Hydatid disease is a parasitic infestation, which is endemic in the Mediterranean region. It is often located in the liver and the lungs, whereas brain stem hydatid cysts are extremely rare. We report a case of a five-year-old female who presented with hemiparesis, and after investigations, she was diagnosed with a hydatid cyst in the pons. She also had cysts in her liver and kidney. The cerebral cyst was completely removed without rupture, using gentle water-jet dissection (Dowling's technique). She was feeling well after 4-month follow-up. We emphasize the importance of keeping hydatid cysts in the differential diagnosis of pediatric infratentorial cystic lesions. Hydatidosis is a zoonotic disease caused by the tapeworm of the complex Echinococcus sensu lato that is classified into 10 genotypes (G1-G10) –4. The MHydatid cysts (HC) could be found in any organ of the body. While the liver and lungs are the most affected, brain stem infection is considerably rare . We repoA previously healthy 5-year-old female, living in a rural area in Syria but does not have direct contact with animals, presented with right hemiparesis that had started 2 weeks earlier. She had also complained of headache, fever, and epigastric pain during the last month, but no vomiting was experienced.She was conscious but asthenic. The physical exam revealed right eye esotropia and ptosis, symmetrical dilated but reactive pupils, right-sided deviation of her mouth's angle, hyperreflexia and weakness in the right side, positive Babinski reflex in her right foot, and mild ataxia.Brain magnetic resonance imaging (MRI) showed a well-defined round lesion in the pons. It was 21 mm in measurement, isointense to CSF, and did not enhance the contrast. There was no edema or displacement of the midline structures . Brain cThe Echinococcus indirect hemagglutination test was positive. Liver enzymes, creatinine, and urea were all normal. The diagnosis of multiple organ involvement with hydatid cysts was highly suspected, and surgical intervention was planned.Suboccipital craniotomy while in the prone position was performed. The dura was opened in a Y-shaped manner. The vermis was split in order to reach the 4th ventricle. The floor of that ventricle was gently dissected along the midline to reach the cyst. Dowling's technique was used to dissect the cyst, which included instillation of normal saline between the hydatid cyst and the surrounding tissue. Using this gentle water-jet dissection, surgeons were able to remove the cyst unruptured. After that, the pathology report showed a hydatid cyst wall without protoscoleces.Albendazole was started 2 days before surgery at a dose of 7.5 mg/kg twice daily and was continued for 4 courses of 4 weeks separated by intervals of 2 weeks.After surgery, the patient's strength of the upper limb improved, but she developed mild lower extremity weakness that improved over the follow-up period of four months.Regarding the cysts that are located in other organs, we advised the patient to repeat the abdominal and chest CT after finishing her chemotherapy, but she did not.Cerebral hydatid cysts are a rare presentation of an endemic disease. They represent 1-4% of all hydatid cysts . They arThey are usually solitary and primary . ChildhoRadiology plays a key role in the diagnosis of hydatid cysts, although histopathological examination remains the gold standard . Their tThe cyst and the pericyst are characteristic imaging components of the HC, where the pericyst is the capsule of the cyst and it is best observed on MRI .The differential diagnosis should include pilocytic astrocytoma that enhances on both CT and MRI and has a distinctive feature which is the existence of a contrast enhancing nodule . ArachnoSerological tests are usually negative in primary cerebral hydatid cysts; however, they become positive in case of associated visceral lesions. Regarding that those tests returns negative after surgical resection, they could be useful as an evidence of recurrence , 11.Surgery is the mainstay of intracranial hydatid cyst treatment, and surgeons should do their best to remove them in toto without spillage . DowlingTreatment with medications is required in patients experiencing recurrence, rupture during surgery, or have systemic hydatid disease. It could also be used preoperatively to reduce the size and number of multiple cysts, and postoperatively as a prophylactic treatment , 7. MediHydatid cyst should be kept in mind as a differential diagnosis of brain stem cystic lesions in endemic areas, especially in pediatric population.


Thorough knowledge of imaging features can enable a radiologist to make a correct diagnosis even in an atypical presentation.Herlyn–Werner–Wunderlich syndrome is a rare complex congenital anomaly of the urogenital tract involving Mullerian ducts and mesonephric ducts. It is also called OHVIRA syndrome . It is characterized by a triad of uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis. Patients usually present after menarche with pelvic pain, dysmenorrhea, mass, and rarely with primary infertility in later years. We report a case of a multiparous female who presented to the hospital with pain in lower abdomen for the past 2 months and acute retention of urine for 1 day. This is an atypical presentation in a multiparous female that has been described in a single case report so far. A 31-year-old female presented to the hospital with a chief complaint of acute retention of urine for 1 day. She also complained of pain in the lower abdomen for the past 2 months. The pain was gradual in onset, intermittent, and with episodes of worsening in between. It was radiating to back and lower limbs and not relieved on rest or medication. The patient reported intermittent bleeding during micturition for the past 2 months. There was no history of trauma, instrumentation, or burning micturition. She had no bowel complaints.The patient attained menarche at 14 years of age and had regular menses since then with average blood flow. She never had complaints of any cyclical dysmenorrhea or any urinary complaints. Her last menstrual period was 20 days ago. She had been married for the last 12 years and was G2P2L2A0 . Both deliveries were done through Caesarean section due to non-progression of labor in first delivery. The patient was informed regarding the presence of didelphys uterus after first delivery.On examination, the patient was conscious and alert. Her vitals were within normal limits. Chest, cardiac, and nervous system examinations were normal. Per abdomen examination revealed soft and tender suprapubic bulge, however, no guarding or rigidity was present. Per speculum examination revealed a large cystic mass in the anterior vaginal wall . CervicaClinical differential diagnoses were ovarian cystic mass and ectopic pregnancy.All laboratory investigations were within normal limits. Urine pregnancy test was negative.T1 weighted images, hyperintense signal intensity with fluid–fluid levels in T2 weighted images was noted communicating with the right cervix and located inferior to cervix suggestive of hematohemicolpos . The obstructed uterine cavity was opened and a probe, 2–4 It is also known as OHVIRA syndrome . Its estimated occurrence is 0.1–3.8% with only a few reported cases occurring during pregnancy.5 It is characterized by uterus didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. The right side is affected twice more frequently than the left side.6,7 The syndrome falls under Type III Mullerian duct anomaly classification system of the American Society for Reproductive Medicine (ASRM). According to the newly proposed classification system based on a review of 79 patients, it is categorized as: Classification 1 - a completely obstructed hemivagina  and Classification 2 - an incompletely obstructed hemivagina .8 Strong suspicion and knowledge of this anomaly are essential for a precise diagnosis.Herlyn–Werner–Wunderlich syndrome is a rare complex congenital anomaly of the urogenital tract that involves abnormal development of the Mullerian and mesonephric ducts in the female embryos.9 Patients can also present with pelvic pain, mass, abnormal vaginal discharge, infertility, endometriosis, complicated pregnancy, and labor.10 The initial clinical diagnosis is incorrect in the majority of the cases because of its rare incidence and misleading presenting signs and symptoms. Menstrual flow from the patent unobstructed hemivagina gives the impression of normal menses. Thus, accurate diagnosis and surgical management may be delayed for several months or even years. Our patient had an atypical presentation being an adult female with no previous history of significant dysmenorrhea and obstetric history of two live births by Caesarean section. She presented with acute retention of urine. Such a presentation in a multiparous female has been described in a single case report so far in the literature.1A typical presentation of this syndrome is dysmenorrhea in adolescent age group, a few months to years after attaining menarche.11 In our case, MRI findings of two widely separated normally developed uterine horns, two separate cervices, patent left vagina and presence of right hematohemicolpos with associated absent right kidney suggested a pre-operative diagnosis of Herlyn–Werner–Wunderlich syndrome. These findings were subsequently confirmed intraoperatively. As per the newly proposed classification system, considering the late presentation of our case and the intraoperative findings, our case was classified as 2.1 that is incompletely obstructed hemivagina with partial reabsorption of the vaginal septum. The intermittent bloody vaginal discharge that has been described in patients with class 2.1 in the article by Zhu et al8 was likely misconstrued as hematuria by the patient in our case.Ultrasonography and MRI are useful in its detection. MRI is the primary modality for diagnosis and pre-operative planning of the Herlyn–Werner–Wunderlich syndrome. It evaluates uterine morphology, detects communication between uterine and vaginal lumen, characterizes fluid contents and diagnose complications like endometriosis.The management in the typical presentation in adolescent or young females is resection of the vaginal septum followed by vaginoplasty. In our case, right hemihysterectomy was performed since the family of the patient was complete and was not planning for pregnancy in the future.Herlyn–Werner–Wunderlich or OHVIRA syndrome is a rare congenital Mullerian duct anomaly which consists of the presence of uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis.MRI is the investigation of choice for detailed evaluation and classification of Mullerian duct anomaly.Awareness of the imaging features of Herlyn–Werner–Wunderlich syndrome on USG and MRI is a prerequisite for early and prompt diagnosis even in an atypical presentation such as in a multiparous female in our case.Early diagnosis and proper surgical management allow rapid relief of symptoms and prevention of potential complications.“Written informed consent was obtained from the patient(s) for publication of this case report, including accompanying images”.


Desmoplastic fibromas exceedingly rarely present in the retro/parapharyngeal space but should be considered in differential diagnosis for benign lumps in these anatomical regions. Desmoplastic fibromas exceedingly rarely present in the retro/parapharyngeal space but should be considered in differential diagnosis for benign lumps in these anatomical regions. While awaiting a tonsillectomy, the patient developed new‐onset snoring and sense of airway obstruction which relieves on neck extension and a lump in his throat. He had no significant past medical history and denied smoking or drinking alcohol.Clinical examination including flexible nasendoscopy demonstrated a firm, smooth swelling arising from the left lateral pharyngeal wall extending superiorly to the level of the soft palate and inferiorly to the level of epiglottis. The oral cavity, oropharynx, larynx, and both piriform fossae appeared normal.a well‐defined 2.9 x 1.9 cm low signal mass inseparable from the left capitis longus muscle on T1 precontrast images with anterior displacement of the well‐preserved prevertebral fat and no locally aggressive features. There was uniform enhancement with contrast and no diffusion restriction. Overall, the appearances were in keeping with a benign soft tissue tumor.A magnetic resonance imaging scan Figures  and 2 shContrast CT reported an absence of calcification or enhancement supporting a benign process with no aggressive features. The patient underwent examination under anesthetic and biopsy of the pharyngeal mass and the fine needle aspiration of the neck lump reported only inflammatory cells and numerous benign squamous epithelial cells with occasional macrophages.The case was discussed at the local head and neck multidisciplinary team meeting with a resulting recommendation of local excision of the primary lesion with the aim of relieving clinical symptoms. The patient was appropriately consented and listed for an external approach neck exploration with excision of lesion.The lesion was accessed by horizontal skin crease incision, clearing level 2a soft tissue, identifying neurovascular structures . Mass was dissected superiorly and freed from the prevertebral muscles. Intraoperative specimens Figures  and 4 coa circumscribed multilobulated tumor composed of sparsely cellular fibromyxoid nodules with scattered bland spindle or stellate cells. No significant nuclear pleomorphism or mitotic activity was seen, and no necrosis was identified. At its periphery the tumor was found to have infiltrated skeletal muscle tissue. The specimen was focally positive for SMA and h‐caldesmon, but negative for MUC4, desmin, EMA, S100 protein, SOX10, ERG, AE1/AE3, and beta‐catenin. Suggestive of a desmoplastic fibroblastoma, although with an exceptional location and multinodular architecture.Histological analysis Figure  of the eThe patient's postoperative period was uneventful except for mild hypoglossal neuropraxic symptoms in the immediate post op period which recovered completely within 2 months.3Desmoplastic fibroblastomas (DFs) are uncommon benign fibrous soft tissue tumors typically occurring between the ages of 40 and 69 and are rarely observed in the tongue, palate, and neck.Radiologically, the appearance of DF is variable and although lesions are usually described as heterogenous and well circumscribed,This case is unique in its clinical presentation with respect to its location and notable multilobular morphology. Although a major percentage of these tumors are delineated, this case showed extension in the adjacent muscle. Follow‐up studies reveal no recurrences of reported cases of this entity and conservative excision is considered curative.Commonest non‐inflammatory prevertebral masses are malignant nodes or invading mucosal head and neck malignancies. Other benign lesions in this region can be vascular malformations, neurogenic, lipogenic, and salivary tumors which can extend into the retropharyngeal space from the parapharyngeal space.4Desmoplastic fibromas exceedingly rarely present in the retro/parapharyngeal space and should be considered in differential diagnosis for benign lumps in these anatomical regions. We have not seen pathology of this type originating from the retro/parapharyngeal space reported in the literature but have shown that diagnostic surgical resection can be performed with the corresponding intent to alleviate symptoms. Once excised and histology is clarified, it is reasonable to manage in the outpatient setting with tapered follow‐up for surgical sequelae and eventual discharge.5Patient consent was obtained for all data in this publication.None declared.Cezary Bielak: wrote abstract, case report, Key clinical message, and manuscript submission.Jake Ahmed: wrote introduction, case report, discussion, and conclusion and created figures.Tehrim Atif: wrote case report, histopathology findings and created figures.Uma Nair: served as lead histopathology consultant, histopathology findings, and manuscript review.Arvind Arya: served as lead ENT consultant, manuscript review, and editing.Hisham Zeitoun: served as lead ENT consultant, manuscript review, and editing.Ligy Thomas: served as team lead consultant, manuscript review, and editing.


Choledochal cysts (CC) are congenital bile duct anomalies, typically present in children. The size of CC vary, but they rarely exceed 9 cm. Surgical resection is the mainstay of treatment. This case report presents 18-year-old female with jaundice and abdominal pain. On imaging she was found to have a type I CC versus a type IVa CC. She was taken to the operating room where she was found to have a 20 cm type I CC. The patient experienced complete recovery after total resection of the extrahepatic cyst with reconstruction with a Roux-en-Y hepaticojejunostomy. Preoperative diagnosis of the type of CCs can be challenging. Proper imaging preoperatively can aid in diagnosis of these cysts, but delineation of anatomy and type may not always be possible. If treated in a timely manner, it can help prevent both long- and short-term complications. Choledochal cysts (CC) are rare congenital anomalies of the biliary ducts. More commonly found in children, the incidence ranges from 1 in 13 000 to 1 in 2 million births [CCs are classified based on the anatomical location, shape and extent of the cystic lesion in relationship to nearby structures , 3. The duct . Type IIThe exact etiology of CCs is unknown; however, delay in diagnosis and treatment CCs have been associated with a number of complications, including stone formation due to biliary stasis, inflammation, infections, pancreatitis, cholangitis and obstruction , 9 AdditAn 18-year-old Caucasian female with BMI of 37 without past medical or surgical history was transferred to our hospital from for evaluation of right upper quadrant abdominal pain and jaundice. Laboratory values were notable for AST of 130 U/L (Ref. range: 10–36 U/L), ALT of 264 U/L (Ref. range: 7–35 U/L), total bilirubin of 2.6 mg/dL (Ref. range: 0–1.4 mg/dL), alkaline phosphatase of 235 IU/L (Ref. range: 44–147 IU/L), Glutamyl-Transferase (GGTP) level of 519 (Ref range: 9–64 U/L), which were concerning for a hepatobiliary etiology.A right upper quadrant abdominal ultrasound was obtained which showed that the gallbladder wall was 3 mm, an obscured common bile duct (CBD), and a cystic lesion communicating with the CBD and a large gallbladder cyst . A contrCCs are congenital biliary duct anomalies. Types I and IV CCs are most prone to malignant transformation, but complete resection decreases this risk of transformation. Typically diagnosed and treated in childhood, they rarely present in adults. Symptomatology is vaguer in adults and this can often lead to delay the diagnosis and treatment. Although rare, CCs should be considered in the differential diagnosis in all patients with a history of biliary colic pain, and dilation or obstruction of the biliary tree. CCs are typically smaller than 9 cm, but in this case, we presented a massive 20 cm type I choledochal cyst in an adult. Timely diagnosis and definitive treatment of patients with CC yields a favorable prognosis and helps to prevent long-term complications associated with CC such as biliary cirrhosis, malignancy and portal hypertension. Therefore, clinicians should be familiar with proper diagnosis and treatment of these entities in both children and adults. Typically, ultrasound is the best initial method for evaluating the entire intrahepatic and extrahepatic biliary system and gallbladder. But, as shown in this case it does not always help in diagnosis especially with very large cysts. MRCP is the current gold standard in the imaging of CC and should be utilized accordingly.Proper knowledge of these cysts, their varying presentations and their correct treatment is vital to surgeons. For our patient, as per the current surgical approach for Type I CC a complete cyst excision, cholecystectomy and bilioenteric reconstruction was performed utilizing the Roux-en-Y hepaticojejunostomy. The surgical treatment employed in this patient successfully resolved the biliary obstruction, restored normal biliary drainage and eliminated long-term risk for malignancy. This approach remains the gold standard. Due to their rare incidence, CCs are sometimes diagnosed intraoperative. It is important to be familiar with the proper diagnosis and management of these uncommon conditions to ensure optimal surgical treatment plane.None declared.None.


Atrial myxoma remains a rare clinical entity with an incidence of surgically resected cases of 0.5–0.7 per million population and prevalence of < 5 per 10,000. It typically manifests in woman after third decade of life; symptoms vary greatly and may present with arrhythmia, intracardiac flow obstruction, embolic phenomenon, and associated constitutional symptoms. Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus. Cerebellar involvement is very rare and only a few cases have been reported in the literature.A 55-year-old Brahmin man with no history of diabetes mellitus and hypertension, presented with complaints of dizziness, headache, vomiting, double vision, and unsteadiness of gait for 2 weeks. His headache was sudden in onset, of a pulsating type and localized on left temporal side. Vomiting was projectile and bilious. Double vision was present in all directions of gaze and he had uncoordinated movement of his body and tilting to the left side. On examination, his cerebellar functions were impaired. He was thoroughly investigated for the cause of stroke after abnormal magnetic resonance imaging results with normal computed tomography angiography of his brain. Echocardiography and computed tomography of his chest showed a mass attached to intra-atrial septum and prolapsing through mitral valve, which was suggestive of left atrial myxoma. Five days following admission, he developed abdominal pain due to thromboembolism causing splenic and renal infarct.Although rare, atrial myxoma has to be considered a cause of stroke and other embolic phenomenon causing multiorgan infarctions. Early and timely diagnosis of the condition can prevent further recurrence and inappropriate anticoagulant therapy. It would be pertinent to have echocardiography done in patients who present with a stroke, arrhythmias, and other constitutional symptoms. The tumor once detected must be removed surgically as early as possible, which not only reduces serious thromboembolic complications but can be potentially curative. Cardiac tumors are uncommon entities in medicine. Primary tumors of the heart are rare entities with an estimated incidence of less than 0.03% of which 75% are benign and half of them are myxomas. Cardiac myxoma (CM) still remains a rare clinical entity with an incidence of surgically resected cases of 0.5–0.7 per million population and prevalence of < 5 per 10,000 .Atrial myxomas are thought to originate from entrapped embryonic foregut. So, they are derived from multipotent mesenchymal cells capable of both neural and epithelial differentiation; hence, they tend to present with emboli. On microscopic examination, they contain scattered cells within a mucopolysaccharides stroma . On grosClinical manifestations may vary greatly. In most cases, the tumor releases fragments or thrombi into systemic circulation leading to embolization and producing systemic and pulmonary manifestations. The most serious complication is neurologic, stroke being the commonest. Other manifestations include heart failure, arrhythmia, and pericardial effusion .Currently, there is no effective medical treatment that arrests the growth of the tumor; thus, surgical excision of the tumor mass is the best modality of treatment. Here we report a case of a 55-year-old man who presented with complaints of headache, vomiting, double vision, and unsteady gait. He was extensively investigated to access the cause of the stroke and, finally, a rare diagnosis of atrial myxoma was made.A 55-year-old Brahmin man presented to our emergency department with complaints of headache, vomiting, double vision, and unsteady gait for 2 weeks. The sudden-onset headache, localized to left temporal region, was also associated with frequent bilious, non-bloody, projectile vomiting. He had reported double vision on the same day in all directions of gaze and unsteadiness of his lower limbs, which led him to tilt toward the left without support, and slowness and incoordination while walking. Furthermore, he had difficulty in holding objects and gripping. There was no fever, loss of consciousness, abnormal body movements, slurring of speech, nasal regurgitation, shortness of breath, chest pain, or palpitation. He occasionally consumed alcohol and was a tobacco smoker without any other significant medical or drug history and no family history of any cardiac disease.On examination, he was alert, hemodynamically stable, and conversant. His vital signs were stable with blood pressure of 150/90 mmHg. Respiratory, cardiovascular, gastrointestinal, and thyroid examinations were otherwise unremarkable. A neurological examination revealed jerky nystagmus with fast component to the left. Hypotonia was present bilaterally on both upper and lower limbs. Past pointing was pronounced on his left hand with heel shin test affected on the left side. He had a wide-based gait and dysdiadochokinesia with normal speech findings suggestive of cerebellar involvement.A complete blood count, lipid profile, thyroid function test, rheumatoid factor, and antinuclear antibody (ANA) test were normal. C-reactive protein (CRP) was positive and erythrocyte sedimentation rate (ESR) was increased to 47 mm/hour. Electrocardiography showed normal functioning heart. Magnetic resonance imaging (MRI) of his brain revealed acute/subacute posterior inferior cerebellar artery (PICA) territory infarct of the left cerebellum with small acute/subacute lacunar infarct of the left pons. Computed tomography (CT) angiography of cerebral vessels showed normal patency of vessels supplying his brain.In order to assess the cause of infarct in his brain, transthoracic echocardiography was performed which showed a 2.5 cm × 2.2 cm mass attached to intra-atrial septum prolapsing through mitral valve with normal systolic and diastolic function suggestive of left atrial myxoma as shown in Fig. However, 5 days after admission, he complained of severe generalized abdominal pain for which a CT scan and other necessary investigations were advised. A CT scan of his abdomen and pelvis was performed which showed non-enhancing hypodense areas in lower pole of his spleen with a defect in one of the branches of the splenic artery suggestive of splenic infarct as shown in Fig. He underwent excision of left atrial myxoma as shown in Fig. Histopathological examination of the excised mass showed marked loose myxoid stroma with scattered spindle cells without atypia confirming the diagnosis of atrial myxoma as shown in Fig. His postoperative period was uneventful and he recovered well. He was doing well at 4-month post-surgery follow-up.We reported a case of 55-year-old man with complaints of vomiting, headache, diplopia, and unsteadiness of gait for 2 weeks. The goals of the initial evaluation were to ascertain whether or not a stroke was present, the affected site of the brain, and, finally, the cause of the stroke.Cerebellar stroke in itself contributes to only a small proportion of all strokes, commonly due to atherosclerosis and other vasculopathies. Atrial myxoma is an exceedingly rare cause of cerebellar stroke requiring a thorough investigation to reach to a diagnosis, which forms a basis for our discussion.CM is the commonest of all primary cardiac tumors. The left atrium is the most common location for the myxoma, as in our case. Right atrial myxoma and ventricular myxomas are even rarer .Clinical manifestations of atrial myxoma vary greatly and patients usually present one of the symptoms in the following tetrad: arrhythmias, intracardiac flow obstruction, embolic phenomena, and constitutional symptoms . EmbolicStroke/transient ischemic attack (TIA) is the most common neurological presentation; most often in multiple sites with syncope, psychiatric symptoms, headache, and seizures . Atrial Patients with PICA territory infarcts most commonly present with acute vertigo, vomiting, headache, gait disturbances, and horizontal nystagmus ipsilateral to the lesion with headache being the most common initial symptom.On clinical examination, left atrial myxoma may simulate many other diseases such as mitral regurgitation, pulmonary embolism, tricuspid stenosis, and tricuspid regurgitation . No physHemolytic anemia and thrombocytopenia, again often noted in left atrial myxomas, are thought to be due to the mechanical destruction of these blood elements by a mobile intraluminal tumor, which was absent in our case perhaps because of the size of the tumor .Transthoracic echocardiography, a non-invasive method, is considered the imaging modality of choice for the diagnosis of CMs, but a transesophageal approach provides a better definition of the location and characteristics of the tumor with sensitivity of almost 100% . Thus, aMRI is more sensitive than CT in identifying subtle abnormalities of the brain as in stroke . Moreoveet al. showed that urgent surgical resection via median sternotomy with the patient on CPB under mild hypothermia is the mainstay of treatment [In general, myxoma represents an emergency. Siminelakis reatment . After dreatment , 8. Consreatment . HoweverRealistically, at stroke onset, one rarely knows if a patient has a myxoma, and it is difficult to evaluate all patients with echocardiography before starting thrombolysis because an incorrect diagnosis can lead to inappropriate treatment with anticoagulation as opposed to surgical resection . Tumor rCM often presents with an embolic phenomenon causing stroke. Cerebellum involvement is not common, which can easily mask myxoma as the differential diagnosis for the cause of stroke. A high degree of suspicion is necessary for early diagnosis and prevention of complications. The commonest means of reaching the diagnosis is echocardiography; it should be done in all cases of stroke as a screening tool to rule out any intracardiac mass, such as CM, as a source of emboli causing stroke. Urgent surgical excision of the mass remains the definitive treatment. Delay in immediate intervention can result in serious thromboembolic complications which can be life threatening. Regular long-term follow-up is necessary.


Posterior rectus sheath hernia is a truly rare finding, with only 11 documented cases since the first report in 1937. A posterior rectus sheath hernia is herniation of bowel and/or omentum through the posterior portion of the rectus sheath, but not through any other structure. This can only occur medial to the spigelian fascia, differentiating it from a spigelian hernia. Previous missed cases have led to complications such as bowel incarceration, obstruction or even strangulation and have required surgical intervention. In this case report, we describe an incidental finding of a non-complicated posterior rectus sheath hernia in an 83-year-old male. Annotated cross-sectional imaging provides anatomical context that is not widely available in the existing literature. Due to its rarity and potential complications, it is also important to report this case in order to enhance the evidence base for posterior rectus sheath hernia and to familiarize this uncommon condition to radiologists, clinicians and surgeons. A CT Urogram was performed for investigation of the haematuria which revealed a small, well-defined, mildly enhancing right renal mass. The outcome from the urology MDT was to have a repeat CT in 6 months. An incidental finding of a left posterior rectus sheath hernia was noted and reported.The patient’s surgical history includes a previous laparoscopic cholecystectomy for cholecystitis in 1991, left inguinal hernia repair in 1992 and a subsequent re-repair with synthetic mesh in 1996. Upon noting the hernia, a retrospective history revealed the patient did experience intermittent abdominal pains. Although the definitive cause cannot be known, it could be related to the hernia.A CT Urogram and a 6 month follow-up Triple Phase CT of the Kidneys clearly demonstrated the posterior rectus sheath hernia with almost no significant interval changes. The contrast enhanced, portal venous phase CT imaging shows splitting of the posterior sheath of the left rectus abdominis muscle with intact posterior sheath on the right side . The def5 Previous cases have been managed conservatively, with surgical repair only occurring if the hernia becomes significantly symptomatic or strangulates. In this case, the patient has no significant symptoms and the appearances are stable on imaging. Therefore, conservative approaches have been taken.Due to the obscurity of the pathology, specific management does not have a good evidence base or NICE guidance. As such, the management has been based upon the general principles of hernia management.4Potential complications documented in the literature are comparable for other hernias, the most significant of which is ischaemia of the bowel.No specific follow-up plan has been arranged given the incidental and largely asymptomatic nature of the hernia. The patient did have follow-up imaging for a renal mass which showed stable appearances of the hernia. Any further interventions should be considered when and if the hernia becomes symptomatic.6The main differential diagnosis is a spigelian hernia. This can be differentiated from a posterior rectus sheath hernia as a spigelian hernia occurs lateral to the rectus abdominis muscle and typically bulges into the subcutaneous tissue. A posterior rectus sheath hernia does not bulge into the subcutaneous tissues and occurs posterior to the rectus abdominis muscle.3Posterior rectus sheath hernia can also present with bowel obstruction. In this context, the differentials would include other causes of bowel obstruction, for example; adhesions relating to previous surgery, malignancy, pseudo-obstruction or ileus.2 making it weaker and more susceptible to herniation.The rectus sheath is a tough fibrous compartment which contains the rectus abdominis muscle and pyramidalis muscle. It extends from the inferior costal margin and ribs 5, 6 and 7 to the crest of the pubis. The sheath has anterior and posterior layers that fuse laterally at the linea semilunaris and in the midline at the linea alba. Above the arcuate line, the anterior compartment consists of the fascia from the external oblique and half of the internal oblique. The posterior compartment is made up from the fascia of the other half of internal oblique, the fascia of transversus abdominis and the transversalis fascia. Below the arcuate line, the anterior compartment is made of fascia from all three lateral abdominal wall muscles and only the transversalis fascia contributes to the posterior compartmentPosterior rectus sheath hernia is an exceedingly rare type of anterior abdominal wall hernias with only scarce cases recorded. It also belongs to the subtype of interparietal hernias in which the hernial sac unusually lies between the various layers of the abdominal wall muscles and does not exit into the subcutaneous tissue as other abdominal wall hernias do.3 Considering this patient’s previous history of hernias, it could be that there is either a congenital propensity to hernias or the hernia has occurred because of previous surgical interventions. In addition, similar to other types of hernias, any conditions which increase intra-abdominal pressure such as obesity, ascites and progressive muscle weakness increase the likelihood of these hernias.The exact cause of these hernias is still not clear with the limited literature available suggesting three main causes: congenital; post-surgical and traumatic .4 Some cases have demonstrated recurrence and complications, highlighting the importance of recognizing it in asymptomatic patients.3Posterior rectus sheath hernia diagnoses have historically been proven by surgery. CT scanning appears to be a modality with high sensitivity for the condition allowing easy and accurate diagnosis, as those cases diagnosed on CT have all been confirmed on surgical exploration.7The management of posterior rectus sheath hernias is currently based upon the general principles of hernia management. Recent evidence has emerged that highlights the potential role of laparoscopic repair in selected cases of abdominal wall hernias compared with traditional open techniques.In conclusion, this case describes a non-complicated posterior rectus sheath hernia with labelled cross-sectional imaging that will act as an aid for radiologists and surgeons in identifying future cases. A small but growing body of cases are now available, including those which focus on surgical techniques. Further research in this area is required to standardize management.A posterior rectus sheath herniation is rare but important to recognize and can be easily overlooked.A lack of familiarity with the nonspecific presentation may result in delayed or even misdiagnosis of this type of hernia.The recent availability and the widespread use of cross-sectional imaging in diagnosis has added a superior and detailed anatomical view sufficient enough to allow easier diagnosis and classification of herniation.


A gallbladder volvulus is a rare medical condition requiring emergency surgery. There are 500 cases reported in the literature, and only 10 % have ever been diagnosed preoperatively. Gallbladder volvulus occurs when the gallbladder torts around the cystic duct and cystic artery resulting in occlusion of both structures and consequently, ischemia of the gallbladder. The diagnosis is challenging because the symptoms mimic cholecystitis without distinct radiological features specific for a volvulus.In this article, we report the case of a 77-year-old female who underwent ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and cholescintigraphy, which all reported features of cholecystitis. She underwent a cholecystectomy on admission day 5 because of refractory pain despite treatment with intravenous antibiotics. Intraoperatively, she was discovered to have complete gallbladder torsion with gangrene. Post-operatively, she had immediate and complete resolution of pain, and made a rapid recovery.We review the available literature to determine radiological characteristics specific to a gallbladder volvulus. Patients without cholelithiasis and incomplete filling of the gallbladder in a nuclear medicine scan should be evaluated for gallbladder volvulus.Through this report, we suggest a high index of suspicion for gallbladder volvulus in elderly female patients with signs and symptoms of acalculous cholecystitis that have no resolution in symptoms with conservative management. A recen2A 77-year-old woman presented with a 1-day history of constant, sharp, right upper quadrant and epigastric abdominal pain, associated with multiple episodes of non-bloody emesis. She did not identify any triggers for the pain, and specifically stated that the pain is not worse post-prandially. She endorsed a history of recurrent episodes of similar pain over the past several months that were 10–15 min s in duration and always self-resolving. Her past medical, surgical, and family history were non-contributory. She was on no home medications. Laboratory findings were initially unremarkable, but upon re-draw the next day, white blood cell count and C-reactive protein (CRP) were mildly elevated. An ultrasound of the abdomen showed a distended gallbladder with mild pericholecystic fluid, a positive sonographic Murphy’s sign, but no cholelithiasis or extrahepatic bile duct dilatation . Given tThe procedure was initiated laparoscopically, but there were dense adhesions in the right upper quadrant not allowing for safe visualization of the gallbladder, which resulted in conversion to an open cholecystectomy. Intraoperatively, the gallbladder was found to be 180 degrees torted in an anticlockwise direction. The torsion caused a complete occlusion of the cystic duct and cystic artery resulting in a gangrenous and necrotic gallbladder . In retr3Gallbladder torsions have been studied and described through case reports. The statistical sensitivity and specificity of clinical, laboratory and imaging findings have not been determined, likely due to paucity of cases . HoweverIn this patient, it was unresolving pain on day 5 of intravenous antibiotics that prompted operative management, but if gallbladder torsion was suspected, a cholecystectomy might have been pursued sooner. In retrospect, cystic duct occlusion on HIDA with a lack of gallstones on cross-sectional imaging should have increased suspicion for gallbladder torsion. However, the patient had no specific signs of torsion on imaging, such as whirling, floating, thumbprinting, bull’s eye, or the cystic duct knot sign.Through this report, we recommend a high index of suspicion for a gallbladder volvulus in elderly female patients admitted with cholecystitis who have no resolution with conservative management, and also have imaging findings of cystic duct occlusion on HIDA without gallstones on MRCP or US.4The differential diagnoses of acalculous acute cholecystitis should include gallbladder volvulus. In a patient with persistent symptoms of right upper quadrant pain, nausea, and vomiting in the absence of gallstones, gallbladder volvulus must be a strong consideration. The findings of incomplete uptake in the cystic duct on HIDA and MRCP may suggest secondary causes of cystic duct occlusion, such as torsion of the gallbladder, but the diagnosis is essentially a clinical diagnosis.The authors report no declarations of interest.The publication of this article was funded by the Department of Surgery, University of Saskatchewan.The study was exempt from the Research Ethics Board (REB) at the University of Saskatchewan as it is a case report, and the study does not influence the care of the patient.Formal consent was obtained from the patient for the publication of this case report and any accompanying images.All three authors were part of the circle of care for this patient while in hospital.Dr. Zarrukh Baig  is the primary author of the article.Dr. Vladimir Ljubojevic (Radiology) interpreted the imaging findings, formatted the pictures, and helped with the writing of the manuscript. Dr. Francis Christian is the primary investigator, the primary surgeon in the care of this patient, and helped with the study concept.Not applicable.Dr. Francis Christian and Dr. Zarrukh Baig are the guarantors of this publication and accept full responsibility for the work and/or the conduct of this study.Not commissioned, externally peer-reviewed.


Although osteoma is a common benign tumor of the paranasal sinuses, its orbital extension is not common. Secondary orbital cellulitis has rarely been reported in association with sino‐orbital osteoma.A 30‐year‐old woman presented with left side proptosis, orbital pain and inflammation. Orbital CT scan showed a well‐defined giant osteoma in the superonasal part of the left orbit originating from the left ethmoidal sinus associated with opacity of the ipsilateral ethmoidal sinus and infiltration of orbital soft tissue. After treatment by systemic antibiotics, osteoma was resected with combined external and endoscopic surgery and the patient recovered uneventfully.Sino‐orbital osteoma may manifest primarily as orbital cellulitis and needs early surgical intervention. She also complained from headache, general weakness and fever. She had a history of congenital strabismus in the left eye but no history of head trauma.On general examinations, her temperature was 38.5°C. Her corrected visual acuity was 10/10 and 7/10 in the right and left eyes, respectively. She had a 5‐mm non axial proptosis and a temporal and downward displacement of the left‐sided globe. In addition to conjunctival injection and chemosis, the eyelids were edematous and inflamed in the left eye. Ocular movements of the left eye were limited in the upward and inward directions. Other ocular examinations including anterior and posterior segments were unremarkable. The afferent pupillary defect was negative Figure .Orbital CT scan showed a dense, heterogeneous, well‐defined and lobulated mass in the superonasal part of the left orbital extraconal space at the common border of the frontal bone and ethmoidal sinuses. As an anatomic variation, frontal sinuses were not pneumatized and left ethmoidal sinus was partially involved by the tumor. Tumor had displaced the globe to the inferotemporal space and exerted a pressure effect on the left medial rectus and optic nerve. Other findings were opacification of the left ethmoidal sinus and infiltration of the left orbital soft tissues Figure .The patient was admitted with the diagnosis of orbital cellulitis and underwent medical treatment with intravenous antibiotics including Ceftriaxone  and Vancomycin (Afachemi) 1 g every 12 hours each.After a 3‐day systemic treatment and partial resolution of the orbital inflammation, at first the patient underwent an endoscopic approach for tumor excision under guidance of a navigation system by a team consisted of otolaryngology and oculoplastic surgeons. After left ethmoidectomy, the ethmoidal part of the tumor was released from its connections in the sinus via the transnasal endoscopic approach. Because of the high density and large size of the tumor, the en‐block excision was only possible when the external approach via the modified Lynch skin incision was added to the endoscopic method. The excised tumor was a polypoid dense white mass measuring 3.5 × 2 × 1 cm. Histopathological examinations disclosed a dense lamellar mature bone tissue with numerous peripheral osteoblasts and interosseous fibrovascular tissues, consistent with a cancellous type osteoma (Figure There was no evidence of cerebrospinal fluid rhinorrhea post‐operatively. In addition to improvement in ocular movements, the proptosis and globe displacement were completely resolved after surgery but the congenital exotropia remained unchanged. Skin incision healed beautifully and no significant scar was seen Figure .The patient was also evaluated for Gardner syndrome by a gastroenterologist and her gastrointestinal endoscopic examinations were unremarkable. In follow up CT scan 2 years after the surgery, there was no evidence of tumor recurrence and the left orbital bony walls were intact excepting the lamina papyracea Figure . The pat3In this article we reported a rare case of orbital cellulitis secondary to a giant sino‐orbital osteoma and its successful management.Osteoma is a slow‐growing mesenchymal tumor which often involves periorbital sinuses in the craniofacial area.Most of the sinus osteomas are asymptomatic and can be an accidental finding of craniofacial imaging.Signs and symptoms of orbital extension of sinus osteoma can be divided into two categories. The first category is the result of pressure effect of the tumor including proptosis, orbital pain, diplopia, decrease in visual acuity, palpable mass and epiphora. The second category includes clinical findings secondary to sinusitis which may be the result of obstruction or damage to the involved sinus and presenting as orbital emphysema, orbital cellulitis and subperiosteal abscess formation adjacent to the involved sinus.Trauma, infection and developmental anomalies are suggested as the etiologic background of osteoma. In rare cases it may be seen in a genetic background such as Gardner syndrome that was rolled out in our case.For symptomatic cases of sino‐orbital osteoma specially giant osteomas, as reported in our patient, different surgical approaches are recommended from a pure external approach to a complete endoscopic technique.In cases with obstructed sinus openings and development of sinusitis, mucocele or cellulitis in the adjacent tissues, repair of the sinus drainage pathway and returning the sinus aeration, similar to what performed in our case, are mandatory.Although partial removal of the sino‐orbital osteomas was reported to be successful in many cases but tumor recurrence was reported in a few cases.In conclusion orbital cellulitis is a rare complication of sino‐orbital giant osteomas, which needs urgent intervention to not only treat the infection but also to remove the tumor and establish the sinus drainage.The study protocol was approved by the scientific and ethics committee of the Ophthalmic Research Center at Shahid Beheshti University of Medical Sciences and adhered to the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from patient to use her medical data and face photographs.The authors have no financial interest in the subject of this article.Abbas Bagheri: Conceptualization; data curation; investigation; project administration; supervision; writing‐original draft; writing‐review and editing. Mohadeseh Feizi: Data curation; investigation; software; writing‐original draft. Reza Jafari: Data curation; investigation; writing‐original draft. Mozhgan Rezaei Kanavi: Data curation; investigation; methodology; supervision; writing‐review and editing. Nasim Raad: Conceptualization; data curation; methodology; validation; writing‐original draft.


Ganglioneuromas (GNs) are benign, differentiated tumors that are derived from neural crest sympathogonia. They can be found anywhere in the body along autonomic ganglia. These tumors are seen most often in individuals over 10 years of age and are usually asymptomatic. However, GNs can grow large and cause symptoms due to mass effect. GNs are rarely located within the suprarenal gland and are benign tumors that are often diagnosed late in their course due to mass effect or found incidentally on imaging studies. We describe a case of a 22-year-old female who presented to clinic with vague abdominal pain. She underwent an extensive workup which ultimately revealed a rare presentation of a left suprarenal GN that required surgical removal. She underwent an extensive workup which ultimately revealed a left suprarenal GN that required surgical removal. The patient underwent laparotomy and surgical excision of the mass and made a full recovery. Ganglioneuromas (GNs) are benign, differentiated tumors that are derived from neural crest sympathogonia. These tumors can be found anywhere in the body along autonomic ganglia. However, the two most common locations are the retroperitoneum (32%-52% of cases) and posterior mediastinum (39%-43%), followed by the cervical region (8%-9%) . In a seA 22-year-old female with no significant past medical history presented to clinic for evaluation of vague abdominal pain. She reported a history of progressively worsening pain in the epigastric region along with nausea and bloating that had been ongoing for the past two months. She had been followed by her primary care physician and reported minimal response to over-the-counter analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs, and antacids. She also noted no improvement with diet changes. Initial bloodwork revealed elevated liver function tests on workup and she was referred for imaging evaluation.An ultrasound was performed which demonstrated cholelithiasis without cholecystitis and a cystic structure between the left kidney and the spleen with atypical features. The patient was sent for a subsequent CT of the abdomen and pelvis with and without contrast which revealed a large left upper quadrant cystic mass with septations and calcifications. The mass compressed multiple structures and displaced the pancreas anteriorly and the spleen laterally. An MRI was performed and demonstrated a 10.0 cm x 12.2 cm x 13.3 cm  retroperitoneal mass with predominate fat signal. Displacement of the left kidney inferiorly, spleen laterally, and stomach superiorly led to a presumed suprarenal origin  utilizing low dose hydromorphone. She had no complications and made a full recovery.Ganglioneuromas are benign differentiated tumors derived from neural crest sympathogonia. These tumors occur mainly in adolescents and young adults. The incidence of GNs is approximated to be one per million people . They caGanglioneuromas are seen most often in individuals over 10 years of age and are usually asymptomatic. They are commonly discovered incidentally on imaging. However, GNs can grow large enough to cause symptoms due to mass effect as was demonstrated in our patient. Although most are nonfunctioning, approximately 37% of GNs secrete catecholamines and their metabolites. These secretions can include vasoactive intestinal peptide which can lead to profuse watery diarrhea in patients [A diagnosis of GN should be suspected in patients with adrenal tumors that demonstrate: (1) no hormonal hypersecretion, (2) presence of punctate or discrete calcifications, (3) absence of vessel involvement, and 4) a low nonenhanced T1-weighted signal with a late and gradual enhancement on dynamic MRI [ a low noDifferential diagnoses of GNs include: ganglioneuroblastoma, neuroblastoma, composite pheochromocytoma, adrenal cortical adenoma, and adrenocortical carcinoma . ConfirmFurthermore, while a great majority of GNs are sporadic, familial disposition as well as associations with Turner Syndrome and multiple endocrine neoplasm II (MENII) have been reported . Our patGanglioneuromas are rarely located within the suprarenal gland and are benign tumors that are often diagnosed late in their course due to mass effect, or found incidentally on imaging studies. We have described a case of a 22-year-old female who was diagnosed with this rare tumor after vague abdominal symptoms prompted further imaging studies. Prognosis in these patients is excellent after resection.


Hepatic cavernous hemangioma is the most common type of benign liver tumor. Although ruptures and hemorrhages of hepatic hemangioma are rare complications, they are associated with high mortality. Most practitioners only pay more attention to abdominal hemorrhages caused by the rupture of hepatic hemangiomas. However, spontaneous intracapsular hemorrhages can often be neglected and poorly understood.A 65-year-old man was referred to our institution with right upper quadrant pain, which had occurred suddenly and without a history of recent trauma. The blood test results were normal. Magnetic resonance imaging (MRI) of the abdomen showed a cystic mass in the right liver lobe. Considering the possibility of hepatic cystadenoma with hemorrhage, the patient underwent a right hepatic lobectomy. The pathological findings unexpectedly revealed intratumoral hemorrhage of hepatic hemangioma. The patient recovered well and was discharged eight days after surgery.Intracapsular hemorrhage of hepatic cavernous hemangioma is challenging to diagnose and has a high potential risk of rupture. MRI is beneficial for diagnosing subacute internal hemorrhage cases, and it is recommended to undergo surgery for patients with a definitive diagnosis. The cavernous liver hemangioma is the most common benign tumor of the liver, and its pathogenesis is still unclear. It is common in middle-aged women . Most of9/L , a red blood cell count of 3.75 × 1012/L , hemoglobin level of 124 g/L , platelet count of 279 × 109/L , an activated partial thromboplastin time (APTT) of 31.8 s , a prothrombin time (PT) of 11.0 s , an alanine transaminase (ALT) level of 17 U/L , an aspartate aminotransferase (AST) level of 17.7 U/L , an alkaline phosphatase (ALP) level of 106 U/L , a total bilirubin (TB) level of 5.6 μmmol/L , and an albumin (ALB) level of 37.4 g/L . Tests revealed that HBsAg was negative, anti-HBs Ab was positive, and anti-HCV Ab was negative. Concentrations of all tumor markers were also determined and showed an alpha-fetoprotein (AFP) level of 1.65 ng/mL , a carbohydrate antigen 19–9 (CA 19–9) level of 5.59 U/mL , and a carcinoembryonic antigen (CEA) level of 0.28 ng/mL . Abdominal MRI revealed an 11.3 cm × 8.2 cm × 9.9 cm cystic mass in the right lobe of the liver, with multiple-room and an uneven signal, and Wan fang database for articles from January 1995 to January 2021. We retrieved only 8 cases reported in Chinese or English. Patient data, including author, gender, age, preoperative diagnosis, and treatment procedures, were extracted. We summarized the relevant findings in Table All patients had no history of trauma. The methods of diagnostic Imaging included Computed Tomography (CT), MRI, or Ultrasound. The six patients underwent surgery directly; one patient first underwent a transcatheter arterial embolization (TAE), then agreed to liver resection, while one selected TAE due to pregnancy. All patients were successfully cured and discharged, and no patients died.Cavernous hemangioma is most common in the liver. The cause of the disease is not clear; it is believed that it may be related to abnormal vasculogenesis and angiogenesis . HepaticPatients with hepatic hemangioma have different clinical symptoms, and abdominal pain is the most common symptom. The majority of patients only have upper abdominal pain; however, typical hepatic hemangioma rupture symptoms include sudden, severe abdominal pain, massive abdominal bleeding or hemorrhagic shock, etc. Fever, however, is a very rare symptom. In the mentioned cases, three patients had fever symptoms, one of which was first diagnosed as a liver abscess , but theWith the improvement of health conditions and people's health awareness, more and more patients with hemangioma of the liver have been found. Hemangioma is diagnosed with various imaging techniques such as ultrasound, CT, MRI, angiography, positron emission tomography (PET), which provide a diagnostic accuracy of > 90% . MRI is Hepatic hemangiomas grow slowly, and the course of the disease lasts for several years. There are no clinical symptoms when the tumor is small. When the diameter is > 4 cm, which is categorized as a “giant hemangioma” that causes abdominal discomfort or pain as the tumor size increases . The incIntracapsular hemorrhage of hepatic cavernous hemangiomas is very rare, which is difficult for us to distinguish from hepatic cyst masses with an intratumoral hemorrhage or even malignant liver tumors. Due to the high mortality of tumor rupture, appropriate treatments are recommended as soon as possible after diagnosis.


Mediastinal thymic cysts are uncommon lesions. Thymic cysts are usually diagnosed incidentally, and their origin could be congenital or acquired. Herein we present the case of a patient who presented with dyspnea. Chest computerized scan showed a large cystic mass. Surgical excision was performed. Pathology findings were consistent with congenital thymic cyst. Thymic cysts are rare benign lesions. They constitute 1% of all mediastinal cysts . This leA 67-year-old woman with a history of closed mitral valve commissurotomy carried out via right thoracotomy 20 years ago present with a 10-month history of dyspnea. Cardiac examination demonstrated an irregularly irregular pulse with a mid-diastolic rumbling murmur at the apex. She demonstrated one plus pitting edema of the lower extremities. Echocardiography showed a calcified rheumatic mitral valve, severe mitral stenosis, moderate tricuspid regurgitation, and loculation in the lung filed. A chest X-ray revealed a radio dense mass in the mediastinum. Computed tomography (CT) of the chest showed a cystic mass in the mediastinum that was about 10.70 × 5.35 cm in size and extended from the upper end of the sternum to 11.52 cm below it (Figure A coronary angiography did not reveal coronary obstruction. She was scheduled for mitral valve replacement, tricuspid valve repair, and excision of the mediastinal cyst. During sternotomy, a cystic lesion was found in the middle mediastinum. The cyst was well defined and encapsulated and had a thin wall without any signs of invasion to the surrounding tissue. The cystic lesion was excised with thymic remnant without rupture and sent for pathological examination. The surgical specimen was a unilocular cyst with a smooth surface and clear content measuring 10×10×5 cm and weighing 236 g (Figure Microscopic examination showed a cystic lesion filled with a clear material with a maximum wall thickness of 0.2 cm compatible with a unilocular thymic cyst Figure . The patient was discharged without any problems on the seventh day after the operation.A mediastinal thymic cyst is a very rare pathological finding comprising only 1% of all mediastinal cysts. Thymic cysts were first defined by Lieutaud in 1832 . Thymic Mediastinal thymic cysts in the elderly patients are extremely rare. Surgical resection results in definitive diagnosis. Prognosis for thymic cyst is good.


Pott’s puffy tumor, typified by a subperiosteal abscess underlying the frontal bone, is an uncommonly encountered clinical entity that can occur in the setting of local trauma or secondary to frontal sinusitis. Diagnosis can be challenging, as cultures may be sterile, and the condition must be differentiated from neoplasm and superficial and soft tissue infection. Although more common in the pediatric population, Pott’s puffy tumor must remain on the differential with a high index of suspicion in adult patients who fit the clinical picture. Early diagnosis with CT or MRI and therapeutic medical and surgical intervention are crucial as intracranial complications, such as abscess and empyema can occur and may be fatal. We present an adult patient with a history of inhaled drug abuse who presented with Pott’s puffy tumor with meningitis and bifrontal epidural abscesses at presentation. There is evidence in the literature that management of sinus-related intracranial epidural abscess with antibiotic therapy and adequate surgical or endoscopic surgical drainage may bypass the need for neurosurgical intervention, as was the case here. Pott’s puffy tumor is osteomyelitis of the frontal bone accompanied by abscess in the subperiosteal region. Generally occurring secondary to sinusitis or trauma, this rare clinical entity and its intracranial complications develop due to the anatomy of the sinuses and their venous drainage ,2. The dWe present a case of Pott’s puffy tumor in an adult patient complicated by pachymeningitis and leptomeningitis and bifrontal epidural abscesses. A 31-year-old man with a history of inhaled heroin and fentanyl abuse presented to our hospital with a one-week history of progressive headache and pain over his left eye with associated swelling and subjective fevers. The patient also reported several days of weakness, fatigue, and poor oral intake but denied any vision changes or eye discharge. He denied any history of recent trauma and denied any other medical or surgical history.3 cells/μL. CT scan of the orbits revealed preseptal and orbital cellulitis with evidence of intracranial extension of the infection with enhancing wall fluid collections suggestive of bifrontal epidural abscesses secondary to frontal sinusitis. Diffuse soft tissue swelling in the bifrontal scalp was consistent with Pott’s puffy tumor , neurosurgery, and ophthalmology were consulted. Further workup with MRI of the brain with and without contrast was performed and demonstrated left periorbital and left frontal subcutaneous soft tissue cellulitis and edema consistent with Pott’s puffy tumor as well as bifrontal pachymeningitis and leptomeningitis and sinusitis with abscess formation in the frontal sinus, left maxillary sinus, anterior left ethmoid sinus, and the bifrontal epidural space Figure .Blood cultures from admission remained sterile. Per ENT, operative intervention was delayed for 72 hours of antibiotic therapy with IV vancomycin 1.25 g every eight hours, cefepime 2 g every eight hours, and metronidazole 500 mg every eight hours; the patient then underwent frontal bilateral sinusotomy, total ethmoidectomy, sphenoidotomy, maxillary antrostomy, and inferior turbinate reduction. Surgical pathology revealed sinonasal mucosa with chronic inflammation, cartilage, and reactive bone. Postoperative CT head with and without contrast revealed decreased left periorbital and frontal cellulitis and bifrontal epidural abscesses that were stable in size with no evidence of mass effect. Per neurosurgery, no acute surgical intervention was necessary for drainage of residual epidural abscesses.Two days postoperatively, the patient signed out against medical advice and was discharged on a six-week course of oral levofloxacin 750 mg one tab daily, linezolid 600 mg one tab daily, and metronidazole 500 mg one tab daily.3 cells/μL; physical exam revealed no forehead or periorbital edema and intact extraocular movements. Repeat CT with contrast showed decreased size of the bifrontal epidural abscesses and improved aeration of the sphenoid and maxillary sinuses.Three weeks later, the patient returned for follow-up in the outpatient clinic. He complained of a mild headache controlled with medication and otherwise reported doing well. The patient was afebrile with a white count of 7.2 x 10Pott’s puffy tumor is an infrequently encountered clinical entity in the setting of improved antibiotic treatment for sinusitis. Although it can be associated with local trauma, Pott’s puffy tumor generally arises secondary to untreated or partially treated frontal sinusitis . While iTypical presentation of Pott’s puffy tumor includes symptoms of fever, headache, periorbital swelling and pain, purulent rhinorrhea, and vomiting. The clinical picture must be differentiated from more common conditions, such as neoplasm and superficial and soft tissue infection. Due to the rarity of Pott's puffy tumor, which is even more pronounced in adult patients such as ours, diagnosis is often challenging and can be delayed, leading to life-threatening complications. Intracranial complications can arise from direct extension or venous drainage and include subdural, epidural, and intraparenchymal abscesses, meningitis, and cavernous sinus thrombosis . While tBecause of its rarity and potentially fatal complications, Pott’s puffy tumor should be on the differential in patients with painful forehead swelling and frontal sinusitis or recent trauma. Diagnosis must be discerned from benign or malignant neoplasm, soft tissue infection, or hematoma with superimposed infection. CT or MRI confirms the diagnosis. Combined medical treatment with antibiotics and surgical treatment with drainage and debridement or endoscopic intervention is the standard of care . As is dA high index of suspicion is necessary to recognize Pott’s puffy tumor and its potentially fatal intracranial complications, especially in adult patients such as ours whose complications may be neurologically asymptomatic. Early diagnosis and therapeutic intervention for Pott’s puffy tumor are crucial to increase the likelihood of favorable outcomes.Diagnosis can be established with CT with contrast followed with MRI of the brain to delineate the extent of intracranial complications, as was performed in our case. Therapeutic intervention is generally pursued in the form of combined medical and surgical management; a case such as ours demonstrates that intravenous antibiotic therapy with prompt surgical or endoscopic drainage of the sinuses may allow for conservative management of intracranial epidural abscesses from a neurosurgical perspective.


Duodenal diverticulosis (DD) is a rare disease in children, and its etiology is unknown. Here, we report a 13-year-old boy with severe abdominal pain. A diagnosis of DD was made based on clinical and image findings. He responds to analgesic, antibiotic and nutritional treatment. The early identification of child with DD as potential cause of severe abdominal pain with pancreatitis is important - because delayed diagnosis might lead to irreversible consequences - to avoid morbidity and mortality, and unnecessary surgery. The duodenum is considered the second most common site of diverticula with the colon being the commonest site . The pre9/L), platelet 412 , serum triglycerides 108 , calcium 9.9 , serum amylase 560  and serum lipase 190 . Serum alanine transaminase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, albumin, and bilirubin were normal. An abdominal X-ray showed nonspecific bowel gas distribution with no signs of bowel obstruction, and no free air or pneumatosis intestinalis. A broad-spectrum antibiotics and acetaminophen were started and the patient kept nil per mouth. A computed tomography (CT) of the abdomen demonstrated the circumferential thickening in the wall of the gastric antrum and pylorus as well as the duodenum. Periduodenal edema and free fluid was identified with the head of pancreas being swollen and edematous suggestive of pancreatitis. There was slight distention of the common bile duct (CBD) with enhanced wall. Two out-pouches from the second part of the duodenum were identified from the medial and superior walls that is fluid filled and showed air fluid level , white blood cell 7.8  reported abnormal wall thickening of the antrum, pylorus, and first and second parts of the duodenum. The two large duodenal diverticula were described again in Figure The head of pancreas was found to be swollen and inseparable from the duodenum and the diverticulum. Signs of acute pancreatitis and dilated CBD were present. Swallowing study demonstrated the duodenal diverticulum as an out-pouch from the medial wall of the second duodenum that was filled with contrast throughout the exam Figure . It alsoThe duodenum is considered the second most common site of diverticula following the colon . DependiDue to the nature of the disease, 90% are asymptomatic and discovered incidentally during an upper endoscopy or barium study . The remPrevious reports suggest that radiographic studies do not routinely add to the accuracy of preoperative diagnosis of diverticular disease . HoweverPatients with asymptomatic duodenal diverticulosis do not require treatment. The management in symptomatic patients is based on their clinical presentation. Patients who present with diarrhea and malabsorption due to small intestinal bacterial overgrowth are treated with antibiotic therapy such as rifaximin . Small bSimilar cases of DD in adults can be easily diagnosed and identified using specific imaging protocols and guidelines. This case is reported because of its rare cause of abdominal pain and challenging diagnostic imaging findings in a 13-year-old child. The early identification of child with DD as potential cause of severe abdominal pain with pancreatitis is important. It needs a skilled physician to detect the DD and to order the appropriate imaging techniques. Delay in making the diagnosis of DD due to its rare occurrence in the children population might lead to drastic repercussions that will lead to high morbidity and mortality that can easily be avoidable.


Mesenteric artery re-vascularization using bypass or angioplasty is a standard of care in atherosclerotic mesenteric vascular disease. However, there are no certain guidelines for the management of non-atherosclerotic thrombophilic mesenteric vessel disease other than anti-coagulation.We are reporting a case of a 36 years old lady with post-prandial angina and weight loss on the background of anti-phospholipid syndrome having tripple mesentric vessel occlusive disease who underwent 2 vessel aorto-mesenteric bypass. During the post-op course, patient had laparotomy with diversion ileostomy for ischemic perforation of the bowel. At present, after 6 weeks patient is recovering well with improved appetite and resolution of symptoms.There are very few cases reported with acute on chronic mesenteric ischemia in England. Nikolas Melas et al. reported similar history in a 57 yrs old Caucasian female. Morbi AH2 highlights timely diagnosis of acute mesmeric ischemia in a 53 yrs old.This case report is unique in a way that combined mesenteric ischemia and APS is a rare combination in a 36 years old.Mesenteric artery bypass is one of the possible solutions to thrombophilic mesenteric disease, however larger studies with longer follow up are needed. The typical presentation includes postprandial pain, weight loss resulting from fear of eating, or unexplained diarrhoea . Mesente2We report case of a young 36 years old English female as per SCARE  criteriaOn admission, her inflammatory markers were significantly high. CT scan showed occlusion of Celiac Trunk and SMA. IMA could not be identified. Very minimal enhancement of small bowel loop effecting the distal ileum in the pelvis concerning for ischemic segment.Despite proactive implementation of treatment dose heparin, aspirin and statin her pain didn’t improve and it was decided by vascular MDT to perform surgery. She underwent emergency aorto-common hepatic and aorto-SMA bypass graft done by team of experienced vascular consultants. After 1st surgery, she underwent explorative laparotomy which showed an intestinal perforation and had resection of 30 cm ischemic bowel. After the procedure, she stayed on treatment dose IV heparin. 5 days post- bowel resection she dropped her Hb and had to undergo 3rd explorative laparotomy for Pelvic hematoma, which was evacuated, cavity was washed and vac dressing applied. In 3rd exploration, anastomosis was intact and bowel was healthy. She had a long hospital stay due to nutrition requirements but recovered well and was discharged after 28 days.3There are very few cases reported in England with acute on chronic mesenteric ischemia. Nikolas Melas et al. reported similar history in a 57 years old Caucasian female, who presented with extreme weight loss, postprandial abdominal pain and diarrhoea. She had CT, SMA occlusion and had bilateral renal arteries stenosis. The occluded vessels were both stented after an angioplasty and ischemic segment was resected. Patient was discharged on lifelong warfarin . Morbi A4Our case report is unique in a way that combined mesenteric ischemia and antiphospholipid is a rare combination in a 36 years old. In a young patient with APS conservative management was an option but she ultimately needed surgery. Not many such cases have been reported in Britain before. It also emphasizes the timely diagnosis and management of antiphospholipid syndrome. It still needs to be seen whether patients diagnosed with APS needs surveillance for bowel ischemia or early intervention with anticoagulants would have made any difference.Nil.NA.Not applicable.Written informed consent was obtained from the patient for publication of this case report.Concept, Discussion and literature review done by Wajiha Zahra.NA.Wajiha Zahra.Not commissioned, externally peer-reviewed.


Approximately 75% of cardiac tumors are benign, and 25% are malignant cardiac tumors. Of these, sarcomas are extremely rare and have been described in isolated case reports. Due to its rarity, there is no published guideline for the management of this pathological entity. We present a case of an 85-year-old female who presented to our hospital with a chief complaint of shortness of breath and pinpointed left-sided chest pain. Computed tomography of the chest showed a filling defect in the left atrium concerning a mass versus thrombus. A transesophageal echocardiogram showed a 4 cm multi-lobular echogenic mass with calcifications in the left atrium likely arising from the pulmonary vein suspicious for malignancy. Cardiovascular surgery department scheduled the patient for surgical debulking/removal via a minimally invasive approach. The specimen was reported to be multi-lobular and was resected in several fragments of tan, fleshy, and somewhat gelatinous appearing tissue in aggregate. Histopathology showed spindle cell malignant neoplasm with small foci of bone and cartilaginous formation, suggestive of osteosarcoma. Expert consultation at John Hopkins reported this to be a high-grade sarcoma with focal osteosarcomatous differentiation. Cardiac synovial sarcomas are less than 0.1% of all primary cardiac tumors reported in the literature. Cardiac synovial sarcomas are not extensively described in literature due to their low incidence and prevalence. Thus, it is important to report cases and follow outcomes. This case reports an extremely rare diagnosis that has been reported in less than seven case reports.  Approximately 75% of cardiac tumors are benign, the most common being myxoma in the left atrium, which requires prompt surgical resection due to the risk of embolization and cardiovascular complications . The remWe present a case of an 85-year-old female with a past medical history of right breast cancer status post mastectomy, hypothyroidism status post thyroid removal, hypertension, hyperlipidemia, and paroxysmal atrial fibrillation who presented to our hospital with a chief complain of shortness of breath and pinpoint left-sided chest pain.On the physical exam, the patient was not in any acute distress. She complained of some mild difficulty breathing; however, no accessory muscle usage noted. Lungs were clear to auscultation bilaterally. The respiratory rate was 18 breaths per minute. Three plus pitting edema was noted from the mid-leg shaft to the ankles bilaterally. In the emergency department, an electrocardiogram revealed normal sinus rhythm with occasional premature atrial contractions. Troponin was negative. The outpatient stress test from two weeks prior did not show any signs of ischemia. Computed tomography of the chest showed a filling defect in the left atrium concerning a mass versus thrombus. An immediate bedside contrast transthoracic echocardiogram was performed and confirmed a filling defect with a mass-like lesion adherent to the superior posterior wall, not obstructing the flow of the pulmonary vein. Given the above finding, the patient was scheduled for a transesophageal echocardiogram the following morning which showed a 4 cm multi-lobular echogenic mass with calcifications in the left atrium likely arising from the pulmonary vein suspicious for malignancy. The cardiovascular surgery department requested pan CT which was negative for metastatic malignancy. Due to the patient's co-morbidities, the cardiovascular surgery team recommended left heart catheterization prior to surgery as the patient may also require coronary artery bypass graft (CABG) alongside the excision of the mass. The patient underwent left heart catheterization, which reported no evidence of occlusive coronary artery disease. Cardiovascular surgery department scheduled the patient for surgical debulking/removal via a minimally invasive approach. The specimen was reported to be multi-lobular and was resected in several fragments of tan, fleshy, and somewhat gelatinous appearing tissue in aggregate (Figure Histopathology showed spindle cell malignant neoplasm with small foci of bone and cartilaginous formation, suggestive of osteosarcoma. Since this finding is an extremely rare case, the pathology was sent out for expert consultation at John Hopkins, which reported this to be a high-grade sarcoma with focal osteosarcomatous differentiation Figures  and 3.Twenty-five percent of cardiac tumors are malignant. Of these, sarcomas are extremely rare and have been described in isolated case reports. Synovial sarcomas mainly occur in para-articular soft tissues of the extremities of young adults and adolescents , 7. CardThe clinical presentation of these patients with primary synovial sarcomas includes chest pain and signs and symptoms of congestive heart failure. Thus, the presentation is nonspecific and can easily be confused for the presentation of congestive heart failure . These tCardia synovial sarcomas are not extensively described in literature due to their low incidence and prevalence. Thus, it is important to report cases and follow outcomes.This case reports an extremely rare diagnosis that has been reported in less than seven case reports. Much remains unknown due to its rarity.


Splenic disease are uncommon and primary tumors of the spleen are very rare. These are classified as splenic cyst, benign and malignant tumors. Splenic lymphangioma is a rare, slow-growing benign tumor of the spleen. More often seen in children, it is a congenital malformation of the lymphatic system and is rarely seen in adulthood. When present in adults, it is usually asymptomatic and would be incidentally detected through imaging studies. Infrequently, some patients would present with abdominal pain, distension, nausea, and may have palpable abdominal mass. It may be solitary or may have multiple splenic lesions.We present of a case of splenic mass in a 56-year old female, which remained undetected until incidentally discovered on work-up for chronic back pain. Laparoscopic splenectomy was eventually performed with eventual resolution of the chronic back pain. Histopathologic examination revealed splenic lymphangioma.Splenic tumors are uncommon. Splenic lymphangiomas presenting in adulthood are extremely rare, and preoperative diagnosis may be difficult in asymptomatic patients.Surgical removal of splenic lymphangiomas may be necessary to relieve symptoms, prevent complications and confirm diagnosis. Splenic tumors are classified as splenic cysts, benign and malignant tumors. Splenic lymphangioma is a rare, disease of the lymphatic system and accounts for <0.007% of all tumors ,2. It a 2A 56-year old woman presented with chronic back pain. No history of trauma and no other associated symptoms. Patient’s personal and family medical histories did not show positive signs and symptoms of any splenic pathology. Physical examination likewise did not show any palpable splenic mass or splenomegaly. Laboratory workup was within the normal limits. She underwent thoracolumbar MRI to investigate her chronic back pain which incidentally showed 5 cm splenic mass which appeared hyperintense on T1-weighted images .Fig. 1NoShe was admitted in our institution and was subsequently prepared for laparoscopic splenectomy. Preoperative cardiopulmonary screening did not reveal any significant comorbidities. She had previous immunization as per established protocols for elective splenectomy. On surgery under general anesthesia, she was positioned in right lateral semi-decubitus position. A 10 mm Hasson trocar was inserted through the left periumbilical area followed by CO2 insufflation. Three more trocars  were inserted at the left subcostal area. Abdominal inspection was done. Splenic artery and vein were identified and doubly ligated and clipped. Afterwards, splenocolic, lienorenal and phrenicosplenic ligaments were dissected and proceeded with ligation of the short gastric vessels. The spleen was then extracted. Grossly, the spleen was enlarged to 6 × 4 × 10 cm A and 2B 3Splenic lymphangioma is a benign cystic neoplasm that resulted from congenital malformation of the lymphatic system and accounts for <0.007% of all tumors ,2. It isSince it is frequently undetected clinically, its diagnosis is often made through imaging such as abdominal ultrasonography, abdominal computed tomography (CT) scan or magnetic resonance imaging (MRI) ,7. Our pA normal spleen would appear as a dark red to blue-black organ at the left upper quadrant of the abdomen . It is cMicroscopically, these cysts are made up of multiple vascular channels lined by single layer of endothelial cells and contain eosinophilic amorphous proteinaceous contents  7]. Lym. Lym7]. Surgical management including both total and partial splenectomy is recommended while conservative treatment is still on debate ,5. LaparHiB, meningococcal and pneumococcal). But with further improvement with the laparoscopic tools as well as more experience by the surgeons, this technique may be considered the future standard procedure for all types of splenectomy [The use of laparoscopic technique warrants careful preoperative planning with consideration of the size and volume of the spleen. Like in other operations, laparoscopic splenectomy entails complications, most common of which is bleeding. Among other complications of this procedure are pancreatitis, ileus, abdominal wall infections/hematoma, pneumonia and atelectasis and overwhelming postsplenectomy infection (OPSI). Included in postoperative planning is the administration of vaccines (enectomy . Malignaenectomy ,13. Its enectomy ,11.4Splenic tumors are uncommon, splenic lymphangiomas presenting in adulthood are extremely rare, and preoperative diagnosis may be difficult in asymptomatic patients. Once diagnosed, surgery may be the most effective modality of treatment and laparoscopic splenectomy may avoid potential complications.No financial or personal disclosures.No external source of funding needed for the case report.This case report was approve d and registered with the ethics board of the University of the Philippines. No issues in the approval of the report were encountered.No patient identifiers were included in the study and full informed consent was obtained.Anthony R. Perez MD, MHA: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Roles/Writing - original draft; Writing - review & editing.Mary Ellen Chiong Perez MD: Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; Writing - review & editing.Ann Camille Yuga MD: Data curation; Formal analysis, Investigation; Methodology; Resources; Software;Validation; Visualization; Roles/Writing - original draft.Brent Viray MD: Data curation; Formal analysis;Investigation; Resources; Writing - review & editing.Registration No. RGAO-2018-0542 Research Grants Administration Office, University of the Philippines Manila.Anthony R. Perez, MD, MHA.Not commissioned, externally peer-reviewed.