Cryptorchidism is the most common congenital malformation of the male genitourinary tract. The cryptorchid testis is most often located in the inguinal canal; however, intra-abdominal locations are not rare. The risk of malignancy in an undescended testis is 10% with the highest risk in an intra-abdominal testis.Here we describe a case of a 40-year-old fertile man of Fulbe origin who presented with a non-tender lower abdominal mass of 2 months’ duration. A scrotal examination revealed just one testis in the right scrotum, with the contralateral scrotum and inguinal canal being empty. An exploratory laparotomy followed by tumor excision and histopathology revealed a testicular seminoma.This case report highlights the need for routine scrotal examination in all men presenting with an abdominal mass so as to rule out the possibility of an intra-abdominal seminoma. Cryptorchidism is the absence of one or both testes from the scrotum . It is tSeveral factors have been discovered to predispose to cryptorchidism including prematurity, low birth weight, small for gestational age, twinning, and maternal cigarette smoking and alcohol consumption during pregnancy . If not The cryptorchid testis predisposes to testicular cancer, ischemia, and infertility later in adulthood . The mosA review of Medline through PubMed from 15 May 2008 to 15 May 2018 revealed just one case of intra-abdominal testicular seminoma reported in sub-Saharan Africa . Here weA 40-year-old Fulbe man from the Adamawa region of Cameroon presented to the out-patient department of our institution with a complaint of a progressively increasing non-tender abdominal mass associated with pollakiuria for approximately 2 months prior to consultation. He is a farmer with no chronic medical condition or past surgeries. He has never been exposed to any carcinogenic substance; he does not consume alcohol, tobacco, or any drugs. He is married and has four children; however, his birth history could not be investigated further. A physical examination revealed a patient who looked well with a blood pressure of 128/82 mmHg, heart rate at 78 beats per minute (bpm), and temperature of 37.4 °C. An abdominal examination revealed a firm, non-tender, non-mobile, hypogastric mass projecting approximately 20 cm above the pubic symphysis (Fig. An exploratory laparotomy was scheduled and carried out, with intraoperative findings revealing a highly vascularized mass fixed to the left inguinal ligament, projecting into the retroperitoneum, with several other small satellite masses attached posteriorly. His peripheral bowels, mesenteries, and bladder were all without any visible structural abnormalities.Progressive dissection and hemostasis was done to free and resect all the masses. The largest had several lobes attached together, weighed approximately 800 g, and measured approximately 11 cm by 7 cm by 5 cm Fig. . Seven sHe was then counselled and referred to see an oncologist for further management. At the time of submission of this manuscript we had not yet received feedback from either our patient or the oncologist.Testicular seminoma is the most common malignancy in men. We managed a man who had an increasing mass in his lower abdomen with few associated symptoms. The absence of one testis from his scrotum was highly suspicious of a seminoma, despite the fact that he was fertile and had no relevant past history. Given the rarity of reported cases in Cameroon and sub-Saharan Africa as a whole, this case will reinforce already existing literature and permit physicians in our setting to think of a seminoma even in ambiguous presentations such as ours.Testicular seminoma is a germinal cell tumor of the testicle affecting the germinal epithelium of the seminiferous tubules . It reprSeminoma is a pathology diagnosis. Patients usually present with a painless testicular lump; however, an intra-abdominal testicular tumor manifests with signs of an increasing abdominal mass sometimes associated with signs of partial bowel obstruction, bladder compression, or even pain from torsion . The incImaging techniques such as ultrasonography, computed tomography scan, and magnetic resonance imaging usually show a well-defined heterogeneous retroperitoneal mass with no ischemia or calcification; findings which are nonspecific and could mimic other frequent pathologies such as enlarged lymph nodes and sarcoma . The defAlthough a malignant neoplasm, testicular seminoma is one of the most curable cancers with a survival rate above 95% if discovered early . SurgicaTesticular seminoma is a frequent malignancy in middle-aged men and cryptorchidism further predisposes to its onset. We therefore reiterate the need for a scrotal examination in men presenting with an abdominal mass, so as to rule out an intra-abdominal seminoma.


Pagetoid dyskeratosis is a benign incidental pathologic finding that has been reported in many distinct skin lesions on various locations of the body. A man who had pagetoid dyskeratosis within lesions of the penile shaft is described and similar cases of pagetoid dyskeratosis in lesions of the male genitalia are reviewed. The patient was a 26-year-old healthy man who developed several asymptomatic penile papules that were refractory to topical imiquimod 5% cream and cryotherapy. Snip biopsies were performed and microscopic examination revealed pagetoid dyskeratosis. PubMed was searched for the following terms: cell, clear, dyskeratosis, genitalia, pagetoid, penile, penis, prepuce, scrotum, and shaft. The papers containing these terms and their references were reviewed. Pagetoid dyskeratosis has been observed in lesions on the prepuce and scrotum; this case report now expands the distribution of this finding to the penile shaft. Clinicians and pathologists should be aware of this intriguing potential incidental finding within skin lesions of the male genitalia. Pagetoid dyskeratosis is a benign incidental pathologic feature. It has been observed in several skin lesions . Herein,A 26-year-old man with no history of genital dermatoses developed new penile lesions; he was evaluated on several occasions by his primary care physician. The clinical impressions of his lesions included both condyloma acuminata and molluscum contagiosum. On separate occasions, he was treated with either topical imiquimod 5% cream or cryotherapy with liquid nitrogen. Two months later, he noticed new lesions on his penile shaft and sought medical evaluation by a dermatologist.Clinical examination showed three 1-2 mm asymptomatic, flesh-colored papules located on the proximal portion of the dorsal penile shaft: proximal, middle, and distal, respectively . The pagetoid cells were most often seen in the superficial layers of the epidermis but were also occasionally present in the parabasal layer .The second report of male genitalia with pagetoid dyskeratosis included a 54-year-old man with a 10-year history of pruritus involving the scrotum. Cutaneous examination of the scrotum revealed mild erythematous and skin-colored patches with focal areas of hyperpigmentation. Histopathologic analysis was consistent with pagetoid dyskeratosis .Our patient had a history of penile shaft and suprapubic lesions that were clinically assessed to be associated with human papillomavirus or pox virus or both. They were treated topically with either imiquimod or liquid nitrogen cryotherapy and resolved. However, he subsequently developed new small papular lesions affecting the previously treated area of his proximal penile shaft that morphologically was not classic in appearance for condyloma acuminatum or molluscum. Indeed, the most prominent feature observed during evaluation of the biopsied lesions was the pagetoid dyskeratosis within the epidermis; the subtle accompanying changes in the dermis  correlated with the clinical presentation of the papules.Microscopically, pagetoid dyskeratosis consists of large round epithelial keratinocytes with pyknotic nuclei and perinuclear halos of washed out cytoplasm. The cells demonstrate premature keratinization into orthokeratotic squames without acantholysis or parakeratosis. They can present individually or in groups often extending upwards in the epidermis. Atypia and mitoses are usually absent .Immunohistochemical staining for high molecular weight cytokeratin and pancytokeratin demonstrates a strong positive signal in the pagetoid cells in comparison to the surrounding keratinocytes , 9. CarcThe pathologic differential diagnosis of pagetoid dyskeratosis includes other conditions with clear cells in the epidermis Table  3, 14-1-114-16. The pathogenesis of pagetoid dyskeratosis remains to be definitively established. Tschen et al. hypothesized that the cells represent a small population of the normal keratinocytes that are induced to proliferate by an external trigger, such as mechanical trauma or friction . Piqué-DPagetoid dyskeratosis is an incidental finding. Typically, there are no clinical sequelae. Therefore, management is directed toward the primary lesion.Pagetoid dyskeratosis is an intriguing benign pathologic feature. It has been observed in a variety of cutaneous lesions located on various areas of the body. Pagetoid dyskeratosis of the male genitalia is uncommon and has been previously described on either the scrotum or the prepuce; our patient’s lesions were on the proximal penile shaft. The differential diagnosis of pagetoid dyskeratosis includes other conditions characterized by clear cells in the epidermis. In particular, in men with genital lesions, the differential diagnosis includes venereal warts. This was excluded based on microscopic findings and negative p16 staining. Pagetoid dyskeratosis-directed therapy is usually not necessary and management of the patient is based upon treating the primary skin lesion.


Distant metastasis to the jaws, including the maxilla or mandible, is very rare. Although the mandible is the preferred sight of these rare metastases, it is extremely rare for oral cavity malignancies to present as pathological mandibular fractures. Here, we present a case of esophageal adenocarcinoma metastasizing to the mandible, and the first reported case presenting with a pathological mandibular fracture secondary to esophageal adenocarcinoma. We also review the 9 other reported cases of metastatic esophageal adenocarcinoma to either the maxilla or mandible. Pathological mandibular fractures are rare and account for only 2% of all mandibular fractures. Causes of pathological mandibular fractures have been reported following tooth removal, dental implant placement, secondary to benign and malignant mandibular pathology, osteomyelitis, osteoradionecrosis, bisphosphonate-related osteonecrosis, and Gorham's disease . Even thThis case report was reviewed by the University of West Virginia Institutional Review Board and found to be exempt and did not require full IRB review.A 69-year-old Caucasian male with a past medical history of hypertension, oromandibular dystonia treated with Botox, and recent diagnosis of gastroesophageal reflux disease (GERD) presented to his primary care provider noting an area of his left chin that was numb. The area was small and could be covered with 1 finger. He followed up acutely three weeks later with significant dysphagia for solids, but not liquids. He was urgently referred for an upper endoscopy. Upper endoscopy revealed LA Class D esophagitis with ulceration in the distal esophagus, and biopsies showed inflamed glandular mucosa with at least high-grade dysplasia. These findings were consistent with a diagnosis of Barrett's esophagus secondary to GERD.Three weeks after his upper endoscopy, he presented to the emergency department with right jaw pain and swelling after hitting his jaw on a work bench. A CT revealed right mandibular angle fracture and coronoid fracture . The facThe patient underwent a second upper endoscopy. Biopsy taken during this second endoscopy was consistent with a moderately differentiated adenocarcinoma of the distal esophagus. A PET/CT revealed a large, hypermetabolic distal esophageal mass consistent with the given diagnosis of esophageal adenocarcinoma. Hypermetabolic lesions involving the regional lymph nodes, lungs, spine, and right mandible, as shown in The hypermetabolic area of the right mandible, in conjunction with the previous retromolar trigone biopsy, confirmed a likely pathological fracture of the mandible secondary to metastatic esophageal adenocarcinoma. The advanced stage of the cancer made him a poor candidate for surgical intervention for either primary tumor or mandibular metastasis. He was referred for palliative chemoradiotherapy. He passed away one month after diagnosis.We are reporting a case of a 69-year-old Caucasian male sustaining a pathological mandibular fracture from metastatic esophageal adenocarcinoma. His pathological mandibular fracture occurred 1 week prior to his diagnosis of esophageal adenocarcinoma. There have been 9 previous cases of metastatic esophageal adenocarcinoma to the jaws reported in the literature and are listed in Only 1% of all oral cavity malignancies arise from metastatic disease, and metastasis to the jaw bones is more common than oral soft tissues . MetastaIn a review of 453 cases of metastatic disease to the jaw bones, the male-to-female ratio was reported as between 1.2 and 1 with a mean age of 53.4 years old at diagnosis . The mospylori are thought to be protective. Alcohol is not considered a risk factor [Esophageal adenocarcinoma has become increasingly more common over the last several decades, and it is now more common than esophageal squamous cell carcinoma in the United States. Men have approximately 6-fold higher risk of developing esophageal adenocarcinoma as compared to women . Our patk factor . In recek factor .th reported case of esophageal adenocarcinoma metastasizing to either the mandible or maxilla and the first reported case of esophageal adenocarcinoma to present as a pathological mandibular fracture.We report a case of esophageal adenocarcinoma presenting as a pathological mandibular fracture. Review of the literature shows this is the 10


Situs inversus, polysplenia, complex jejuna atresia are rare anomalies in isolation. Their association in a single patient is even rarer with challenges in diagnosis and management.A 5 day old neonate presented with features of small bowel obstruction. Radiological investigations revealed situs inversus abdominalis with dilated proximal small bowel loops. At laparotomy, abdominal situs inversus, polysplenia, multiple jejunal atresias with apple peel appearance of the ileum with malrotation was seen.The association of situs inversus, polysplenia and complex jejunal atresia is very rare. Pre-operative diagnosis of situs inversus is important for appropriate incision placement and surgical planning. It is k2A 5-day-old girl was referred to us with bilious vomiting and abdominal distention since birth. The baby was born at term by caesarean section to a 30 year old primigravida mother. The baby weighed 2.79 kg at birth. Antenatal ultrasonography at 32 weeks gestation had revealed multiple, dilated, fluid filled bowel loops. At admission, the baby was dehydrated with a distended abdomen. Rest of the systemic examination was unremarkable. Blood investigations were within normal range. X-ray abdomen revealed few dilated bowel loops, paucity of distal gas shadows and nasogastric tube in the right upper quadrant of abdomen . UltrasoSince pre-operative diagnosis of abdominal situs inversus was known, a left upper quadrant transverse incision was given in contrast to the classical right upper quadrant transverse incision. Laparotomy confirmed situs inversus abdominis with the liver and duodenal C loop on the left side a. The baPost-operatively the child was shifted to newborn ICU. Immediate post-op period was uneventful. The baby was started on tube feeds by post-op day (POD) 3, however oral feeds were not tolerated till POD 14. This may be due to hypo-peristalsis in the dilated proximal jejunum. Full oral feeds were reached by POD 28 and the baby was discharged. At 18 months follow up, the baby is thriving well and is asymptomatic.3The normal anatomy of internal organs is known as situs solitus. Mirror transposition of situs solitus is known as situs inversus wherein the solid organs are mirrored. It can be either total or partial. Situs inversus has been known to be associated with multiple anomalies – the most common being cardiac and abdominal. Fonkalsrud et al., in their study of patients with situs inversus, showed 15 patients with situs inversus having major abdominal anomalies requiring surgical attention and 8 of them had duodenal or jejunal atresias [Polysplenia refers to presence of two or more spleens. The location and number of spleens are variable; their number may range from 2 to 16. The common presentation is vague abdominal pain, nausea, and vomiting. Polysplenia syndrome refers to its association with various organ abnormalities in the abdomen and chest. It is often recognized in childhood, though about 10% cases present late during adulthood. Situs inversus is present in 20% cases and more than 40% have associated cardiac anomalies [Lee et al. recently reported a 12.1% rate of complex jejuno-intestinal atresias  among all patients with small intestinal atresias, and these patients suffered increased morbidity and mortality rates . None ofThe association of complex jejunal atresias with apple peel appearance of the remaining ileum along with malrotation and polysplenia in a patient with situs inversus is very rare. There have been only anecdotal reports in literature with similar findings. Rasool et al. reported polysplenia syndrome associated with situs inversus abdominus and type I jejunal atresia in a 2 day old female baby . However4The association of situs inversus, polysplenia and complex jejunal atresia is very rare. Pre-operative diagnosis of situs inversus is important for appropriate incision placement and surgical planning.Nil.Nil.Ethical approval has been exempted by our institution, SGPGIMS ethics committee.YES, Informed consent was obtained from parents for reporting this case.Abhishek Chinya: writing the paper.Kirti Naranje: writing the paper.Ankur Mandelia: writing the paper, study concept or design, data collection, data analysis or interpretation.NA.Dr. Ankur Mandelia.Not commissioned, externally peer-reviewed.


Bipolaris hawaiiensis.To report the clinical characteristics, laboratory findings, and treatment of a rare case of keratitis caused by pigmented fungi Bipolaris species. The patient was treated with topical natamycin 5%, topical voriconazole 1%, and oral itraconazole followed by intracameral amphotericin B (5 μg/mL). The patient responded well to the treatment.A 55-year-old man presented with a history of trauma with vegetative matter in his left eye. Slit lamp biomicroscopic examination revealed the presence of a brownish-black pigmented plaque with surrounding infiltrates. Corneal scrapings revealed multiple septate hyphae. Culture revealed growth of the B. hawaiiensis is a rare cause of corneal phaeohyphomycosis.Our patient responded well to intracameral amphotericin B, which obviated the need for penetrating keratoplasty.Brown pigmented infiltrates are an important clinical feature of dematiaceous fungi.  Oral itraconazole and topical natamycin have been used for this condition, while a few case reports have described additional use of topical amphotericin B in refractory cases. We report a case of keratomycosis, caused by B. hawaiiensis, that was treated with intracameral amphotericin B and showed a good response.A 55-year-old male farmer with a history of trauma to the left eye with vegetative matter presented at the ophthalmology clinic with complaints of diminution of vision, redness, photophobia, and black discoloration of his left eye. The visual acuity in the right eye was 6/6, while vision in the affected eye was restricted to the perception of light.Bipolaris species. Lactophenol cotton blue staining showed acute-angled septate hyphae with boat-shaped conidia [Figure 2]. The hypopyon remained refractory to treatment after which amphotericin B (5 μg/mL) was injected intracamerally. The infiltrates became organized and the hypopyon disappeared. The lesion healed completely with central scarring and vascularization [Figure 3]. The final visual acuity was finger counting close to the face with accurate projection of light.Slit lamp biomicroscopy revealed conjunctival congestion, a central pigmented corneal ulcer, and hypopyon. There were no other predisposing factors such as diabetes or other immunocompromised states. The central ulcer measured 6.5 x 5.5 mm, and showed a pigmented, elevated brownish-black plaque measuring 4 x 4 mm, with surrounding infiltrates. The ulcer appeared dry, with the presence of immobile hypopyon [Figures 1(a) and (b)]. The right eye presented with a clear cornea, early cataract, and a normal fundus. The plaque was scraped off and used to inoculate culture media. Due to the typical appearance of the ulcer , we initiated hourly topical antifungal natamycin 5% treatment along with two-hourly topical moxifloxacin 0.5%, and cycloplegic and lubricating eyedrops. The culture revealed growth of the Bipolaris species is classified as a dematiaceous or darkly pigmented fungus that causes phaeohyphomycosis, rarely infecting humans. The most frequently reported species are B. spicifera, B. australiensis, and B. hawaiiensis. Anadi et al have reported corneal ulcers due to Bipolaris spp. infection in a leprosy patient, while Bashir et al have reported keratomycosis with endophthalmitis in an immunocompetent individual.B. hawaiiensis is widely distributed in plants or soil and is commonly found in tropical regions. Dematiaceous fungal keratitis presents typically as recalcitrant-pigmented plaques that prevent the penetration of drugs, making superficial keratectomy essential in many cases. Culture shows dark septate hyphae with numerous conidia of the Bipolaris species. Although, the use of topical natamycin has been reported to be successful in treating most cases of dematiaceous fungal keratitis, our case responded well to intracameral amphotericin B injection, which obviated the need for long-term use of oral antifungal drugs as well as therapeutic penetrating keratoplasty.The Nil.There are no conflicts of interest.


There were multiple nodular lesions showing increased 18F-FDG uptake in both lungs. There was a soft tissue lesion with slightly increased 18F-FDG uptake, which extended to the intraluminal region of the thoracic esophagus. Increased metabolic activity was detected in the asymmetric stomach wall thickening site and in a soft tissue lesion located on the gall bladder wall that was filling the lumen. Multiple hypodense/hyper-metabolic lesions were identified in the liver. Multiple hyper-metabolic polypoid soft tissue lesions were visualized in almost the entire colonic segments. Multiple hyper-metabolic peritoneal implants were noted in all abdominal quadrants. Increased 18F-FDG uptake was detected at the right surrenal gland soft tissue lesion. There was a hyper-metabolic soft tissue lesion on the posterior wall of the rectum. Hyper-metabolic lytic lesions were seen at the thoracal and lumbar vertebrae, left scapula, left iliac bone, sacrum and left femur. There was no evidence of 18F-FDG avid skin lesions in both attenuation corrected and non-corrected images.Primary malignant melanoma occurs most often in the skin and much less frequently in the choroid layer of the eyes, in the leptomeninges, oral cavity, nasal mucosa, pharynx, esophagus, bronchus, under the nail and vaginal or anorectal mucosa. Primary melanoma of the gastrointestinal tract has been confirmed for lesions occurring in the esophagus, stomach, small bowel, and anorectum through several published reports, as these are the areas where melanocytes normally exist. The occurrence of primary malignant melanoma in the colon is relatively rare, because melanocytes are embryologically absent in the large bowel. Herein we report a patient whose colonic malignant melanoma was diagnosed and disseminated metastatic lesions were revealed with


Primary pulmonary meningioma (PPM) is an extremely rare benign tumor. Previous reports indicated that CT features of PPM are single, solid, well-demarcated, homogeneous mass. In this study, we report a case of PPM with atypical CT features.A 65-year-old female presents to clinic with 1-week acute upper respiratory tract infection. Her chest CT scan revealed a 25–29 mm, round-like, heterogeneous lobulated solitary pulmonary nodule in the right lower lobe. Based on the microscopic features and a wide range of immunohistochemical examinations including vimentine, progesterone receptor (PR), CD34 and S100, the mass was diagnosed as PPM after surgery.PPM is a rare disease, CT features of PPM could be heterogeneous and lobulated. Expression of vimentine, PR, CD34 and S100 helps to diagnosis of PPM. Primary pulmonary meningioma is an extremely rare tumor with uncertain origin. Most PPMs are asymptomatic, grow slowly, and present a benign biological behavior . HistoloA 65-year-old female presents to clinic with 1 week cough. She denies fever, dyspnea, chest pain or constitutional symptoms. She had a history of type II diabetes but with an inadequate controlled serum glucose level for 10 years. Her neutrophils, C-reaction protein (CRP), procalcitonin and tumor markers such as carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), squamous cell carcinoma antigen (SCC) were all in normal range. Her T-SPOT.TB assay examination were negative. A CT scan of her chest reveals a 25–29 mm, round-like, heterogeneous lobulated solitary pulmonary nodule without showing any cavity lesions or calcification, in the peripheral right lower lobe. No obvious enlarged hilar or mediastinal lymph nodes were observed (Fig. The patient received lobectomy of right lower lobe and systemic mediastinal lymph nodes dissection. A gross examination revealed a 3.5 × 2 × 1.5 cm, well-demarcated, white-pan solid mass. Microscopically, the tumor was composed of spindle cells with a whorl pattern. No atypical cells and mitotic figures were observed Fig.  and b. IPrimary pulmonary meningioma is an extremely uncommon lung neoplasm which was first described in 1981 by Erlandson. To date, no more than 50 cases have been reported in the English literature. The origin of PPMs remains uncertain, intrathoracic differentiation of meningocytes, ectopic embryonic remnants, minute pulmonary meningothelial-like node may account for the pathogenesis of PPM. Macroscopically, the tumors are solitary, well circumscribed with a yellow-tan to grey cut surface. Histologically, the classical features of PPM showed whorls of spindle cells interspersed with abundant psammoma bodies. Tumor cells were positive for vimentine and EMA, and were negative for SMA, TTF-1, Chromogranin A, synaptophysin. Additionally, we found that PPM cells also expressed PR, CD34 and focally for S100 [The incidence of the disease is slightly higher in women than in men, and the median age is 57 years, with a range of 18–108 years. We report here a 65 year old female with no specific symptoms, no evidence of infection, tuberculosis, no enlargement of hilar and mediastinal lymph nodes, no lesion of extrathoracic organs. However, CT scans of our patient revealed a round-like, heterogeneous lobulated solitary pulmonary mass, possible diagnoses were tuberculoma, metastatic tumor, and benign pulmonary tumors. Previous studies indicated that most PPMs were peripheral, round-shape, well circumscribed and a homogeneous pattern on CT scans. Typical CT features of pulmonary metastases tumors were single or multiple, round, well circumscribed with smooth margin. A halo of ground-glass opacity surrounded the tumor may cause haemorrhage. Others preoperative differential diagnoses including sclerosing hemangioma, hyalinizing granuloma, intrapulmonary fibrous tumor and inflammatory pseudotumor, but the final diagnosis relies on pathological examination. Surgical resection was the curable treatment method, and the prognosis of PPM patients were excellent. Matteo and colleagues  summarizPPM is an extremely rare benign tumor. The CT features of PPM can be presented as heterogeneous, lobulated mass. Expression of vimentine, EMA, PR, CD34 and S100 helps to diagnosis of PPM.


Mesenteric and Intramural Hematoma leading to small bowel obstruction is a rare, but a fatal complication of anticoagulant therapy.We present this unique case of 61 year old male with non traumatic mesenteric and intramural hematoma secondary to warfarin leading to small bowel obstruction requiring surgical resection.Although there have been few cases reported in literature about intramural small bowel hematoma, however, associated with small bowel obstruction secondary to warfarin therapy are less frequently seen. Diagnosis of intramural hematoma can be made with Computed Tomography (CT) of abdomen. The most effective treatment approach is conservative management after excluding any signs of small bowel obstructions, peritonitis and bowel necrosis.Therefore, early diagnosis is vitally essential to avoid morbidity in patients with these symptoms. Physician should have a higher index of suspicion to recognize and diagnose this complication is essential for early treatment intervention to prevent morbidity. There are various potential complications related to anticoagulants, therefore, patients are required to monitor frequently. A rare but life threatening complication of anticoagulant therapy is spontaneous intra-abdominal hematoma. According to the literature, intramural small bowel hematoma is commonly seen secondary to blunt abdominal trauma.The rarity of intra-abdominal hematoma and complications secondary to anticoagulants uses occur in about 1 case per 2500 patients on anticoagulant therapy per year . All ble2A 61 year old male with history significant for right lower extremity deep venous thrombosis (DVT); on warfarin 7.5 mg, hypertension, diabetes mellitus, asthma, and chronic kidney disease presented to the emergency department with 3 day history of generalized abdominal pain associated with multiple episodes of nausea, vomiting and obstipation. Patient was awake, alert and oriented. Blood pressure was elevated, rest of vitals were benign. On physical examination, patient had distended abdomen with mild generalized tenderness, no signs of peritonitis. Remainder of his exam was un-remarkable. Labs were significant for INR; >6 and PTT; 91.9. CT abdomen was obtained that showed high grade small bowel obstruction , Fig. 2.3Spontaneous intramural and mesenteric intestinal hematoma secondary to anticoagulant therapy are rare but fatal complication reported in medical literature . AccordiIn most literature it is reported that complication of small bowel hematoma and bleeding in patient with anticoagulant therapy is most commonly cited risk factor is severe hypertension ; our patThe spectrum of clinical symptoms may vary from mild abdominal pain followed by nausea/vomiting to severe intestinal obstruction, peritonitis, necrosis and acute abdomen. Rarely, patient may also present with hemorrhage, hematemesis, rectal bleeding and or melena . In few Currently, the initial diagnostic radiographic approach to evaluate intramural small-bowel hematoma is abdominal ultra sonogram with a confirmatory Abdominal CT scan . CharactSince the intramural small-bowel hematoma secondary to warfarin is rarely seen, there are no evidence based literature suggesting appropriate treatment. The most effective intervention recommended is conservative management after excluding any signs of small bowel obstructions, peritonitis and bowel necrosis. In the event of small bowel obstruction, immediate intervention and appropriate surgical resection of the obstructed bowel are essential. In this case, after initial resuscitation surgical intervention with diagnostic laparoscopy of the obstructed small bowel segment with intramural hematoma was resected and anastomosed primarily.4This case report illustrates a unique entity of prolonged use of anticoagulant therapy causing intramural small-bowel hematoma and ischemic bowel disease. Physician should have a higher index of suspicion to recognize and diagnose this complication is essential for early treatment intervention to prevent morbidity. Patients with a history of prolonged anti-coagulants should be monitored closely with prolonged INR values, especially in patients presenting with abdominal tenderness. Due to the rarity of this complication of warfarin anticoagulant therapy, evidence in literature is scarce about appropriate management. More identification of such cases, observation and close surveillance is necessary to find the pathogenesis, early diagnosis and appropriate management to prevent unnecessary surgical approach and morbidity with favorable outcomes.No conflicts.No source of funding.Ethical approval is not required by our institution. This was a case report and permission and consent has been taken from the patient.We have obtained a written informed consent from the patient for publication of this case series report and also accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Khuram Khan- Abstract, Figure collections, writing, format.Saqib Saeed- writing, editing, others.Sara Alothman- others, writing, format.Farhana Iqbal- writing, editing, figure collections.Brian Donaldson-review, final writing, editing.Alexius Ramcharan- other, review, editing.It's case report. Nothing to register.Khuram Khan.Not commissioned, externally peer reviewed.


Streptococcus anginosus. A diagnosis of thrombophlebitis of the portal vein associated with CCF was made, and the patient was immediately managed with an intravenous broad-spectrum antibiotic and anticoagulation. After the portal vein thrombosis (PVT) propagation and inflammation had subsided, cholecystectomy and partial resection of the transverse colon were performed. Pylephlebitis is rare but is a life-threatening complication of intra-abdominal infection. A high index of suspicion is required, and a CT scan should be performed immediately for an early diagnosis and appropriate treatment.Pylephlebitis is defined as a septic thrombophlebitis of the portal vein and its tributaries that is associated with multiple suppurative abdominal infections. We report a case of pylephlebitis associated with a cholecystocolonic fistula (CCF). A 41-year-old man presented with upper abdominal pain and anorexia for 1 month. Abdominal contrast-enhanced computed tomography (CT) revealed thrombosis in the left and anterior branch of the portal vein and thickening of the walls of the portal vein and periside portals. The gallbladder was collapsed and pneumobilia was seen in the biliary tract. Blood culture was positive for  Pylephlebitis is defined as a septic thrombophlebitis of the portal vein and its tributaries that is associated with intra-abdominal inflammation and infections such as diverticulitis, appendicitis, cholangitis, and cholecystitis . Althoug3; C-reactive protein (CRP), 14.53 mg/dl; mildly elevated serum levels of aspartate aminotransferase (AST), 70 IU/l; alanine aminotransferase (ALT), 113 IU/l; total bilirubin, 1.5 mg/dl; alkaline phosphatase (ALP), 768 IU/l; and gamma-glutamyl transpeptidase (γGTP), 103 IU/l; prothrombin (PT) activity, 42.3% (PT-INR 1.53); fibrin degradation product (FDP), 149 μg/ml; fibrinolysis degradation product (D-dimer), 1.9 μg/ml; and antithrombin III, 93.1%. Abdominal enhanced computed tomography (CT) showed portal vein thrombosis (PVT) in the left and anterior branch of the portal vein and the wall thickening of the portal vein. The gallbladder was collapsed and pneumobilia was seen in the biliary tract  also showed a fistula between the gallbladder and the colon. A gallstone in the common bile duct was not seen by cholangiopancreatography (MRCP)  and anticoagulation therapy was started (danaparoid sodium at 2500 IU/day). Blood culture on admission was positive for y (MRCP) . Follow-y (MRCP) . PostopePylephlebitis is defined as a septic thrombophlebitis of the portal vein and its tributaries that is associated with multiple suppurative abdominal infections. This disease was first described by Waller in 1849 as a source of pyogenic intrahepatic abscesses , 6. ThisBacteroides fragilis followed by E. coli and Streptococcus sp. [The diagnosis of pylephlebitis relies on the demonstration of portal vein thrombosis in the setting of suppurative bacteremia through aspiration of the portal vein. However, portal vein aspiration is seldom performed due to its invasiveness. Instead, surrogate markers such as the patient's clinical condition, imaging, and peripheral blood culture results are used. Among them, CT is the most frequently used diagnostic modality because CT is helpful for making a diagnosis of the exact extent of the thrombus and identifying the source of infection in the abdomen. Bacteremia has been documented in 23% to 88% of patients. The most common bloodstream isolate was ccus sp. .Once a diagnosis of pylephlebitis is established, appropriate treatment should be started as soon as possible. The treatment of choice is mainly based on broad-spectrum antibiotic therapy. Antibiotic coverage should be targeted towards Gram-positive, Gram-negative, and anaerobic bacteria until culture and sensitivity results are available. The most commonly reported cause of pylephlebitis is diverticulitis, followed by appendicitis, cholecystitis, pancreatitis, and other intra-abdominal infections . To the The role of anticoagulation therapy in the management of pylephlebitis remains controversial. The aim of anticoagulation is to prevent propagation of the thrombosis and further complications such as portal hypertension and bowel ischemia and to attain portal vein patency. Kanellopoulou et al. analyzed 100 cases of pylephlebitis in the literature and found that patients who received anticoagulation therapy more often had a favorable outcome than did patients who were treated with antibiotics alone [Invasive procedures such as surgical thrombectomy can result in rapid recanalization of vessels, but high morbidity and mortality rates have been reported. Percutaneous transhepatic mechanical thrombectomy might also be effective for recent thrombosis, but damage of the vascular wall is frequent and may cause rethrombosis . These iIn conclusion, pylephlebitis is a rare but life-threatening complication of intra-abdominal infections if not diagnosed and treated before the development of severe sepsis. Therefore, a high index of suspicion is required and a CT scan should be performed immediately for an early diagnosis and appropriate treatment.


In laparoscopic surgery, marking of tumor location has been gaining importance. Tattoo marking has been often used but the technique carries the risk of accidental peritoneal scattering or other organ injury. We have been involved in the development of a novel fluorescent clip for marking tumor sites and supposed that its usage would reduce risks related to other marking methods.A 52-year-old man was diagnosed with sigmoid colon cancer and polyp, and was scheduled for laparoscopic sigmoidectomy. On the day before operation, fluorescent clips  were endoscopically placed around the tumor and polyp sites, 4 clips for each lesion attached every 90 degrees within the colonic lumen, respectively. During the operation, locations of the fluorescent clips were easily confirmed using a full-color fluorescent laparoscope, VISION SENSE . Curative operation was performed accordingly with the preoperative pathological and radiological findings. The postoperative course was uneventful.Locations of intraluminally placed fluorescent clips were clearly and easily recognized through the serosal layer of the intestinal wall using a fluorescent laparoscope. Complications related to dye scattering or intestinal wall/other organ perforation were not observed suggesting that future incorporation of this tumor site marking technique into laparoscopic surgery might be beneficial.The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope. This method is expected to be safe and risks of accidental puncture related to tattoo marking method can be reduced or almost eliminated. Even though it is possible to palpate the serosal side of the colon mucosa with laparoscopic devices , some submucosal (SM) or muscularis propria (MP) lesions cannot be intraoperatively localized. In such cases, tattoo marking method has been often used but the procedure carries risks of accidental intestinal puncture potentially leading to peritoneal scattering or puncture(s) of other abdominal organs . We supp2A 52-year-old man presented to our hospital with fecal occult blood. Based on endoscopy of the lower intestinal tract findings, he was diagnosed with sigmoid colon cancer  and 6 mm-polyp, and was scheduled for laparoscopic sigmoidectomy with D3 lymph node dissection.The patient’s consent on intraoperative use of the newly designed fluorescent clip and on reporting the study results had been obtained and the study was approved by the Institutional Review Board (No. 13-B-344).Following 2-days bowel preparation, fluorescent ZEOCLIP FS clips were placed during colonoscopy on the day preceding the surgery in two sites because removal of both the tumor and the polyp was planned. For each site, 4 clips were intraluminally placed every 90 degrees around the corresponding lesion, respectively . Since tth post-operative day.The surgery was performed the following day as scheduled. Locations of the fluorescent clips were easily confirmed using a full-color fluorescent laparoscope, VISION SENSE  , and a s3In the present case, we confirmed that intraluminally placed fluorescent clips could be easily detected through the translucent intestinal wall using a fluorescent laparoscope. The clips were easily placed preoperatively. Suctioning during sigmoidoscopy was applied to improve clip attachment and to avoid slipping by decreasing intraluminal pressure within the colon. According to manufacturer’s preclinical data, clip attachment weakens within a week after its placement though the fluorescence may be detected longer (data not shown). This is the first reported case on successful use of marking fluorescent clips to detect tumor site during laparoscopic surgery.Conventional preoperative tumor site marking methods include tattoo marking, non-fluorescent clip placement and intraoperative endoscopy. Peritoneal scattering and accidental puncture of the intestinal wall and abdominal organs are potential drawbacks of the tattoo marking technique. Ink scattering may cause peritonitis or affect recognition of the tumor site and lead to inaccurate dissection margins ,7. This Recently, there have been reports on applying indocyanine green (ICG) solutions instead of black ink for marking ,10 howevIntraoperative endoscopy and non-fluorescent clipping have been introduced to mark and/or confirm tumor locations during surgery. Although intraoperative endoscopy may be useful, its disadvantages such as prolonged operation time, colon insufflation that interferes with operative procedure and need of a skilled endoscopist, might reduce its widespread application .In our method of marking a tumor site with fluorescent clip(s), the clips were attached as with the conventional clip placement technique under endoscopy performed prior to surgery. The shape of the fluorescent ZEOCLIP FS clip did not significantly differ from those of non-fluorescent clips but due to fluorescent coating a slight decrease in grasping force might occur and that might cause potential slipping. More cases need to be examined to confirm this possibility.4This is the first case report on tumor site marking with fluorescent clips for laparoscopic tumor resection. Preoperative endoscopic placement of the fluorescent clips was easy as was their intraoperative recognition. The fluorescent clips might reduce possibility of accidental intestinal wall puncture that occasionally occurs with the tattoo marking technique.The authors declare no conflicts of interest.We have no sponsors.This study was approved  by the Research Ethics Committee at the International University of Health and Welfare, Tochigi, Japan.We had obtained such consent.SN have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data.MY have been involved in drafting the manuscript or revising it critically for important intellectual content.HO have get in on a discussion about this study.DS have get in on a discussion about this study.MK have get in on a discussion about this study.YK have get in on a discussion about this study.NS have get in on a discussion about this study.SH have get in on a discussion about this study.YS have given final approval of the version to be published.All authors read and approved the final manuscript.This paper is case report.Satoshi Narihiro.Not commissioned, externally peer-reviewed


The conservative management of large, odontogenic, developmental cysts involving the jaws in young children using the technique of decompression has become increasingly popular to reduce the incidence of morbidity associated with aggressive treatment modalities. The lack of development of a stock device has made clinicians to explore various possible and readily available materials to customize the devices. This paper highlights the use of a novel material to be used as a decompression device that is readily available and can be used with good patient compliance and a predictable outcome. The management of cystic lesions of the jaws has evolved over decades, ranging from radical methods, such as enucleation, which involves the removal of the entire cystic lining along with the involved permanent teeth to more conservative approaches, such as marsupialization that involves the creation of a window in the cystic wall to facilitate the spontaneous regression of the cyst or a combination of both, which is described as Partsch procedures. As an extension of this procedure, Thomas, in 1947, introduced the concept of tube drainage, which is popularized as decompression [The treatment of cysts that are odontogenic in origin becomes crucial especially when they originate as developmental lesions affecting the maxilla or mandible in the mixed dentition period. So, the management of these cystic lesions, especially in young children, is of concern with regard to the involvement of permanent teeth buds embedded within the lesion and the adjacent neurovascular bundle. A more conservative means like marsupialization or decompression alone could aid in preserving the vital structures.We present, in this paper, a case report that was diagnosed as a dentigerous cyst involving the anterior maxilla with multiple, impacted, permanent teeth buds involved in a single follicle and that was managed using a conservative approach in conjunction with orthodontic traction to aid in the eruption of the involved teeth.An 11-year-old boy reported to the department of oral and maxillofacial surgery, Bhimavaram, Andhra Pradesh, India, with a chief complaint of swelling over the left cheek since three months. The swelling was asymptomatic and gradually progressing. A detailed history from the attending parent revealed no significant medical history and no previous history of trauma in the concerned area. On an extraoral examination, there was a gross facial asymmetry on the left side of the face due to the presence of a swelling that extended superiorly from the infraorbital margin to the upper lip inferiorly, obliterating the nasolabial fold. No secondary changes were noticed over the skin. There was no sensory deficit in relation to the facial structures. On a thorough intraoral examination, dentition was mixed, with mild caries affecting the deciduous teeth, none involving the pulp, and revealed a bicortical swelling on the left side extending from the labial frenum medially till the distal aspect of the deciduous second molar, obliterating the labial and buccal vestibule  revealed a well-defined unilocular radiolucent lesion circumscribing the permanent teeth buds of the central, lateral incisor and canine in the second quadrant Figure . It measThe paranasal sinus (PNS) view revealed radiolucency extending superiorly till the infraorbital margin with the canine involved Figure . The canAspiration of the cystic contents revealed a straw-colored fluid. Based on the clinical and radiographic findings, a provisional diagnosis of a dentigerous cyst was made Figure . A diffeUnder general anesthesia, the extraction of the deciduous central, lateral incisors and canine was done and an opening was created in the anterior wall of the cyst through which part of the lining was removed and sent for histopathological examination. To maintain the patency of the opening, a marsupialization catheter device customized from the tip of a suction catheter Figure  was inseThe histopathological report obtained confirmed the diagnosis of a dentigerous cyst. The patient was regularly recalled every week and was assessed for the maintenance of patency through the device. Radiographs were taken at regular intervals to aid in assessing the eruption of the impacted permanent teeth. Device removal was performed after three months Figure .After a period of three months, the radiographic examination revealed a gradual resolution of the radiolucency of the lesion and a spontaneous eruption of the central and lateral incisors, indicating osteogenesis Figure . So, durInitially, brackets were bonded on the central and lateral incisors and the canine and the flap was closed. Strap-up was done with 0.016 Niti wire. Later, leveling and alignment was done for about six months with 0.0018 Niti 17x25 Niti, 19x25 Niti, 19x25 SS Figure . After rThe decompression of a cyst, by definition, involves any technique that relieves the pressure within the cyst that causes it to grow, as described by Pogrel . It is aDecompression differs from marsupialization in that the patency of the opening is maintained by placing a tube drain that is secured to margins Figure , while iVarious catheters have been devised by many authors to serve as decompression tubes that are custom made from intravenous lines, nasal cannulas, pediatric anesthesia tubes, plastic dental syringes, urethral catheters, and a thermoplastic resin to aid in the drainage .Len Tolstunov in 2008 has proposed certain characteristics of devising an ideal decompression tube to be used .1)        Have a design that prevents it from falling into the bone cavity or coming out from it at the end of the procedure;2)        Be small enough and does not interfere with daily mastication;3)        Be fixated easily to the soft tissue around it with sutures;4)        Provide easy daily cleaning of the cystic cavity through its opening by the patient or staff; and5)        Be hygienic and not accumulate food particles (should not be porous) over the time of its function (weeks and months).But, none of the custom-made devices satisfies all these ideal characteristics. The lack of development of a stock device has made clinicians explore various possible  and readThe uniqueness of the present case lies in the utilization of a suction catheter as a decompression device. It is a readily available supply that could serve this purpose, although its use has not been reported yet. The advantage of this device lies in its design.1)    The end of the suction catheter, which is wide at the top and gradually tapers, mimicking a funnel, ensures it does not get easily displaced into the cystic cavity during its usage.2)    The plasticity of the device enables it to be easily adapted to the opening and be secured with sutures.3)    It is readily available in the operatory in a sterile pack.4)    The thickness of the tube prevents the regrowth of tissue over it for a longer period of time.5)    It is easily acceptable to the patientAll these features make it an exemplary and a feasible device to be used with a good clinical outcome.The ultimate advantage of using these decompression devices, especially in the younger population to preserve the involved tooth buds, makes it an acceptable technique. The limitation lies in that patient compliance is required during the follow-up extending for a long period of time and proper postoperative care. Hence, this technique is contraindicated in noncompliant individuals.The use of a suction catheter proves to be an effective decompression device that can be used with ease and with a predictable outcome without any recurrence of the lesion over a long period of time with good patient compliance. Thus, the authors believe that the device used in this report satisfies all the mentioned requirements of a decompression device for a minimally invasive surgical technique, further favoring its usage.


The nodule located at the left anterior segment near the lingular segment is traditionally resected by left upper lobectomy. We performed video-assisted thoracoscopic surgery (VATS) segmentectomy and could achieve a complete resection that is minimally invasive and oncologically sufficient.An 82-year-old woman was found to have a nodule in the left anterior segment of the lung on chest computed tomography (CT). The nodule was 1.9 cm in size and strongly suspected to be lung carcinoma. No suspicious regions of metastasis were observed; thus, we diagnosed stage IA2 and decided to perform anterior and lingular segmentectomy by VATS.Because of the location, the tumor is traditionally resected by left upper lobectomy. However, we planned a minimally invasive intervention and performed anterior and lingular segmentectomy by VATS using a CT-guided nodule marking prior to the surgery.This technique resulted in complete tumor resection with minimal adverse effects. Furthermore, pulmonary segmentectomy is a useful method that can perform minimally invasive and oncologically sufficient for early stage lung cancer patients. The nodule located at the left anterior segment near the lingular segment, which is our case, is traditionally resected by left upper lobectomy. However, we planned a VATS segmentectomy to reduce the invasiveness to the patient. Segmentectomy has a risk of locoregional recurrence if a sufficient margin cannot be secured. We envisaged that a CT-guided nodule marking prior to VATS segmentectomy could achieve a complete resection that is minimally invasive and oncologically sufficient.This case report has been written in line with the SCARE guidelines .22.1An 82-year-old woman being treated for pyelonephritis was referred to our hospital because of a nodule in the left anterior segment of the lung on chest CT. The nodule was part solid, 1.9 × 1.1 cm in size and reveal a pleural tag . The maxWe recommended the patient to undergo a lung resection for the diagnosis and treatment of the nodule, and she agreed. We believed that this lesion could be completely resected by anterior and lingular segmentectomy based on preoperative imaging diagnosis. However, if the nodule is not palpated, then a sufficient tumor margin may not be secured; thus, we decided to perform a CT-guided nodule marking prior to the surgery.2.2Prior to the surgery, she went to the CT room and was injected with indocyanine green under the visceral pleura near the tumor using a 23-G needle while checking the site using CT fluoroscopy . When thThe patient received epidural and general anesthesia. She was intubated with a double-lumen endotracheal tube and placed in a lateral decubitus position.A utility incision (3.0 cm) was created in the seventh ICS on the posterior axillary line and was protected with a wound retractor XS (Medtronic Company). This utility incision was used to insert a thoracoscope and remove the resected specimen. Incisions for two 12-mm thoracoscopic port (Medtronic Company) were created in the fourth and sixth ICS on the anterior axillary line, which were used by a surgeon. In addition, a 1.0-cm incision was created in the sixth ICS under the scapula, which was used by an assistant.First, we confirmed an indocyanine green marking under the visceral pleura of the upper lobe. Based on the position of the marking, it was considered that the left anterior and lingular segmentectomy was possible as planned. We could not locate the tumor only by observing and palpation. The mediastinal pleura near the superior pulmonary vein were opened along the phrenic nerve, and the lingular vein was exposed. The inferior and superior lingular veins were separated from each other and resected after the ligation of the proximal end with a 3-0 silk suture. Subsequently, the anterior vein was exposed and separated into two branches (V3a and V3b + c) and the branches were resected after ligation with a 3-0 silk suture. The anterior artery was exposed and separated into two branches (A3a and A3b + c) by lifting the apicoposterior vein caudally A. Then, The specimen was placed in a bag . Then, a subaortic and paraaortic lymphadenectomy was performed. A wash of the thoracic cavity confirmed the absence of bleeding. The residual lungs were well inflated. Further, a 24-Fr chest drain (Medtronic Company) was placed, and the incisions were closed.2.3The operative time was 268 min, and the blood loss was approximately 100 mL. The chest drain was removed 2 days after the surgery, and the postoperative hospital time was 6 days; no complications were noted. The pathological stage was T1aN0M0 stage IA1 as categorized by the UICC TNM Classification (8th edition).3Recently, pulmonary segmentectomy has been frequently performed for early-stage lung cancers or metastatic lung tumors. According to some reports comparing segmentectomy with lobectomy in early-stage lung cancers, no significant difference in the overall and disease-free survival is noted . HoweverVATS is currently a better option than thoracotomy for lung resection; however, VATS segmentectomy is more difficult than thoracotomy . On the VATS segmentectomy is equivalent to VATS lobectomy in terms of the lymphadenectomy result, overall and disease-free survival, 30-day mortality, postoperative complications, and shorter length of hospital stay ,10．Segmentectomy has a risk of locoregional recurrence if a sufficient margin cannot be secured. Furthermore, it is difficult to delineate safe margins for lesions that are not visible and palpable. We usually perform preoperative CT-guided marking in the case of not visible and palpable lesion close to the intersegmental fissure. The preoperative CT-guided marking technique can visualize the location of the lesion. Thus, it is useful for delineating safe margins in VATS segmentectomy for invisible lesions.4The operative time was prolonged due to the complex procedure and confirmation of segmental bronchus by intraoperative bronchoscopy. It is necessary to shorten the operative time to further reduce the invasiveness.5VATS segmentectomy is safe and reliable and may further broaden the indications for VATS. In this report, we have described specific technical aspects of VATS left anterior and lingular segmentectomy for the impalpable lung nodule using a CT-guided nodule marking prior to the surgery, highlighting the port design and dissection methods for the segmental vessels, bronchus, and intersegmental lung parenchyma. The technique resulted in complete tumor resection with minimal adverse effects.The author has no conflicts of interest to declare.Authors had no sources of funding.The IRB committee of our hospital decided that approval is not necessary for this case.Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Kotaro Mizuno: Conceptualization, Methodology, Writing – Original Draft, Writing – Review & Editing, Supervision.Tadashi Sakane: Writing – Review & Editing.We haven’t registered our report to the registry system because this report is a case report.Kotaro Mizuno.Not commissioned, externally peer-reviewed.


Hepatic haemangioma is the most common benign liver lesion in the general population. It often exhibits a uniform pattern of characteristics, thus being called “typical.” However, a certain number of hepatic haemangiomas have special or uncommon characteristics and are termed “atypical.” The majority of patients are asymptomatic. Its differential diagnosis is critical, and its differentiation from other aetiological possibilities can be challenging, especially in cases of atypical haemangiomas, which may lead to confusion or even misleading diagnoses. We report on a 55-year-old patient with atypical multiple hepatic haemangiomas mimicking metastasis or echinococcus infection. Hepatic haemangiomas are benign non-neoplastic hypervascular liver lesions. According to newer nomenclature, these lesions are known as slow flow venous malformations. We retain in the article the word haemangiomas, as this term is ubiquitous in the literature and familiar to most clinicians and also to be consistent with the majority of the existing literature.Most haemangiomas present with typical and common characteristics in the general population, but those termed “atypical” occur less frequently. The spectrum of atypical haemangiomas is important and can help one avoid most diagnostic errors. However, in some cases the diagnosis will remain uncertain at imaging, and will require histopathological examination. The case presented exhibits the presence of multiple lesions that make diagnosis difficult, owing to similarity with other relevant differential diagnoses, such as metastases or hepatic lesions from echinococcus. We consider it important to publish this case because of its peculiar characteristics.A 55-year-old female patient with a history of systemic lupus erythematosus was admitted to the haematology external consultation service as a result of a clinical picture of fatigue and constitutional syndrome of 5 months’ duration.She presented with an extrainstitutional CT that demonstrated multiple focal, hypovascular liver lesions with microcalcifications  that occThe patient was evaluated without positive findings upon physical examination. The extrainstitutional paraclinical tests showed negative tumour markers and normal tests of liver function.Because of the imaging findings, it was decided to hospitalize the patient to characterize the hepatic lesions with contrast MRI with gadopentetate dimeglumine (Magnevist), 15 ml, infusion rate 2.2 psi, to stage the possible tumour lesion with a study algorithm of an unknown primary tumour. No specific liver contrast medium was used.T2 sequences and hypointense in T1 sequences, without identification of a fatty component in their interior. Predominant restriction in the periphery was observed in diffusion sequences. After contrast administration, some lesions showed discrete heterogeneous peripheral enhancement, whereas others showed intralesional nodular enhancement. Cholangioresonance sequences were performed with results in normal ranges  were requested but all results were in normal ranges.The diagnostic possibilities based on the imaging findings were infectious involvement by echinococcus versus metastatic lesions of an unknown primary tumour.An ultrasound-guided biopsy of the dominant lesion located in the right lobule was performed to clarify the diagnosis. A report was obtained within 3 days of the procedure; the pathology findings of the collected liver samples reported “fragments of liver tissue replaced by a benign lesion of vascular origin characterized by the presence of numerous anastomosing vascular channels within it, lined by endothelial cells without atypia, separated by fibrous connective tissue septa with ectatic and obliterated vessels; findings are consistent with sclerosing cavernous haemangioma” .1 Most lesions tend to be smaller than 5 cm and asymptomatic.2Hepatic haemangiomas are benign vascular non-neoplastic liver lesions of the hepatic mesenchyme that are well circumscribed and sponge shaped; the majority are congenital and mostly of the cavernous subtype.2 being a common lesion in the general population. These haemangiomas are more commonly diagnosed in patients between 30 and 50 years of age and in women relative to men, at a 5:1 ratio.1The prevalence of cavernous hepatic haemangiomas ranges from 1–20%,1Most of the lesions are unique; only 10% of cases exhibit multiple lesions.4In case of typical haemangioma, imaging modalities are highly reliable for diagnosis, especially MRI, which has a sensitivity and specificity of greater than 90%. With respect to the appearance of typical haemangiomas in ultrasound, an echogenic, homogeneous mass is evidenced with well-defined margins and posterior acoustic enhancement.1In CT, these lesions show low attenuation in the simple phase; after contrast administration, globular discontinuous enhancement occurs peripherally, and this peripheral attenuation is equal to the density of the contrast of the aorta; in the venous and late phase, there is centripetal enhancement that progresses to completely fill the lesion.T2-signal intensity, similar to the cerebrospinal fluid. With administration of contrast medium, specificity increases up to 98% for the characteristic enhancement pattern identical to that described in CT.1 In MRI as well as in ultrasound, three imaging patterns have been described:In MRI, the lesions present well-defined margins and very high Pattern 1—uniform high signal intensity after contrastPattern 2—peripheral nodular enhancement with centripetal progression until uniform signal intensity is reached 5Pattern 3—peripheral nodular enhancement with centripetal progression and a persistent central scar.3Among the atypical haemangiomas reported in the literature, we found the following to have been described: giant, of heterogeneous uptake, rapidly filling, calcified, hyalinized, cystic or multilocular, with liquid-liquid levels and pedunculated. These can be associated with abnormalities underlying the lesion, such as arterioportal shunts, peripheral nodular hyperplasia and capsular shrinkage, which are also present in the diffuse focal lesions of haemangiomatosis.This case presented itself as a diagnostic challenge because multiple lesions, predominantly echogenic, with some being heterogeneous and others having calcifications with target appearance, were evident on ultrasound. The low enhancement and heterogeneity detected in all phases of MRI and CT could be explained by the presence of microcalcifications and/or microinfarctions. The appearance of the haemangiomas in the diffusion images reinforced the annular imaging, and in late post-contrast images the lesions remained almost unchanged with respect to the venous phase.6 Haemangioma-like hydatid diseases are difficult to distinguish from atypical haemangiomas; they are clearly demarcated but not homogeneous and very often represent a significant diagnostic change.6 In this case, the liver lesions had an ultrasound appearance similar to that described in hepatic alveolar echinococcosis as “hailstorm pattern,” which is characterized by hyperechoic lesions with irregular boundaries, non–homogeneous, with or without acoustic shadow.Regarding differential diagnoses, hydatid disease at ultrasound can present several patterns such as “hailstorm” appearance, pseudocystic, haemangioma-like, ossificans and metastasis-like lesions.7 These can be observed at the marginal or central level of the lesion. Calcified haemangiomas can exhibit poor contrast, especially in the arterial phase of CT or MRI. Therefore, a liver haemangioma should not be ruled out in hepatic lesions that do not enhance in the arterial phase or contain small calcifications.Hepatic haemangiomas rarely show calcifications. These have been reported in 10% of the ultrasound images and 20% of CT scans.8Liver metastases are another differential diagnosis to consider in this case, especially because there are multiple lesions. These can be classified as hypervascular  and hypovascular . They can also have calcifications, especially in the case of metastases of mucinous carcinoma of the colon, breast, stomach or ovary as well as in melanoma, thyroid carcinoma, chondrosarcoma, leiomyosarcoma and neuroblastoma. Such calcium deposits can be dotted, amorphous, scaly, granular or poppy-seed-like.9In conclusion, although rare, the possibility of multiple haemangiomas with microcalcification, target appearance and low enhancement can be included in the differential diagnosis of other liver lesions such as metastatic disease and hydatid disease.2 In some patients who are symptomatic because of extrinsic compression, haemangiomas have been managed with surgical resection. Non-surgical treatments include hepatic arterial embolization and radiotherapy; however, these are rarely first-choice treatments.2With regard to treatment, with asymptomatic atypical cavernous hepatic haemangiomas clinical and imaging follow-up is indicated, preferably in 6 to 12 months, using the same diagnostic modality as that used for diagnosis. But owing to radiation issues, monitoring with MRI is suggested, for the purpose of comparison. If there is no change, further follow-up is not recommended.1 Most lesions tend to be smaller than 5 cm and asymptomatic.Hepatic haemangiomas are benign vascular non-neoplastic liver lesions of the hepatic mesenchyme that are well circumscribed and sponge shaped; the majority are congenital and mostly of the cavernous subtype.Among the atypical haemangiomas reported in the literature, we found the following to have been described: giant, of heterogeneous uptake, rapidly filling, calcified, hyalinized, cystic or multilocular, with liquid-liquid levels and pedunculated.The appearance of the haemangiomas in the diffusion images reinforced the annular imaging and in late post-contrast images the lesions remained almost unchanged with respect to the venous phase.Haemangioma-like hydatid diseases are difficult to distinguish from atypical haemangiomas; they are clearly demarcated but not homogeneous and very often represent a significant diagnostic change.The possibility of multiple haemangiomas with microcalcification, target appearance, and low enhancement can be included in the differential diagnosis of other liver lesions such as metastatic disease and hydatid disease.With regard to treatment, with asymptomatic atypical cavernous hepatic haemangiomas clinical and imaging follow-up is indicated, preferably in 6 to 12 months.


Obturator hernia is an extremely rare condition accounting for almost 0.07%-1% of all abdominal wall hernias, usually occurring in the elderly and emaciated females with a history of previous abdominal surgery. The symptoms of this particular hernia are non-specific; therefore, a high index of clinical suspicion should always be made. This rare condition may lead to acute small intestinal obstruction. The pre-operative diagnosis is challenging and often misleading on occasions, especially in co-morbid cases. This leads to delayed diagnosis and surgical intervention, hence causing an increased morbidity and mortality rate. The computed tomography (CT) scan of the abdomen and pelvis is the gold standard for diagnosis. We present a case of an 80-year-old female, with known comorbid of hypertension, initially diagnosed as peritonitis and on further examination revealed strangulated obturator hernia with proximal perforation, that underwent lower midline laparotomy with resection of necrotic bowel, an end-to-end anastomosis, and repair of the defect by vicryl suture. Obturator hernia is a rare type of abdominal wall hernia, accounting for 0.07%-1.0% of all hernias . The incThe awareness of this condition is stressed due to infrequent incidence, non-specific symptoms, and inconclusive diagnostic imaging. The following reasons can make this condition a real diagnostic challenge. Early diagnosis and surgical intervention are imperative to reduce the risk of mortality and morbidity since delayed response can lead to strangulation of entrapped bowel loops. This case was initially diagnosed on computed tomography (CT) as peritonitis secondary to obturator hernia; later during laparotomy, it was found to be a Richter hernia.A frail, 80-year-old woman, known case of hypertension and chronic myeloid leukemia (CML) presented to the emergency department (ED) with a history of dull pain in the lower abdomen since the past four days. Along with this, she complained of absolute constipation, with three episodes of dark-colored non-projectile vomiting for four days. Her past medical history showed the presence of melena, constipation and gastroesophageal reflux disease (GERD), while her past surgical history revealed a laparoscopic cholecystectomy for cholelithiasis a long time ago. She is currently taking anti-hypertensive medications, hydroxyurea for CML and oral antacids to relieve abdominal pain when needed.On examination (O/E), the patient was afebrile, comfortably lying on the bed and well oriented to time place and person with no signs of dehydration. Initial vitals included blood pressure (BP) of 150/100 mmHg, a regular pulse of 80 beats/min and a respiratory rate of 16 breaths/min. On inspection of the abdomen, she had diffuse abdominal distention, and while on palpation, she had mild diffuse tenderness at the right iliac fossa region, which was radiating towards left iliac fossa. Lastly, on auscultation, sluggish gut sounds were heard. No lymph nodes were palpable. Afterward, a nasogastric tube (NG) was inserted, which drained 200 ml of green-colored aspirate within 12 hours. The patient had negative Howship-Romberg sign and Hannington-Kiff sign. The hernial orifices were clinically normal, and the rectal examination was negative.Blood investigations revealed thrombocytosis and neutrophilic leukocytosis with a total leukocyte count (TLC) of 42.6x109/L. Serum electrolytes were abnormal which became normalized after adequate intake of fluid. The abdominal ultrasound reports showed dilated bowel loops and increased bowel gases. Left-sided small, simple renal cortical cysts were also noted. The chest and abdominal CT scans revealed dilated bowel loops and free gas under the diaphragm . CT of the abdomen and pelvis is considered a gold standard for diagnosis and must be considered in elderly patients with non-specific small bowel obstruction. This condition is also diagnosed during emergency surgery for small bowel obstruction. The only possible treatment is surgical treatment, which can be through either laparotomy or laparoscopy, with repair of obturator canal either with omentum, mesh or sutures. The abdominal approach is often favored, although the laparoscopic approach has shown to have fewer complications . The abdObturator hernia is a rare condition. It should be vigorously suspected as a cause of small bowel obstruction in thin, elderly females. In cases of great clinical suspicion of obturator hernia, a CT scan is essential to establish a pre-operative diagnosis. Often, diagnosis is delayed due to non-specific early symptoms, which can lead to perforation, peritonitis, and resection of gangrenous bowel, ultimately leading to significant post-operative mortality and morbidity. In a clinical setting, often obturator hernia is misdiagnosed as a femoral or inguinal hernia, which can lead to inappropriate management. Therefore, when accurately diagnosed, the only treatment is surgery, which is either through laparotomy or laparoscopy.


Rhabdomyosarcoma (RMS), a tumor of skeletal muscle origin, is the most common soft tissue sarcoma encountered in childhood and adolescence; it is primarily found in the head and neck region, it is relatively uncommon tumors of the oral cavity. Clinical signs depend on the exact location of the lesion in the oral cavity and its development. Authors reported the case of a 14-year-old patient who presented an oropharyngeal mass causing voice dysfunction, after two surgical operation the patient experimented two 2 recurrences of the lesion. The histopathological examination objectifies an oropharyngeal rhabdomyosarcoma. Immediate postoperative outcome was uneventful with improvement in the voice dysfunction and dysphagia one month after surgery. Complementary treatment (chemotherapy and radiotherapy) was not available and accessible to the patient. Twenty months (20) after surgery, the examination found a recurrence of the tumor with pulmonary metastases and neurological complications. Oropharyngeal rhabdomyosarcomas are rare. Their interest lies in the fact that they often affect children and adolescents. The prognosis remains unfavorable in our context, even for cases accessible to surgery since complementary treatment with chemotherapy and / or radiotherapy does not exist. The prognosis depends on tumor size, location, staging, age of patients and especially the quality of the management. Rhabdomyosarcoma (RMS) constitutes a heterogeneous and aggressive malignant soft tissue neoplasm arises from undifferentiated mesodermal tissue -4. RMS iA 14-year-old patient, from the rural area, with precarious socio-economic status, consulted at the Ear Nose Throat (ENT) department of Maradi CHR for an oropharyngeal mass evolving for several months. The last three months, the mass has increased in volume significantly. The patient had functional signs such as dysphonia, dysphagia and pain. At admission, the patient had a good general status. The conjunctiva and mucous membranes were normal-colored. At the opening of the mouth, the examination of the oropharyngeal cavity, noted an indolent mass, nodular, bloody and located on the right side of the oral cavity. The major axis of the mass measured approximately 5 to 6 cm . The bioImmediate postoperative outcome was uneventful with improvement in the voice dysfunction and dysphagia one month after surgery. The patient was referred to Niamey at the oncology department for adjuvant chemotherapy, but the parents reaffirm that they could not afford to bring their son to Niamey. After a return visit at 3 and 6 months at the CHR of Maradi, the patient was lost sight of. He returned 14 months after surgery with an oropharyngeal tumor recurrence. In addition to dysphagia and dysphonia, the patient had facial palsy ipsilateral to the tumor. The biological assessment noted anemia at 10 g/dl. The ultrasound showed images in favor of extending the tumor to the parotid. A whole blood transfusion was done to correct the anemia. A second tumor reduction surgery was performed . The immThis study has limitations. Indeed, we perform the surgery in a context of limited resources. On the one hand, the patient comes from disadvantaged rural areas, consulted late and does not have sufficient financial resources to cope with the cost of care. On the other hand, our hospital does not have multidisciplinary services that allow a holistic treatment of patients. Our patient with oropharyngeal RMS did not receive any additional treatment (chemotherapy and radiotherapy) for the surgery. However, the surgical management of this RMS had improved the quality of life of our patient and the results of this experiment deserve to be discussed with the scientific literature. The first case of rhabdomyosarcoma was published in 1854 by Weber; it was probably a botryoid RMS of the tongue , 11. RMSThe histologic classification of rhabdomyosarcoma remains very controversial, as several distinct morphological variants have been reported , 4. Hornst surgical resection, our patient presented with pulmonary and lymph nodes metastases. For Kim et al. [The cytotoxic actions of chemotherapeutic agents are not tumor-specific and are not effective in advanced and metastatic RMS , 8, 10. m et al. , the medm et al. . At the The oropharyngeal rhabdomyosarcomas are rare. Their interest lies in the fact that they often affect children and adolescents. The prognosis remains unfavorable in our context, even for cases accessible to surgery since complementary treatment with chemotherapy and/or radiotherapy does not exist. The improvement of the technical platform for earlier diagnosis and multidisciplinary management is necessary to meet the experts' recommendations on the treatment  and follow-up of RMS.The authors declare no competing interests.


Fibroma is a benign tumor of the connective tissue and is classified among the fibrous and fibrous histiocytic lesions. In the pediatric age group, both the differential diagnosis and surgery of maxillary swellings are difficult.A 26-month old girl applied with swelling and malformation in the nose. She complained of swelling in the right cheek, nasal obstruction and dyspnea during the night time. Her family stated that she had a head trauma 45 days before the application. We observed a rigid mass in the lateral side of the right nasal region consistent with severe edema. The pediatric endoscopic examination displayed a passage obstruction and an expansion of the lateral wall towards the septum. We performed right Caldwell-Luc approach with the endoscopic transnasal approach. The pathological examination with the light microscope displayed dense and thick collagen fibers and fusiform fibroblasts mixed up with these collagen fibers.Fibroma and fibroma like lesions are rare and difficult to diagnose. In the Pubmed database, we did not encounter any large-scale study focused on this type of tumors except for some case reports of fibromyxoma. In respect of the findings in the literature, along with the pathological criteria, the clinicopathological correlation and radiological imaging may facilitate the diagnosis. Furthermore, a good cooperation with the patient and his/her family and a reliable history like trauma are also critical.The possibility of trauma should be definitively questioned during the history of pediatric patients, who applied with a maxillofacial swelling with the presence of persistent edema and differential diagnosis for the soft tissue tumors like fibroma should be considered. Although the histological characteristics may be useful for the diagnosis of some lesions, additional detailed clinical and radiographic examinations are usually required for a definitive diagnosis . As a fi2A 26-month-old girl presented to our outpatient clinic with the complaint of swelling and malformation on the nose. She complained of swelling in the right cheek, nasal obstruction, and nocturnal dyspnea. Her family explained that she had a head trauma approximately 45 days before presentation. Her family had immediately applied ice on the trauma area and fetched her to an ENT specialist. According to the anamnesis, the ENT specialist prescribed a medical treatment after the clinical examination. Thereafter, a plastic surgeon performed an incision on the lesion to drain blood depending on a prediagnosis of hematoma; however, the swelling did not regress.At the time of presentation to hospital, we observed a rigid mass on the lateral side of the right nasal region consistent with edema. The skin color was slightly changed and we noticed an incision scar on the lesion. The rhinoscopic examination showed a narrowed passage on the right side. As the obstruction observed during the endoscopic examination did not regress with the decongestant impregnated embedded gauze pad, we suspected that it would be a turbinate hypertrophy. We observed that the lateral wall expanded towards the septum. The direct x-ray examination did not show a prominent fracture in the nasal region . The CT 3Fibroma is a benign tumor of the connective tissue and is classified among the fibrous and fibrous histiocytic lesions. Pure benign neoplasms of the fibrocyte are rare in any part of body. A fibroma may vary greatly in size, and be pedunculated or stalked-sessile, pale pink and hard upon palpation, containing fibrocytes. Fibromas consist of epithelium that is soft and circular or polyp-shaped, and the volume can often reach a very large size. When the term fibroma is used without a modifier, it is usually considered to be benign ,9. TheseRegarding the findings in the literature, the concomitant consideration of the clinical and pathological findings and radiological imaging along with the pathological assessment may facilitate the diagnosis. Furthermore, a good cooperation with the patient and his/her family and a reliable history of patient are also critical. Hereby, in our case, the main objective was to draw attention to the possibility of the emergence or activation of additional pathological events besides the fracture, which may occur or become active due to the trauma. The distinctive feature of our case was not the mass itself but the immediate admission of the patient to a health center after the trauma. The cause of the swelling – edema due to the trauma or the mass itself – was another confusing finding during the examination. Therefore, in similar cases of maxillofacial trauma with persistent edema, CT and MRI examination along with the direct x-ray examination may support the diagnosis of the additional pathological events.As far as know we couldn’t any clinical studies on both fibroma and trauma-related fibroma of the maxillar sinus in pediatric age as was detected in the literature. Wenig et al.  publisheIn conclusion, the possibility of trauma should be questioned during the history of patient in pediatric patients, who applied with a maxillofacial swelling, persistent edema. A differential diagnosis procedure for the soft tissue tumors like fibroma should be considered in the maxillofacial swelling.There is not any conflict.There is not any sponsors or any knowledgement.This is case report which doesn’t requıre ethical approval in our institution.I have took from parental or guardian consent on behalf of the patient.I ‘m single author for this study that I have contrıbution of each paper that design, data collectıon, data analysis, writing paper and others.Mehmet Akdağ, Assoc. of ProfessorA rare case report: fibroma in maxillary sinus following nasal trauma.Mehmet Akdağ.Not commissioned, externally peer-reviewed.


Helicobacter pylori gastritis and is rarely associated with other conditions including lymphoma. LG is of clinical importance since its recognition should prompt further clinical evaluation for other disorders.Lymphocytic gastritis (LG) is uncommon and presents histologically with a nonspecific inflammatory pattern. It is most often associated with celiac disease and  Helicobacter pylori infection, and rarely with other conditions including lymphoma.Lymphocytic gastritis (LG) is associated with celiac disease and A 50‐year‐old female presented with a 2‐week history of epigastric pain, nausea, vomiting, and weight loss. An abdominal CT scan and endoscopy were unremarkable. A gastric biopsy was obtained.The biopsy revealed a moderately dense lymphocytic infiltrate involving the lamina propria. In addition, the surface epithelial cells and gastric pit demonstrated markedly increased intraepithelial lymphocytes (IELs) with >25 IELs/100 epithelial cells. The IELs were predominantly small lymphocytes, including many with a halo appearance . Antibiotic therapy for KC: served as the primary author and is responsible for this literature review and construction of the manuscript. WNR: served as the hematopathologist on the case and was responsible for the histopathological work‐up and final diagnosis as well as senior author managing the construction and edits of the manuscript and guiding the primary author through the submission process.


Malignant fibrous histiocytoma has been uncommonly described in dogs. Several extranasal neoplasias have been reported to result hypertensive epistaxis. There are, however, no published case reports of extranasal malignant fibrous histiocytoma with concurrent hypertension and epistaxis in dogs.A 10-year-old dog presented with a spontaneous massive epistaxis persisting for 5 days. The dog exhibited unstable hypertension, which was considered as a cause of epistaxis. The complete blood count, prothrombin time, and activated partial thromboplastin time were within the reference limits, and other systemic examination showed no abnormalities except for a splenic mass occupying more than one third of the abdomen. Histologic examination of the resected spleen revealed the characteristic features of a malignant fibrous histiocytoma. One week after splenectomy, the hypertension and epistaxis resolved clinically and did not recur on the 5-month follow-up.The dog’s blood pressure and epistaxis normalized after malignant fibrous histiocytoma resection suggesting that hypertensive epistaxis may be a rare manifestation of canine malignant fibrous histiocytoma. Malignant fibrous histiocytoma (MFH) is a soft tissue sarcoma characterized by the presence of variably fibroblastic to less obviously histiocytic cells and variable numbers of associated non-neoplastic inflammatory cells , 2. MFH Epistaxis is a common and potentially severe or fatal otolaryngologic emergency in dogs that may be caused by either local disease within the nasal cavity or systemic illness , 9. CaniA 10-year-old spayed female Alaskan malamute (body weight 38 kg) was admitted to the Konkuk University Veterinary Medical Teaching Hospital with persistent intermittent bilateral epistaxis of 5 days’ duration. Per the owner’s report, once initiated, the epistaxis did not stop for 2 h despite nasal plugging. During the initial physical examination, the dog was bright and alert, with no nasal bleeding. No purpuric spots were observed throughout the body, and an oral examination revealed no remarkable findings. Thoracic auscultation revealed no abnormal sounds in the lung and cardiac fields, and an automated oscillometric blood pressure measurement revealed mild hypertension (systolic blood pressure 148 mmHg). However, abdominal palpation revealed a large, round, firm, painful mass on the upper-middle abdomen.9 cells/L; reference range 6–17 × 109 cells/L) and anemia . Serum chemistry revealed mildly elevated alkaline phosphatase activity  and hypoalbuminemia . The results of coagulation tests were within reference limits .Complete blood count, serum biochemistry profile, prothrombin time, and activated partial thromboplastin time analyses were performed to rule out coagulapathies, polycythemia, and thrombocytopenia as causes of epistaxis Table . The comThoracic radiography revealed a mild broncho-interstitial pattern in the overall lung field and a normal cardiac size. An abdominal ultrasound examination revealed a splenic mass with a heterogeneous appearance and irregular but encapsulated borders.The dog’s owner elected to pursue a rhinoscopy and computed tomography (CT) of entire body. Following anesthetization of the dog, the rhinoscopy was performed using flexible endoscopes Fig.  and b. AThe owner consented to a surgical excision of the splenic tumor, and the dog underwent a surgical exploration of the abdominal cavity while in the dorsal recumbent position. A large (16 cm × 14 cm × 10 cm) mass at the tail of the spleen was found to attach to the greater omentum. The involved section of the greater omentum was resected, and a total splenectomy was performed. The abdomen was lavaged with warmed sterile saline and closed routinely. The dog recovered uneventfully with routine postoperative antibiotics. Histopathologically, the resected spleen comprised pleomorphic neoplastic cells; these included both round histiocyte-like cells and spindle cells with occasional multinucleate cells and mitotic activities ranging from one to four mitoses per high-power field Fig. . An immu9 cells/L), anemia , and thrombocytopenia . A serum chemistry analysis detected elevated hepatic enzyme levels  and mild hypertriglyceridemia . An abdominal ultrasound revealed multiple nodules and masses of various sizes, shapes, and echogenecities that were spread diffusely throughout all liver lobes, leading to the diagnosis of metastatic liver masses and nodules. However, the owner declined further examinations and therapy because of the poor prognosis, and the patient was discharged at the owner’s request. The dog died 3 days later at home; however, the owner unfortunately refused a necropsy.ButorphanolTo the authors’ knowledge, no previous report has described concurrent hypertension and epistaxis in the dog with MFH. In the present case, the hypertension and epistaxis resolved after the surgical resection of MFH. Accordingly, this the first report of concurrent systemic hypertension and epistaxis attributable to MFH in a dog, with resolution after splenectomy. The lack of clinical reports describing these concurrent diseases processes might be attributable either to the low prevalence of splenic MFH in dogs or the fact that blood pressure evaluations are not routinely performed when abdominal masses are detected.Epistaxis may be caused by local disease within the nasal cavity or by systemic diseases that result in hemostatic disorders . In a reIn dogs, hypertension generally develops at an older age and more commonly affects males than females . The mosThe surgical resection of a MFH to control concurrent systemic hypertension in a dog has not previously been reported. In the present case, the hypertension was suspected to be caused by the MFH; therefore, its removal would theoretically reduce the blood pressure to within reference limits. Indeed, after splenectomy, the systolic blood pressure in the dog returned to normal and the epistaxis subsequently disappeared. The significance of the relationship between MFH and hypertensive epistaxis in the present case is unclear because epistaxis occurs even in healthy dogs. However, given the effectiveness of MFH resection in this dog, further investigations are needed to clarify the relationship between MFH and hypertensive epistaxis.In older dogs, splenic masses are commonly occurred and may be malignant, benign, or non-neoplastic . SeveralIn the present study, the nasal examinations which included CT and rhinoscopy, yielded no remarkable findings, and the cause of epistaxis remains unknown. We suggest two possibilities regarding hypertension and epistaxis in this dog with MFH. First, the dog might have previously exhibited hypertension and subsequent vascular abnormalities which is commonly referred to as a target-organ damage in the veterinary medicine , and wouWe report herein the clinical course of hypertensive epistaxis with the putative complication of splenic MFH in a dog. This is the first report of such a case in the literature. Although MFH is an extremely rare cause of the clinical signs observed in this dog, it should be considered in the differential diagnosis for uncontrolled epistaxis without clotting profile abnormalities. Furthermore, our findings warrant an investigation of biological behaviors in a larger number of cases and follow-up blood pressure evaluations in dogs with malignant tumors.