or evidence of infection or trauma in the affected region. The patient’s medical history was unremarkable.Intraoral clinical examination revealed a well-circumscribed, smooth-surfaced mobile, nodular swelling measuring approximately 2.3 × 2 cm in the left planum buccale, covered with normal pink mucosa. The lesion was hard and noncompressible on palpation, the temperature was not elevated, and the lymph nodes were neither enlarged nor palpable. In addition, no increased teeth mobility was observed in the affected region .Based on the clinical presentation, the differential diagnosis included pyogenic granuloma, oral lipoma, and other benign or malignant neoplasms such as hemangioma, non-Hodgkin’s lymphoma, or metastasis in the oral cavity. Therefore, to improve perioperative radiological and surgical management, dental MRI was performed using a 15-channel mandibular coil  to provide high spatial resolution and excellent soft-tissue contrast .2, 14 elements phased array coil between two bars. Fasteners allow precise positioning of the patient’s head in the anteroposterior and cranio-caudal direction. As visualized in The 15-channel mandibular coil (field of view: 32 × 16 × 16 cm) used in this setup is an optimized 14 + 1 receive coil array and position system specifically designed for high-resolution imaging of dental structures in the oral cavity. It compromises a curved 12 × 38 cmDental magnetic resonance imaging protocols included conventional MRI protocols; native T1 ax and T2 fat-saturated (FS) cor Turbo Spin-Echo (TSE) 2D acquisitions, a 3D DESS protocol, a 3D-T2-STIR protocol, and a T2-weighted Dixon TSE protocol. MR images were acquired on a 3-Tesla Skyra  with the following main technical scanning parameters:3 together with a receive bandwidth of 355 Hz/Px. The other sequence parameters were: field of view, 242 × 242 × 78 mm3; acquisition matrix, 320 × 320 × 104; slice oversampling, 100%; no parallel acquisition; one signal average; acquisition time, 12:24 min:s; TR/TE1/TE2 11.2/4.2/7.7 ms; flip angle, 30°; selective water excitation; 2D T1 TSE ax: field of view, 180 × 180 × 99 mm3; acquisition matrix, 384 × 288; 30 slices; acq. resolution of 0.47 × 0.62 × 3.0 mm3; receive bandwidth of 260 Hz/Px.; TR/TE 482/9.5 ms; flip angle, 134°; phase oversampling, 60%; echo trains per slice/TSE factor, 154/3; no parallel acquisition; 1 signal average; acquisition time, 3:46 min:s; 2D T2 TSE FS ax: field of view, 180 × 180 × 86 mm3; acquisition matrix, 384 × 307; 26 slices; acq. resolution of 0.47 × 0.59 × 3.0 mm3; receive bandwidth of 260 Hz/Px.; TR/TE 7710/89 ms; flip angle, 150°; fatsat; phase oversampling, 10%; echo trains per slice/TSE factor, 20/17; no parallel acquisition; 2 signal averages; acquisition time, 5:25 min:s; 3D T2 TSE STIR cor: field of view, 210 × 210 × 64 mm3; acquisition matrix, 256 × 243 × 64; acq. resolution of 0.82 × 0.86 × 1.0 mm3; receive bandwidth of 630 Hz/Px. TR/TE/TI 3300/197/220 ms; flip angle mode, T2 var; phase/slice oversampling, 70/12.5%; phase, GRAPPA 2; 1.4 signal average; acquisition time, 7:04 min:s; 2D T2 TSE Dixon ax: field of view, 210 × 210 × 168 mm3; acquisition matrix, 320 × 240; 43 slices; acq. resolution of 0.66 × 0.88 × 3.0 mm3; receive bandwidth of 340 Hz/Px.; TR/TE 5000/80 ms; flip angle, 131°; phase oversampling, 60%; echo trains per slice/TSE factor, 11/19; GRAPPA 2; 1 signal averages; acquisition time, 3:52 min:s  turbo spin-echo (TSE) protocols revealed a hypointense lesion in T1-weighted images in the axial orientation measuring approximately 20 × 5 mm and a 12 × 8 mm hypointense lesion in the coronal T2 FS TSE reconstruction, ruling out a fat-containing tumor or cystic process .Dental MRI showed a well-demarcated lesion with a maximum extension of 21.3 × 5.6 mm , 13 × 8.6 mm , and 10.1 × 9.8 mm  on a T2 STIR protocol, with homogenous low signal intensity in the central area of the lesion, while the peripheral area showed a high signal intensity. The lesion originated from the planum buccale and did not infiltrate adjacent structures, with a displacement of the second upper molar . The DESThus, complete surgical excision of the lesion was planned. The surgical procedure was performed under local anesthesia and aseptic conditions without perioperative complications. Safety precautions included wearing goggles, using gauze in the surgical field, and suctioning under high vacuum. The lesion was completely excised with a BP blade (no. 15). After good coagulation, the wound was sutured (PTFE 3-0). The patient was prescribed chlorhexidine mouth rinse two times a day for 5 days . The lesSoft-tissue lesions of the mucosa can be diverse and difficult to diagnose and treat, as there can be multiple predisposing factors for tumor development, such as poor oral hygiene, excessive smoking, harmful habits, insufficient dental restorations, or mechanical irritation. The proven initial tools for diagnosis are clinical and radiological findings, which are important for early detection of any premalignant respective malignant pathologic abnormalities, although the definitive diagnosis is provided on the basis of histopathological analysis . DespiteOral irritation fibromas, a usually focal proliferation of fibrous tissue secondary to chronic irritation, can be identified in most cases with a relatively high degree of confidence based on medical history and clinical features. However, differentiation can be difficult, as it can have a similar clinical appearance to other benign or malignant neoplasms . In the Histopathological examination is also the most effective diagnostic tool for diagnosing irritation fibromas with the most significant possible degree of certainty. As for etiology, the precise mechanisms of tissue enlargement are still unclear, but irritant fibromas show a specific pattern of collagen fiber arrangement that depends on the location of the lesion and the extent and direction of chronic irritation. There are two types of patterns: the radiating pattern, which occurs in immobile sites with a higher degree of trauma, such as the palate, and the circular pattern, which appears in more flexible anatomic regions, such as the buccal mucosa due to minor trauma . It is sIn addition to established diagnostic tools, advances in dental MRI with the use of black bone MRI sequences such as STIR or DESS open the possibility of detailed anatomical images of soft and hard tissues in the oral and maxillofacial region, leading to improved preoperative radiological assessment and surgical planning ,15,29,30A comparison of black bone MRI sequences in their application in the dental field confirmed that they are best suited to overcome the limitations of hard tissue imaging in oral and maxillofacial radiology ,17,33. T” diagnostic modality. Second, both conventional X-ray-based imaging and MRI can visualize anatomy and pathological changes. They complement each other with their different indications, strengths, and weaknesses. The clinician must decide which imaging modality is indicated respectively most appropriate from medical, ethical, economic, and patient-specific perspectives. The interpretation of imaging data should always consider the patient’s medical history, concomitant diseases, and previous interventions that may affect the imaged structures. From a clinical perspective, it is important to understand that obtaining a high standard of diagnostic information is a complex process that is always influenced by three fundamental factors—the patient, the imaging device, and the image detector.Several guidelines should be considered before performing three-dimensional imaging procedures. First, cross-sectional imaging—despite being considered an indispensable tool in modern medical diagnosis—must always complement thorough clinical examination, rather than be a “stand-aloneAs demonstrated in the case report of this article, the STIR imaging protocol in combination with the 15-channel mandibular coil is a further step towards personalized medicine and can be used for depicting soft-tissue pathologies. This additional information can provide useful supplemental information to assess what type of lesion is present and minimize the risks and ineffectiveness in preoperative decision-making by taking into account patient-specific factors. In conclusion, a thorough multidisciplinary coordinated preoperative evaluation of all case-specific factors, including medical history, clinical, and especially radiological and histopathological features, is crucial in borderline cases to provide the best possible treatment of oral cavity soft-tissue tumors.


To the best of our knowledge, double or multiple extralobar pulmonary sequestrations (PSs) with anomalous arterial supply in the ipsilateral thoracic cavity have rarely been reported before. PS can be divided into two types: intralobar sequestration (ILS) and extralobar sequestration (ELS). We encountered a 5-month-old infant with double ELS in the left thoracic cavity that was incidentally detected during thoracoscopic surgery. Surgical exploration revealed two separate, well-circumscribed abnormal masses in the left thoracic cavity, and the patient was successfully treated using thoracoscopic surgery. Postoperative pathology confirmed that both masses were PS tissues. Accurate preoperative diagnosis using CT alone may be inadequate in this type of case. Therefore, thoracoscopy may be more suitable for diagnosing and treating unusual ELS. Pulmonary sequestration (PS), also known as accessory lung, is a lung malformation characterized by a mass of non-functioning lung tissue without connection to the normal tracheobronchial tree . In embrThe patient was a 5-month-old male infant diagnosed with ELS at the 22nd week of pregnancy. Ultrasound revealed a lesion adjacent to the inferior lobe of the left lung with a size of about 3 cm x 2.5 cm × 2 cm. Subsequent follow-up ultrasonography showed that the lesion volume had gradually increased. The child was born smoothly through vaginal delivery without any respiratory abnormalities such as respiratory distress. Since birth, the child developed normally and had no respiratory symptoms. The patient’s mother was very anxious about the risk of infection or torsion of the lesion since birth. The reason for this admission was that the infant’s mother required further imaging evaluation and surgical resection of the lesion. After admission, an enhanced chest CT revealed a clearly defined mass below the inferior lobe of the left lung with a size of 3.8 cm × 3.5 cm × 2.8 cm . On the via intercostal incisions. We unexpectedly found two separate and well-defined masses in the left thoracic cavity, whose colors were inconsistent. We named these two masses the inferior ELS and the upper ELS. The surface of the inferior ELS was pink and was covered with tortuous blood vessels. The base of the inferior ELS was closely related to the left diaphragm (The patient underwent thoracoscopic surgery on the 2nd day of admission. After general anesthesia, the patient was placed in the right lateral position. Surgery was performed under artificial pneumothorax by thoracoscopy using a 10 mm trocar and double 5 mm trocars iaphragm . Incisiniaphragm . The dariaphragm . The uppiaphragm . The opeiaphragm , 4.To our knowledge, this is the first report of a child with double ELS with anomalous arterial supply in the left thoracic cavity. Before this reported patient, the cases of rare PS mainly included the following types: variation of the source of arterial supply , 8, variThe incidence of PS is approximately 0.1-6.4%, with ELS accounting for approximately 15-25% of these cases, which is relatively rare . ELS covThe following imaging methods are used for diagnosing PS: ultrasonography, chest radiography, CT, MRI, and angiography. Chest radiography can provide an initial diagnostic clue for PS, especially in patients with local lesion infections. Angiography has been used for diagnosis in the past, especially for identifying feeding vessels; however, the recommended gold standard for diagnosing PS is now CT or MRI . CT angiThe most appropriate management for ELS is controversial because some studies demonstrated that ELS may remain asymptomatic throughout life and may even disappear , 17. A sIn conclusion, we reported a case of double extralobar pulmonary sequestration with anomalous arterial supply originating from the abdominal aorta. For such patients, it is difficult to obtain accurate diagnoses using only preoperative CT. MRI may be a necessary option before surgery to better visualize anomalous vessels and detect their variants. Therefore, thoracoscopy may be considered because of its minimally invasive diagnostic and therapeutic roles. In this case, surgeons should be reminded of the importance of careful intraoperative exploration to avoid omissive excisions when dealing with patients diagnosed with ELS preoperatively.The mother of the patient: “I am very happy now. I am very surprised that there are two lesions in my baby’s chest and thank the doctors for dispelling my concerns.”The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of Children’s Hospital Affiliated to Shandong University and Jinan Children’s Hospital. Written informed consent to participate in this study was provided by the participant’s legal guardian/next of kin.RG and HX were responsible for the conception of the idea of the case report. YZ and HZ contributed to the data collection. LL prepared the first draft of the manuscript. SZ wrote a few sections of the report. All authors contributed to the revision and submission of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Torsion of the greater omentum is an uncommon cause of acute abdominal pain. Omental torsion can be divided into primary and secondary. Owing to its nonspecific abdominal pain, preoperative diagnosis is difficult. Ultrasound sonography and abdominal computed tomography scans do not have a major role in preoperative diagnosis. The definite diagnosis is usually made during operation.A 7-year-old Persian boy was referred with right lower quadrant pain associated with nausea and vomiting. Laboratory blood tests and urinalysis were requested that revealed normal values. Ultrasonography was performed, revealing inflammatory changes with mild free fluid collection in the interloop. The patient underwent an open appendectomy, confirming a normal appendix with omental torsion. Two days later, he was discharged home without postoperative complications.In patients with acute abdomen, particularly those with acute appendicitis symptoms, omental torsion should be considered in the differential diagnosis. Omental torsion is a rare cause of acute abdomen  that resA 7-year-old Persian boy was referred to the emergency room with complaint of abdominal pain. His symptoms had started 2 days ago in the right lower quadrant and gradually increased, accompanied with nausea and vomiting.He was fully vaccinated, had no significant family, social, or environmental history and had normal growth and development with no history of previous illness.The child was not ill, and his vital signs included blood pressure of 111/720 mmHg, pulse rate of 75 beats per minute, respiratory rate of 17 breaths per minute, and temperature of 37 °C. Abdominal examination revealed right lower quadrant tenderness and rebound tenderness, while other parts of the abdomen had no pain or tenderness. There were no other findings on physical and neurological examination.3/µL (4.5–11 × 103/µL) ; red blood cells 4.77 × 106/µL (4.7–6.1 × 106/µL); hemoglobin 10.1 g/dL (11.2–14.5 g/dL); hematocrit 33% (39–50%); mean corpuscular volume 69.2 fL (80–100 fL); red cell distribution width 17% (11.5–15%); platelets 294 × 103/µL (150–450 × 103/µL); aspartate aminotransferase 22 U/L (8–33 U/L); alanine transaminase 27 U/L (7–55 U/L).Laboratory tests such as complete blood count and liver function tests revealed normal values as follows: white blood cells 6.7 × 10Ultrasonography revealed enhanced pericecal fat echogenicity due to the inflammatory changes with mild free fluid collection in the interloop Fig. . The patThe patient was nil per os (NPO) after hospitalization.We hydrated the patient with stat 300 cc lactate Ringer and 600 cc dextrose 5% in 0.9% sodium chloride once every 8 hours. Antibiotic therapy include ceftriaxone 750 mg twice a day, metronidazole 300 mg every 8 hours, and analgesic [Apotel as needed (PRN)] was prescribed intravenously. After surgery, the patient’s symptoms were ameliorated and he was discharged from the hospital 2 days later. Oral medication including metronidazole, cefixime, and analgesic was prescribed.He had no complications on follow-up office visits after surgery for 6 months.The omentum is a four-layer sheet of the peritoneum that descends from the stomach and binds to the transverse colon. It is capable of sequestrating inflamed organs owing to its mobility  4.Omental torsion can be primary or secondary. Primary omental torsion is more prevalent in obese children and may occur in the absence of intraabdominal pathology. In contrast, secondary omental torsion, which is uncommon in children, is due to hernias, cyst or omental tumor, foreign body, adhesions, and postsurgical scarring. Risk factors for torsion include trauma, increased intraabdominal variations, pressure of fat deposits (particularly in obese patients), hyperperistalsis, omental anatomic variations, overeating, overexertion, and sudden changes in body position.Increased omental weight due to fat deposits leads to decreased blood supply to the omentum in obese children and causes traction or torsion to the distal part. It occurs in 0.1–0.5% of children with presumptive appendicitis undergoing operations. Omental torsion occurs in adults more than children and is more common in males between 40 and 50 years 66%). With similar body weight, omental fat accumulation is higher in males compared with females of similar body weight, which may explain the higher prevalence in males  56.56%. With Pain is the main clinical presentation of omental torsion, and it can be located in the right upper or lower quadrants, depending on the omentum affected site. The pain is nonradiating and constant, with sudden onset , 8. MostClinical presentation simulates other acute abdominal conditions. Differential diagnoses include cholecystitis, acute appendicitis, cecal diverticulitis, abdominal wall hematoma, perforated duodenal ulcer, and intestinal obstruction. In women of reproductive age, ectopic pregnancy, ovarian cyst torsion, and salpingitis should also be included. In children, mesenteric adenitis and Meckel diverticulum should also be considered. Another diagnostic possibility is torsion of an accessory spleen when it presents, which is usually located inside the omentum . The durIn our experience, radiological studies, have usually been nonspecific. However, recent studies have outlined specific findings on ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) . The chaThe treatment of omental torsion is controversial. Most patients recover with conservative treatment since imaging techniques can diagnose it early and lead to self-limiting and benign disease. Moreover, the total resolve of the inflammation, fibrosis, and retraction often occurs within 2 weeks  15. HoweFurthermore, laparoscopic advantages are (1) facilitation of peritoneal aspiration and washing, (2) complete examination of the abdomen to confirm the diagnosis, and (3) reduction of the postoperative adhesion, wound-related complications, and postoperative pain .In conclusion, omental torsion is a rare cause of acute abdomen. This case was treated successfully with omental resection. Most patients recover conservatively; however, because of the limitations in definitive diagnosis and prolonged hospital admission in conservative management, we suggest that surgical resection should be performed as soon as possible when the diagnosis is suspected.


Groove pancreatitis is a chronic type of segmental or focal pancreatitis seen to affect the groove, which is the region between the head of the pancreas, the duodenum, and the common bile duct. Despite its incidence remaining unknown, it accounts for 2.7% to 24.5% of pancreaticoduodenectomies performed for chronic pancreatitis. A diverse etiology has been implicated but the exact cause is yet to be identified. As it closely mimics pancreatic malignancy and remains mostly undiagnosed preoperatively, many patients often end up undergoing a pancreaticoduodenectomy. Awareness of this entity and early diagnosis will help us address this issue with more conservative measures than by resorting to a morbid procedure such as a pancreaticoduodenectomy.We report a case of a 50-year-old male, a chronic alcoholic, with a two-year history of upper abdominal pain, postprandial vomiting, and weight loss. An abdominal contrast-enhanced computed tomography (CECT) scan was suggestive of either a pancreatic malignancy or a possibility of groove pancreatitis. However, postoperative histopathological examination confirmed the lesser known groove pancreatitis. Here, we review the clinical, radiological, and pathological characteristics of groove pancreatitis, as its diagnosis and management still pose a challenge. Groove pancreatitis is a chronic type of segmental or focal pancreatitis affecting the groove region between the head of the pancreas, the duodenum, and the common bile duct. It was first reported by Becker in 1973 -4. AwareA 50-year-old male with a history of consuming large amounts of alcohol and smoking for 30 years presented with chronic epigastric pain of two years duration. It was associated with the postprandial, non-bilious type of vomiting, weight loss, and loss of appetite over the recent year. Examination revealed epigastric tenderness and a lump of size 4x5 cm. His serum amylase and lipase were 80U/L and 101U/L, respectively.A contrast-enhanced CT (computed tomography) scan of the abdomen and pelvis revealed an asymmetric, heterogeneously enhancing, hypodense lesion involving the pancreaticoduodenal groove causing thickening of the medial wall of the second part of the duodenum (D2) with luminal narrowing and few cystic areas within it, having a mass effect on the common bile duct (CBD). The carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and bilirubin levels were normal  with luminal narrowing. Intraoperatively; a 4x4 cm hard mass originating from the head of the pancreas causing narrowing of D2 with suspicion of extension into the distal CBD was also noted. The lesion was operable and malignancy could not be ruled out on the table as an intraoperative frozen section was not done. Hence, a decision to perform Whipple’s pancreaticoduodenectomy was made. The repair consisted of a pancreaticojejunostomy, choledochojejunostomy, gastrojejunostomy, and finally a Roux-en-Y jejunojejunostomy , it is identified as a sheet-like mass between the pancreatic head and the duodenum. Delayed enhancement on gadolinium-enhanced MRI images reflects the fibrous nature of the lesion. Cystic lesions of the groove and duodenal wall may also be seen on T2-weighted images.Magnetic resonance cholangiopancreatography (MRCP) may reveal a dilated or normal main pancreatic duct (MPD) or a dilation at the ampulla of Vater. MRCP is sensitive to assess anomalies of the CBD, pancreatic duct (PD), and ampulla and may also reveal an increase in the distance between the duodenal lumen and distal duct .Endoscopic ultrasound (EUS) represents one of the most sensitive methods for the detection of pancreaticobiliary pathologies. EUS can detect thickening or stenosis at the second part of the duodenum, intramural cysts, stenosis of CBD, masses arising in the groove region or pancreatic head, presence of calcifications or pseudocysts, and dilatation of the MPD. Additionally, EUS offers the advantage of a nonoperative tissue diagnosis - the guided fine needle aspiration cytology (FNAC), which can help differentiate pancreatic adenocarcinoma from chronic pancreatitis .In the absence of severe symptoms, a prospective diagnosis may favor a conservative line of management which includes keeping the patient nil per oral, complete abstinence from smoking and alcohol consumption allowing pancreatic functions to recover along with adequate analgesia .If these measures fail, endoscopic interventions are an alternative. They include endoscopic drainage of the minor papilla or pancreatic duct stenting, which are both less invasive than surgery -14.However, in the presence of severe symptoms , inability to distinguish from malignancy, or in the failure of all other treatment modalities, surgery is the only mainstay. The surgical treatment of choice is either Whipple’s procedure or pylorus-preserving pancreaticoduodenectomy .To distinguish groove pancreatitis clinically or radiologically from a primary pancreatic, duodenal or ampullary malignancy still remains a challenge thus making an early diagnosis difficult and often leading to a morbid surgery. Making a prospective diagnosis still poses a dilemma, as most cases of groove pancreatitis are diagnosed after a histopathological examination post-surgical excision. Newer studies suggest a more conservative or less invasive endoscopic approach for the condition. Surgical excision is needed only if all measures fail to provide adequate symptomatic relief or if there is a suspicion of malignancy. However, this is only possible if the diagnosis can be made prospectively rather than retrospectively.


Optic nerve infiltration as the first sign of isolated central nervous system relapse of acute lymphoblastic leukemia (ALL) is rare. A seven-year-old girl with standard-risk B-cell ALL who was in remission presented with sudden onset of left eye pain and loss of vision. Examination revealed no perception to light in the left eye with positive relative afferent pupillary defect. The optic disc was hyperemic and swollen with total obscuration of the disc margin associated with central retinal artery and vein occlusion. Magnetic resonance imaging of the brain and optic nerve showed left intraorbital optic nerve thickening associated with perineural enhancement and intraconal fat involvement.Lumbar puncture revealed leukemic infiltration with blast cells after a week of eye symptoms, while bone marrow aspiration was negative for malignant cells. A diagnosis of left leukemic optic nerve infiltration with central retinal artery and vein occlusion was made. A high index of suspicion with repeat cerebrospinal fluid sampling is crucial to confirm the diagnosis as vitreous biopsy may fail to reveal infiltrative cells. Optic nerve involvement is reported to occur in one-sixth to 34% of leukemic cases ,2. HowevThis article was previously presented as a meeting poster at the 33rd Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS)-Singapore National Eye Centre (SNEC) 30th Anniversary Virtual Meeting on July 30-31, 2021.A seven-year-old girl with standard-risk B-cell ALL diagnosed two years ago who had completed her systemic and prophylactic intrathecal chemotherapy and was in complete remission for two months presented with sudden onset of left eye pain and loss of vision. It occurred upon awakening from sleep and was associated with throbbing headaches. She did not have any complaint over the right eye. She had no history of hyperleucocytosis, extramedullary disease, or CNS involvement during her first diagnosis of ALL. Systematically, there was no preceding fever or signs of systemic infection.Her left visual acuity was non-perception to light with positive relative afferent pupillary defect. Right visual acuity was 3/3 on the Sheridan Gardiner test. Anterior segment was unremarkable in both eyes. Left eye fundus examination revealed a markedly swollen, hyperemic optic disc bulging into the vitreous with total obscuration of the disc margin. Retinal veins appeared very dilated and tortuous with presence of pale, edematous macula and retina. There were flame-shaped intraretinal hemorrhages in all four quadrants with vitreous hemorrhage inferiorly. There were no cotton wool spots Figure , Panel BAn urgent magnetic resonance imaging (MRI) of the brain and optic nerve showed left intraorbital optic nerve thickening associated with perineural enhancement and intraconal fat involvement Figure . The rigFundus fluorescein angiography revealed a complete absence of choroidal, retinal artery, and venous filling of the left eye for up to seven minutes while the right eye showed leakage from the optic disc  and initial lumbar puncture (LP) were negative for malignancy. Second LP was done a week later together with anterior chamber tapping and vitreous biopsy. Cerebrospinal fluid cytology showed presence of blast cells, suggestive of leukemic infiltration of the CNS Figures , 3B. AntIn view of relapse of leukemia with isolated CNS involvement, she was started on reinduction chemotherapy UK ALL R3 including intrathecal methotrexate. Neither local ocular chemotherapy nor radiotherapy was initiated. To date, her left eye remains without perception to light with right eye vision maintained without deterioration to date.ALL is an aggressive malignant proliferation of lymphoblasts with peak prevalence between the ages of one and four . It can Optic nerve is known to be a sanctuary for leukemic cells which is relatively unaffected by systemic chemotherapy and even intrathecal chemotherapy . Cases oIn our case, despite intrathecal chemotherapy, which was given for CNS prophylaxis at the first diagnosis of ALL, and achieving complete remission after completion of chemotherapy, she developed isolated CNS relapse.The majority of patients with CNS relapse present with symptoms such as altered mental status, headache, and cranial nerve palsy while only a minority (6.5%) report blurred vision as the initial complaint . This waRosenthal classified optic nerve infiltration in leukemia into prelaminar and retrolaminar . In prelThere are limited cases reported on central retinal vascular occlusion in ALL in contrast to other lymphoproliferative disorders such as lymphoma -12. A caA review by Myers et al. found that malignant cells are identified in the cerebrospinal fluid in a majority of leukemic infiltration cases . In our Vitreous biopsy has value in diagnosing a leukemic relapse when there is presence of dense vitreous cellular infiltration . Shenoy Optic nerve infiltration may be the only initial presentation indicating relapse of ALL following attainment of disease remission. A high index of suspicion and prompt diagnosis may not only avoid irreversible loss of vision but more importantly can be life-saving for the patient. Repeated cerebrospinal fluid analysis may be necessary in the event of initial negative results for malignancy.


The differential diagnosis of abdominal pain ranges from benign to life-threatening conditions. This case report describes the importance of the differential diagnosis and a faster and more accurate diagnosis. A 75-year-old male presented to the emergency room (ER) with diffuse abdominal pain, associated nausea, vomiting, diarrhea, and a fever of 38.5ºC since the previous day. Medical history included hypertension, dyslipidemia, and obesity. Clinical examination showed hypotension and a distended abdomen with diffuse tenderness in all quadrants. Blood tests revealed a hemoglobin of 11.3 g/dL, and an arterial blood gas test revealed metabolic acidosis and lactate of 8 mmol/L. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed a large aneurysm in the infrarenal aorta with an extension of about 17x8x8 cm and an exuberant mural thrombus. The patient underwent endovascular treatment of the aneurysm; however, he died during surgery. The definition of an abdominal aortic aneurysm (AAA) is based on the diameter of the abdominal aorta; an abdominal aortic diameter of 3.0 cm or more is considered to be aneurysmal  and causA 75-year-old male presented to the ER with diffuse abdominal pain, associated nausea, vomiting, diarrhea, and a fever of 38.5ºC within one day of evolution. The past medical history of the patient was remarkable for long-standing hypertension, dyslipidemia, and obesity. He did not have the habit of smoking or alcohol consumption. His medication included amlodipine, atorvastatin, and acetylsalicylic acid. Upon examination, the patient was alert and looked distressed while his pulse rate was 130 bpm, blood pressure was 67/38 mmHg, respiratory rate was 26 bpm, and temperature was 36.7℃. His abdomen was distended, and he had diffuse tenderness on palpation of the abdomen and no other remarkable findings. Bowel sounds were present and normal. His peripheral pulses were reduced and capillary refill time was increased. Initial consideration included sepsis; this patient was resuscitated with 0.9% NaCl at 30 ml/kg and broad-spectrum antibiotics. Laboratory investigation revealed a hemoglobin level of 11.3 g/dL, creatinine 2,78 mg/dL, and urea 70 mg/dL. Arterial blood gas revealed metabolic acidosis and lactate of 8 mmol/L (Table Point-of-care ultrasound was not available. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis was performed and revealed a large aneurysm in the infrarenal aorta with a longitudinal extension of about 17 cm, starting distally to the emergence of the renal arteries until the bifurcation of the iliac arteries and with slight extension to the proximal left iliac artery, of 8.1 x 8.0 cm, and did not exclude aneurysmal rupture or dissection. A mural thrombus about 4.6 cm thick was present  was placed in order to start treatment with norepinephrine and referred to a vascular surgery team because there was a possibility that the aneurysm was ruptured. The patient was admitted for surgical treatment. During surgery, it was possible to observe a ruptured aneurysm, aortic thrombosis, and intestinal ischemia. However, it was not possible to repair the aneurysm, and the patient progressed to refractory hemorrhagic shock and died during the surgery.Getting the correct diagnosis quickly can be difficult and challenging. The diagnosis is made by CT scan with angiography, ultrasound, or magnetic resonance angiography, however, a CT scan with angiography is the imaging modality of choice for the diagnosis and follow-up . BedsideThe evaluation of abdominal pain requires an extensive differential diagnosis, including acute aortic syndrome, such as a ruptured aneurysm, which quickly becomes life-threatening and requires prompt medical treatment. Despite CT scan with angiography remaining the imaging modality of choice, bedside ultrasound helps establish a correct diagnosis and rule out other causes.


In the present case report a 7-year-old male Whippet competing in lure-coursing presented with third-degree recurrent lameness of the right forelimb, pain on palpation of the caudal aspect of the carpus and swelling of the forearm proximally to the accessory carpal bone. Clinical, radiographic, and ultrasonographic evaluation diagnosed a flexor carpi ulnaris (FCU) chronic tendinopathy unresponsive to previously attempted conservative treatments such as oral non-steroidal anti-inflammatory drugs (NSAIDs) administration along with padded palmar splint application and rest. The dog was subjected to one injection of autologous platelet-rich plasma (PRP) obtained using a double centrifugation tube method, followed by two platelet lysate (PL) injections. Treatment was administered at three-week intervals. The healing process was assessed through clinical and ultrasonographic imaging (US) on the day of the first injection (T0), and at week three (T1), six (T2), twelve (T3), fifty-two (T4), and one-hundred-and-four (T5). Fiber alignment score (FAS) and echogenicity score (ES) were developed by modifying a previously published US assessment scale. At T1, ES, and FAS improvement was detected, and at T2, further improvements in ES and FAS were observed. Ultrasonographic results were clinically consistent with the improvement in lameness: lameness grade 3/4 was detected at T0 and grade 2/4 at T1. A lameness grade of 1/4 was detected at T2, and grade 0/4 was observed at T3, T4, and T5. Moreover, at T5, the dog returned to competition, and no history of re-injury was reported. Our results suggest that the treatment of FCU tendinopathy in lure-coursing dogs with a combination of consecutive injections of autologous PRP and PL could be feasible. Additionally, no adverse reactions were observed. The flexor carpi ulnaris (FCU) muscle in dogs acts as a flexor and an abductor of the forepaw. It also has an antigravitational function. It consists of two bellies: the ulnar and humeral heads. Both end distally on the accessory carpal bone with two tendons. The ulnar head extends distally with a flat tendon laying lateral and palmar to the superficial digital flexor muscle, covering the humeral head. Progressing distally, it ends at the apex of the accessory carpal bone, which is separated from the humeral head tendon. The humeral head tendon is short, strong, and inserts into the apex of the accessory carpal bone .Although only occasionally reported, lesions of the actual tendon itself have been described in Coursing dogs as typical sport-related injuries, and lesions of the insertion of the FCU tendon have been described in veterinary sports medicine as a consequence of strain followed by inadequate rest . A singlIn human sports medicine, wrist and hand injuries reportedly affect a large part of the sporting population, and FCU tendinopathy is described as an overuse injury involving sports with a high potential of wrist and hand trauma such as tennis, handball, netball, or basketball .The diagnosis of hand injuries in human medicine is considered challenging, and the importance of ultrasonographic evaluation of musculoskeletal diseases is increasing with applications in wrist injuries , 6. In vThe treatment of injuries caused by the insertion of the FCU tendon in humans has been reported to be conservative or surgical. The first consists of non-steroidal anti-inflammatory medications, splints, therapeutic strengthening, stretching programs, and steroidal injections. In contrast, surgical treatment is applied to patients who fail conservative management and has been reported as excision of the pathological tissue of the tendon .In veterinary medicine, surgical treatment of injuries to the FCU tendon at its insertion has been reported in cases of avulsion from the accessory carpal bone providing suture of the damaged portion, splint in flexion of the carpus for 2 or 3 weeks, and restriction of activity for at least 6 weeks  and platelet lysate (PL), has gained interest because of the concentrated content of bioactive factors, which is correlated to tissue healing properties. These factors include cytokines and growth factors, such as transforming growth factor-β (TGF-β), insulin-like growth factor 1 (IGF-1), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and basic fibroblast growth factor (bFGF), that by acting individually or in synergy can promote cell proliferation, cell migration, and recruitment along with angiogenesis, hence initiating a healing response within the damaged tissue –13. ThesThe canine flexor tendon has been studied as an animal model for flexor tendon healing and repair after different types of injuries for treatment in humans . Thus, tIn this study, a single case of FCU tendinopathy in a lure-coursing dog that was not responsive to conservative treatments and treated with multiple injections of autologous PRP and PL is described along with an ultrasonographic follow-up of the healing process 2 years after treatment.A 7-year-old male Whippet competing in lure-coursing was referred to our hospital with a history of third-degree recurrent lameness to the right forearm. Symptoms were noticed 3 months before the clinical evaluation, and analog episodes were reported during the previous 3 years. Lameness was evident during walking, and it was worsening during sports activity as reported by the owner. No history of trauma was reported.Conservative treatment with rest was previously suggested, and only a short leash walk was allowed. A padded palmar splint was administered and 4 mg/kg Carprofen was orally administered once a day for 2 weeks . No respOn clinical examination, the dog was found to be in good general health. Orthopedic examination showed third-degree right forelimb lameness, based on a previously reported orthopedic lameness evaluation system  Table 1Table 1. Radiographic examination of both carpal joints on the mediolateral and craniocaudal standard views was performed without the need for anesthesia and showed soft tissue thickening in the projection area of the right FCU tendon, just proximal to the accessory carpal bone. Enthesophytes were detected at the proximal pole of the left accessory carpal. No changes were detected bilaterally on the craniocaudal standard view .Ultrasonographic evaluation of both carpal joints was performed using an 18 MHz linear transducer probe . For each assessment, a complete examination of the FCU tendon was performed using both longitudinal and transverse scans. The obtained images at each examination were evaluated and scored from 0 to 3 for two parameters, echogenicity score (ES) and fiber alignment score (FAS), modifying a previously published ultrasonographic assessment scale  Table 2Table 2. The clinical, radiographic, and ultrasonographic findings led to the presumptive diagnosis of FCU insertional tendinopathy. Because of the failure of conservative treatment, a regimen involving a PRP injection followed by two subsequent PL injections was suggested.®, BD, Italy). The treatment program consisted of three ultrasound-guided injections of autologous PRP prepared as previously described (Blood samples (30 mL) were obtained from the jugular vein using an ACD-A 10% tube , an ultrasonographic examination was performed to assess the ultrasonographic appearance of the FCU tendons bilaterally. Before injection, no anesthesia was required, and the injection area, which was already clipped for ultrasonographic examination, was aseptically prepared. The treatment was inoculated in both heads of the right FCU tendon using a sterile 22G needle The second and a third injection were performed at three (T1) and 6 weeks (T2), respectively, following the same protocol used for the first treatment and using the obtained PL (after freeze-thaw cycle) to continue the stimulation of the healing process.The clinical and US outcome are summarized in Clinical assessments were performed every 3 weeks starting from the day of the first injection to the day of the last injection and every 12 weeks thereafter. In the present study, we report the clinical outcomes on the day of the first injection (T0), at three (T1), six (T2), twelve (T3), fifty-two (T4) and one-hundred-and-four (T5) weeks.Before treatment, the dog presented with third-degree (3/4) right forelimb lameness, swelling of the palmar surface of the carpal joint, and pain on palpation of the affected region.At T1, pain on palpation and swelling of the carpal region were slightly decreased; moreover, a reduction in the degree of lameness was observed (grade 2/4). The second injection was administered on the same day and it consisted of PL. At T2, the last PL injection was administered, and no pain on palpation was detected, with mild swelling of the carpal region. A grade 1/4 of lameness was recorded. At T3, 3 months after the first injection, no pain on palpation or swelling of soft tissues was detected, and grade 0/4 lameness was observed. T4 and T5 clinical examinations were consistent with T3 findings, with a complete restoration of forelimb function and return to sport. No reinjuries were reported.Ultrasound evaluation images are shown in At T1, the US examination was mildly improved with ES 2 and FAS 2 compared to the contralateral one, which was still consistent with T0. Doppler ultrasound examination revealed the presence of a small amount of neovascularization. At T2, the US examination showed additional improvement with ES 1 and FAS 1 compared to the contralateral limb: T3, T4, and T5. US evaluation showed ES 1 and FAS 1 with the same ultrasonographic appearance for the FCU tendons of both forelimbs.FCU tendinopathy is poorly described in veterinary literature and rarely reported as a cause of forelimb lameness in pet dogs but is listed among the typical injuries of lure-coursing dogs . Its diaIn the One Health scenario, the investigation of the treatment of flexor tendon diseases in dogs can be useful for the collection of preclinical data. The flexor tendon system of dogs has often been studied as an animal model for the investigation of the flexor tendon healing process, and the results have already been applied in human medicine . MoreoveNevertheless, the lack of standardization of PRP administration modality represents an important aspect to evaluate in both human and veterinary approaches .In the present case report, an ultrasound-guided peritendinous injection of autologous PRP followed by two further injections of PL was administered for the treatment of chronic right FCU tendinopathy in a lure-coursing dog. The patient presented with chronic lameness and ultrasonographic signs of FCU tendinopathy that developed during sporting activity and was unresponsive to previously administered conservative standard treatments such as rest, splint immobilization, and NSAIDs oral administration. The lack of response to the conservative approach and the risk to develop gastro-intestinal tract problems with a long-term treatment with NSAIDs were the two pressing elements of the management of the injury. Thus, the peritendinous injection of 1 mL of autologous PRP, followed by two further administrations of 1 mL per injection of PL, was the novel approach of choice. Different studies have shown the beneficial effects of PRP and PL on tendon healing in veterinary medicine –33. The The results were beneficial for the dog, as the applied therapeutic program resulted in the disappearance of lameness and ultrasonographic improvement of fiber alignment along with echogenicity of the injured tendon. Moreover, during the treatment and follow-up period, the patient did not suffer from any re-injury episodes; after T4, the dog returned to the same competition level before injury. The ability to return to sports could suggest restoration of the biomechanical properties of the tendon after the injections to an adequate level that allowed the dog to return to competition. This might be related to the supposed capability of low WBC PRP to support the production of collagen type I (COL1) fibers during the tendon healing process. COL1 is the major component of fibrillar collagen in tendons and is responsible for linear fiber alignment. On the contrary collagen type III, that is synthetized during primary tendon healing process, leads to the formation of disorganized scar tissue, which is more prone to re-injury in cases of excess load . The subThe US observations of the process are another important aspect of the present case report because, to our knowledge, no studies have been published on US evaluation of the healing process of FCU tendinopathy. Musculoskeletal ultrasonography is an imaging technique that has been used and validated for the diagnosis of several tendinopathies in both humans and dogs. It provides a non-invasive diagnosis and allows for feasible and cost-effective consecutive examinations to assess the response to treatment; moreover, it is useful for evaluating the changes in size, shape, and echogenicity of the tendon, avoiding patient sedation , 38. UltTo our knowledge, no studies on the successful treatment of a lure-coursing dog's FCU tendinopathy by multiple ultrasound-guided PRP and PL administration have previously been published. The feasibility of this therapeutic approach could be considered satisfactory and safe in this case, as the dog returned to competition without any adverse treatment reactions. The ultrasonographic evaluation of the healing process played a pivotal role in a return-to-play oriented approach, and our results might be considered encouraging for the study of a more standardized application protocol of PRP administration for canine athletes, helping to collect preclinical data for human research.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because the owner of the dog signed a written consent. Written informed consent was obtained from the owners for the participation of their animals in this study.AF and ME followed the clinical case and performed the PRP and PL injections. MP and LM contributed to study design and supervised the study. ME, EC, and LM wrote the original draft of the manuscript. AF, ME, EC, LM, and MP revised and edited the manuscript. All authors read and approved the final manuscript.