Pilomatrixoma is a follicular benign tumor of unknown etiology that originates in the matrix of a hair follicle. It develops more frequently in children and young adults, with a slight predominance in female patients. It is a slow-growing tumor that presents as a mobile nodule, firm, and with well-defined borders. The present study aimed to report the clinical, histopathologic, and radiographic aspects of pilomatrixoma in the cheek area of a 20-year-old female patient as the established treatment at an oral maxillofacial department. Pilomatrixoma is rarely included in the differential diagnosis of masses and nodules in the skin, and it is often confused with other nodular lesions, such as epidermoid cysts. The diagnostic method to identify this entity is an incisional biopsy. Because of its high incidence in the head and neck region, oral surgeons should be well-acquainted with this type of tumor so that it can be included as a diagnostic hypothesis of masses and nodules of the head and neck. CTNNB1 gene, which encodes the beta-catenin protein. It is a benign follicular cutaneous neoplasia originating in the cells of the hair follicle matrix.1,The etiology of pilomatrixoma, or pilomatricoma, has not yet been clarified, but evidence suggests a mutation in the The lesion was first described by Malherbe,The incidence of dermatological lesions is still uncertain and scarcely studied, with reports of indices ranging from 0.001% to 0.12% of all studied dermatological material.1,4,Surgical excision is the treatment described in the literature. There are few reported cases of surgical curettage, but without long-term follow-up. This procedure has an excellent prognosis with low recurrence rates (between 0% and 2.63%).1This study aims to report a case of pilomatrixoma located in the maxillofacial region and to discuss its clinical, radiological, histopathological, and surgical features.A 20-year-old white female patient complained of a progressive bulging of the right jugal region over the last seven months. She reported that 4 months after noticing the lesion, she had an episode of edema and pain in the affected region, which was controlled with analgesics and non-steroidal anti-inflammatory drugs.On physical examination, she presented with a well-defined nodule in the right cheek region, approximately 2.5 cm in the largest diameter, hardened, painless on palpation, and not fixed to the deep tissues. The lesion was superficial and the overlying skin became ischemic when finger-pressed A.Intravenous contrast-enhanced CT showed a mixed image with the presence of hyperdense dots attached to the adjacent skin B. ClinicThe patient underwent incisional biopsy under local anesthesia by cutaneous access.The treatment proposed was a complete surgical excision. Under general anesthesia, an extraoral incision of approximately 3 cm in the caudal part of the nodule was performed. The lesion had dimensions of approximately 24 mm × 14 mm × 12 mm C and 1D.In 1973, Moehlenbeck,4-2,The most frequent lesion location is the head, with an incidence between 39.6% and 51.5%, followed by the neck, upper extremities, trunk, and lower extremities.2,5-1,1,2,The lesions are typically solitary, with multiple manifestations occurring in 1.9% to 8.2% of cases.2On the histological evaluation of pilomatrixoma, the matrix cells present a slightly basophilic cytoplasm with a large, oval nucleus and a prominent nucleolus. A transition from these cells in the matrix to ghost cells is observed. Other components include multinucleated giant cells, nucleated squamous cells, and chronic inflammatory infiltrate.The most commonly used complementary imaging modality is an ultrasound, with a diagnostic rate of 15.3%,The definitive treatment of pilomatrixoma is total surgical excision. When the lesion is tightly adherent to the adjacent skin, it is necessary to remove the skin together with the lesion. In the present case, the lesion was easily dissected from the skin.Pilomatrixoma is an uncommon lesion that is easily confused with other pathologies. Oral surgeons must be able to recognize and differentiate this lesion to include it as a diagnostic hypothesis in head and neck lesions.


Middle-aged women with ureterovaginal fistula (UVF) after hysterectomy represent a painful condition for the patients in the community. Accurate diagnosis and proper planning before surgery are essential for effective outcomes. CT urography is the modality of choice in diagnosing ureterovaginal fistula. CT urography helps in evaluating the fistula as well the associated renal complications following the condition. Here we present a case of ureterovaginal fistula reported with a history of vaginal hysterectomy for subserosal fibroid in December 2021.  Since a urogenital fistula forms after gynecological conditions or obstetric surgery, treating urinary incontinence is a difficult undertaking. It is a terrible condition, and clinical problems are made worse by social and psychological elements. Vesicovaginal fistula is the most common urogenital fistula. The ureteral fistula often joins the vagina but sporadically may also connect to the uterus or fallopian tube . EndometA 42-year-old female presented to the department of obstetrics and gynecology with complaints of leaking urine from the vagina for three weeks. On per-speculum examination, there was evidence of dripping urine from the vagina. The patient has a history of large subserosal fibroid for which she was advised for a total hysterectomy. A large subserosal fibroid was identified arising from the posterior wall of the uterus, and a vaginal hysterectomy was performed, leaving the bilateral adnexa and vagina in situ. The procedure was uneventful, and the patient was discharged in three days. The patient developed urinary incontinence and left-sided flank pain two months after the surgery. The patient was then advised for CT urography for further evaluation. On the excretory phase 3 mins), axial and coronal images are showing normal excretion of contrast in the right renal collecting system filling the bladder but no excretion of contrast in the left renal collecting system. The cavity in the vaginal stump appears distended with fluid-filled collection within, possibly urine Figure . Excreto mins, axFistulous tracts between the vagina and ureter are rare, occurring primarily as complications of obstetric and gynaecologic procedures such as low transverse cesarean section or uterine curettage for elective abortion . Pelvic Ureterovaginal fistulas can also be a side effect of pelvic procedures, most commonly hysterectomy. In a 15-year review of genitourinary fistulas at the Mayo Clinic, ureterovaginal fistulas accounted for 31 of 303 cases, with the vast majority resulting from hysterectomy . Due to Despite the regular act of micturition, the primary ureterovaginal fistula presentation is an incontinence disease. Incontinence usually develops 1 to 4 weeks after surgery . AffectePrevention of renal impairment requires early diagnosis. The diagnosis is made using various imaging techniques, which include excretory urography, intravenous CT urography, and magnetic resonance imaging (MRI). Vesicovaginal fistula frequently coexists. The diagnosis is confirmed by the evidence of contrast extravasation from the ureter into the vagina, which may be seen on a delayed phase CT scan. Patients with renal failure or conditions where CT is contraindicated can use MRI . MRI canThe fistula may be able to heal with conservative therapy using a percutaneous nephrostomy tube and/or ureteral stent. Once the ureterovaginal fistula is diagnosed, an immediate ureteral stent or nephrostomy tube placement should be tried. Prompt urine drainage is necessary to maintain renal function even if surgery is subsequently required ,13.The morbidity linked to ureteral injury may be severe, leading to a protracted hospital stay, a poor surgical outcome, additional invasive procedures, decreased renal function, and a lower quality of life for the patient. Following a vaginal hysterectomy, the risk of ureteral complications is similar to that of an open laparotomy. The most effective ways to avoid harm are surgical skills, understanding of the anatomy of the pelvic wall, and meticulous identification and mobilization of the ureter. It's essential to get a diagnosis early to avoid needing long-term care. In the vast majority of patients with early diagnosis, endoscopic procedures are adequate. Our case was managed with a percutaneous nephrostomy tube followed by antegrade stent placement. However, severe ureteral strictures, urogenital fistulas, and renal insufficiency caused by ureteral injuries necessitate more comprehensive reconstructive surgery.


Epithelioid angiomyolipoma is a rare variant of angiomyolipoma and a part of the microphthalmia transcription factor (MiTF) tumors. We report a case of epithelioid angiomyolipoma of the kidney that occurred in a 40-year-old male. The tumor was composed of sheets of uniform epithelioid cells with clear to granular eosinophilic cytoplasm and hyperchromatic nuclei. The tumor extended into the vascular margin and perinephric fat with identified angiolymphatic invasion. Immunohistochemistry showed diffuse staining for HMB45, Melan A, and focal staining for SMA. No expression for EMA, AE1/AE3, CK7, S100, or Desmin was noted. The patient underwent a left nephrectomy with no recurrence. It is defined by the presence of round to polygonal cells with abundant pink to eosinophilic/clear cytoplasm and varying degrees of nuclear atypia.1.1A 40-year-old male with a past medical history of tuberous sclerosis presents with 5 months of painless gross hematuria and mild left mid quadrant abdominal pain. Abdominal MRI showed a large left renal mass with a central stellate scar, measuring 16 × 14 × 11 cm. The patient underwent a left nephrectomy, and the tissue was sent for histopathological examination. Under microscopy, tumor cells were relatively uniform epithelioid cells with clear to granular eosinophilic cytoplasm. 2,,,Epithelioid angiomyolipomas are a rare variant of angiomyolipoma  that demonstrate predominant epithelioid histology (>80%).Immunohistochemistry staining demonstrates tumor cells that are positive for cathepsin K, HMB45, Melan A, microphthalmia transcription factor (MITF), tyrosinase, CD68, and TFE3.Tumors are variably positive for SMA. Tumors are negative for PAX8, cytokeratins , S100, and SOX10. The molecular profile associated with these tumors reveals a loss of heterozygosity of chromosome 16p (TSC2) that has been reported in some cases.Similar to classic angiomyolipoma may or may not be associated with tuberous sclerosis complex (TSC) which is caused by inactivating losses of TSC1 (9q34) or TSC2 (16p13.3). A previous meta-analysis of 69 well-documented cases of EAML showed that 38% were malignant.3Epithelioid angiomyolipomas are rare and potentially malignant with the tendency for recurrence and frequent metastasis. EAMLs may be misdiagnosed as malignant renal neoplasm on incidental radiology evaluation.


A vas deferens abscess is a very rare complication of acute vasitis and lower urinary tract infection. A case of vas deferens rupture due to an abscess with severe pelvic inflammation requiring surgical drainage is reported.Teaching Point: Vas deferens abscess rupture is an example of a very rare complication of severe inflammation of the vas deferens. Abscess in the vas deferens (VD) is a very rare condition. Most VD inflammation is considered a retrograde infection from the lower urinary tract, that is, the urethra, prostate, seminal vesicles, and urinary bladder 2. There A 65-year-old man was referred to the emergency department with fever and abdominal pain. He had a medical history of benign prostatic hyperplasia and neurogenic bladder. In laboratory tests, pyuria, leukocytosis, and an elevated serum C-reactive protein level were noted. A contrast-enhanced computed tomography (CT) scan showed a large abscess in the extraperitoneal space and the sigmoid mesocolon . A wall The VD is located in the extraperitoneal space and courses from the epididymis to seminal vesicle above the prostate. The VD may be affected by inflammation of adjacent organs . The mosIn our case, there were dystrophic prostate calcifications. On previous imaging studies, there was no calcification near the distal end of the right VD. It is most likely that prostatitis was complicated with multifocal prostate abscesses. It is speculated that the tiny stone in the distal VD appeared to be a prostatic calcification migrated upward due to inflammatory weakening of the ejaculatory duct. It is important that this assumption is substantiated by the fact that at the time a bladder catheter was inserted at the emergency room, the catheter tip was located outside the prostatic urethra, indicating that there was already damage to the prostatic urethra. Inflammation from the prostate spread to the VD, with migration of prostatic calcification into the VD, which appears to have been predisposing for the VD rupture.During initial reading of the CT study at the time of the admission to the emergency department, the VD rupture was not reported. A retroperitoneal abscess was reported, without clear origin, such as UTI or diverticulitis. Thus, in the process of carefully relooking for other causes, the VD rupture was observed.To our knowledge, there is no previously reported case of VD rupture due to an abscess in the literature. We share a case of a very rare clinical experience of complicated VD rupture due to an abscess.


Ameloblastic fibrodentinosarcoma (AFDS) is a rare odontogenic tumor histologically characterized by a sarcomatous ectomesenchymal component associated with variable amounts of benign ameloblastomatous epithelium and the presence of dysplastic dentin.2AFDS has a predilection for the mandible, and it is most commonly seen in male patients in the third decade of life. Patients often present with a painful swelling, and AFDS is radiographically characterized by a multilocular radiolucent lesion with indistinct margins, with or without radiopaque foci. Metastases are rare, but recurrences have been reported. The treatment of choice is wide surgical resection.Given the above, the aim of this report is to describe a case of aggressive mandibular AFDS with emphasis on clinical, radiological, and histopathological aspects.A 19-year-old man was referred to public service for oral pathology consultation in 2014. The extraoral inspection showed a large swelling with strong facial asymmetry on left side of the face . IntraorThe radiographic exam revealed an ill-defined radiolucency measuring about 7 cm × 4.5 cm associated with impacted molar (36), lacking sclerotic borders and associated with the presence of multiple radiopaque flecks. Expansion and thinning of cortical bone were also observed . CalcifyAn incisional biopsy was performed and submitted to histopathological exam. Microscopic examination of the sections routinely stained in hematoxylin and eosin revealed a biphasic neoplastic proliferation of odontogenic epithelial and mesenchymal tissue. The odontogenic epithelial component consisted of multiple cords and islands bounded by columnar to cuboidal ameloblast-like cells, with reversed nuclear polarity. In the center of these structures, the neoplastic cells had a loose aspect, resembling the stellate reticulum of the enamel organ. The mesenchymal component consisted of a primitive connective tissue that displayed marked pleomorphism characterized by variation in cell size and shape, as well as nuclear hyperchromatism, alteration in nuclear to cytoplasmic ratio, and scattered mitotic figures . Areas oThe oncologist and surgeon chose to perform chemotherapy previous to the surgical treatment. Initially, three cycles of a drug combination were administered, comprising vincristine, cyclophosphamide, and cloxorubicin. The patient did not respond well to initial treatment and did not appear for the surgery on the day scheduled, returning only after four weeks. Thus, a new combination of drugs in three cycles was instituted, consisting of ifosfamide, carboplatin, and etoposide in order to reduce tumor size before surgery.However, after two cycles of chemotherapy with different drugs, the patient showed a significant increase in tumor mass with skin invasion, limited mouth opening, and extreme facial deformity . After tThe patient has been re-evaluated every three months with chest X-ray and CT scan of the head and neck. There has been no evidence of regional or distant metastasis, and the patient has been under clinical follow-up for one and a half years.Odontogenic tumors (OT) consist of a group of rare and heterogeneous lesions, representing less than 4% of all specimens of the oral and maxillofacial region. Malignant odontogenic neoplasms are even rarer and constitute a small percentage of OT. In various series published worldwide, the frequency varies between 0% and 6.1%.Microscopically, the bland epithelial component of AFDS is similar to that seen in ameloblastic fibrosarcoma, although it is less frequent.8Despite the morphological differences, the World Health Organization (WHO) distinguishes odontogenic sarcoma devoid of dental hard tissue (ameloblastic fibrosarcoma) from those displaying focal evidence of dentinoid (ameloblastic fibrodentinosarcoma) or dentinoid plus enameloid (ameloblastic fibro-odontosarcoma), but the WHO panel acknowledges that presence or absence of dental hard tissue in an odontogenic sarcoma is of no prognostic significance. The literature reports that the biological behavior of the AFDS is, in general, similar to other odontogenic sarcomas, with high local aggressiveness and low potential for regional lymph node involvement or distant metastasis.8Radiographically, AFDS can show a uni- or multilocular appearance, with poorly circumscribed outlines associated with tooth and one or more dense opacities. The present case showed a multilocular appearance associated with the left lower first molar 36) and slight dense opacities. These radiographic findings and the location of the mass highly suggest the possibility of odontogenic cysts and tumor.6 and slivs. 37.1%). Furthermore, odontogenic sarcomas are more frequent in the mandible (79% of cases) than the maxilla (21%), with the majority of the cases located in posterior region of the mandible.The mean age at the time of diagnosis of AFDS in 62 cases reviewed by Bregni et al.Odontogenic sarcomas are reported as a highly recurrent lesion. Till date, 25 35%) of the 71 reported cases have had at least one recurrence during follow-up period and 14 patients (19.7%) have died of their disease within three months to 19 years. Clinical findings vary among reported cases, but usually signs and symptoms include pain and swelling. Despite regional lymph node involvement or distant metastases reported in few cases, some authors have considered AFDS as a low-grade sarcoma.5% of the8In a recent multicenter epidemiological study conducted in Latin America, 25 cases of malignant odontogenic tumors were reported, and six cases were odontogenic sarcomas. All cases had the diagnosis of ameloblastic fibrosarcoma and no case of AFDS was identified.The treatment of choice for AFDS is radical surgical excision without primary neck dissection. Some investigators recommend adjuvant chemotherapy and/or radiotherapy, but its benefits are uncertain.In summary, this case report describes the first case of AFDS in Brazil and emphasizes the importance of considering the odontogenic sarcomas as a differential diagnosis of maxillary osteolytic lesions, despite being extremely rare lesions. Thus, these lesions are a challenging diagnosis for clinicians and pathologists.The authors declare no conflicts of interest.


Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations.A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis.The patient was diagnosed with omental torsion based on imaging and laparoscopy.Laparoscopic exploration was performed.The patient was discharged seven days after satisfactory postoperative recovery.Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis. Because the clinical signs and symptoms of omental torsion are similar to those of other common acute conditions, it is difficult to make a correct preoperative diagnosis. Most cases are diagnosed intraoperatively; however, the combined use of computed tomography (CT) and ultrasound makes preoperative diagnosis possible. Herein, we present a case of laparoscopic omentectomy and appendectomy for primary omental torsion in a child with acute appendicitis that could not be ruled out.Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain. More than half of the cases  were in the age group of 30 to 50 years, and the number of male patients was twice that of female patients.22. Abdominal examination revealed tenderness in the right lower quadrant without rebound tenderness or muscle tension, while the bowel sounds were normal. Laboratory tests demonstrated leukocytosis (11.68 × 109/L), normal percentage of neutrophils, and an elevated hs-C-reactive protein (69.06 mg/L). Abdominal ultrasonography showed effusion in the right lower ventral space and no apparent enlargement of the appendix. CT was performed because physical examination, laboratory tests, and abdominal ultrasound could not confirm the cause of the abdominal pain. A CT scan of the abdominal and pelvic cavity revealed concentric lines of fat and fibrous tissue surrounding the high-density central vessel in the right lower quadrant and iliac fossa  were inserted under direct vision in the left lower quadrant and left central quadrant. The procedure was performed using standard laparoscopic instruments and a 30° 5-mm telescope. During the abdominal exploration, free hemorrhagic fluid was first observed in the abdominal and pelvic cavities Fig. A. FurtheMacroscopically, the postoperative specimen showed a size of about 7 cm × 5 cm, suggesting infarction according to twisting and dark red in color Fig. A. HistolShe recovered well after surgery without any complications and was discharged from our hospital 7 days later Fig. B.3 When compared with appendicitis, the incidence of this pathology is 0.0016% to 0.37%, accounting for less than 4 in 1000 acute appendixes. Preoperative diagnosis of omental torsion is difficult, and only 0.6% to 4.8% of cases are accurately diagnosed before operation. Particularly in pediatric cases, the incidence of omental torsion was estimated to be between 0.024% and 0.1% in patients undergoing surgery for suspected acute appendicitis.,7Torsion of the omentum is a rare clinical disorder characterized by twisting of the omentum along its long axis that ultimately leads to vascular impairment. It is an uncommon cause of acute abdominal pain, accounting for approximately 1.1% of all acute abdominal cases. Primary omental torsion is a rare condition that occurs without an associated or secondary intraperitoneal pathology. The first report of omental torsion with no underlying pathology in the literature was attributed to Eitel in 1899. The pathogenesis of primary omental torsion is unclear, but it has several “predisposing factors”, such as excessive fat deposition (obesity) and anatomical abnormalities of the omentum. Precipitation factors include strenuous exercise, sudden changes in body position, gastrointestinal motility after satiety, cough, sneezing, inflammation, edema, and trauma.,9 Secondary torsion is more common and has the following underlying causative factors: omentum bifid, inguinal hernia, tumors, cysts, inflammation, previous abdominal surgery, and trauma. Because the anatomic cause or pathology could not be determined in our patient, a diagnosis of primary omental torsion was made.Torsion of the omentum can be divided into primary and secondary, with the latter having a higher incidence. In addition, on physical examination, abdominal tenderness, rebound tenderness, and muscle tension are more common in the right lower quadrant, and abdominal masses can sometimes be palpable. Omental torsion can mimic a variety of other acute abdominal conditions such as acute appendicitis, acute cholecystitis, acute pancreatitis, digestive tract perforation, intestinal obstruction, and gynecologic diseases. In children, the differential diagnosis may also include acute intussusception, mesenteric lymphadenitis, allergic purpura, and ascariasis. Therefore, it is difficult to accurately diagnose omental torsion preoperatively. Laboratory tests often suggest leukocytosis, elevated C-reactive protein levels, and an elevated erythrocyte sedimentation rate. Laboratory test results are also nonspecific and cannot differentiate other abdominal disorders. Therefore, relying on laboratory test results may delay diagnosis and lead to an increase in the degree and severity of omental torsion.The clinical presentations of the primary and secondary omental torsion were nearly identical. There were no characteristic signs or symptoms in either primary or secondary omental torsion. The predominant symptom of omental torsion is worsening nonradiating abdominal pain, mostly localized in the right lower quadrant, while fever is not a common presentation. Torsion of the left omentum is very rare because it is shorter, lighter, and less mobile than that of the right side. Gastrointestinal symptoms such as nausea, vomiting, and diarrhea are less common.,15 A CT scan shows either a whirling pattern of fibrous and fatty folds within the omentum or an inflamed fat-containing mass with concentric streaks around the vascular pedicle. The key to diagnosing omental torsion is the presence of a characteristic concentric linear strand. Ultrasonography revealed a hyperechoic, incompressible, oval mass close to the abdominal wall, often with free intra-abdominal fluid. Hence, ultrasonography is also essential to confirm the diagnosis of omental torsion preoperatively, in the absence of other abdominal pathological signs. On the basis of the patient's characteristic CT findings, the preoperative diagnosis was consistent with the final surgical exploration.Most cases are diagnosed intraoperatively; however, the combined use of CT and ultrasound makes preoperative diagnosis possible. Generally, conservative treatment includes prophylactic antibiotics and analgesics, although select patients should undergo careful imaging to rule out other acute abdominal pathologies. Complications such as abscess formation, adhesions, and intestinal obstruction may occur during conservative treatment due to the persistent presence of necrotic tissue in the omentum. However, there have been cases of primary omental torsion successfully cured with conservative treatment. Surgical treatment should be actively selected when the diagnosis is uncertain or the patient's clinical, laboratory, and radiological manifestations worsen with conservative treatment. Surgical resection of the affected omentum, possibly achieved laparoscopically, is the best treatment option. The advantages of laparoscopic techniques include a thorough examination of the abdominal cavity to confirm diagnosis, facilitated aspiration of exudate, and peritoneal irrigation, in addition to the benefits of minimally invasive surgery, which include decreased postoperative pain and wound-related complications. The pathophysiology of omental torsion involves twisting around the vascular axis several times, ultimately resulting in vascular damage and compromised blood supply. As the degree of torsion increases, the arteries gradually occlude, leading to acute hemorrhagic infarction and eventually to necrosis of the omentum. Therefore, to avoid a large amount of toxins returning to the blood through the omentum vein and aggravating the symptoms of postoperative poisoning, the necrotic omentum cannot be recovered before resection.Under different conditions, both conservative and surgical treatments can be used for primary omental torsion.In conclusion, primary torsion of the omentum is a rare pathology with acute abdomen as the main manifestation, and the majority of cases are misdiagnosed as acute appendicitis. The concentric lines of fat and fibrous tissue often seen on CT scans may prompt preoperative diagnosis and determine the surgical approach. The laparoscopic approach allows thorough exploration of the abdominal cavity and further surgical intervention, especially in patients with ambiguous symptoms and nonspecific abdominal pain. The possibility of omental torsion should be considered when free hemorrhagic fluid is present in the abdominal cavity.The authors thank the patient and his family for their consent to publish this report.Data curation: Ran Huang.Supervision: Ran Huang, Chun Li, Weisong Li.Visualization: Chun Li, Weisong Li.Writing – original draft: Yue Wang, Weisong Li.Writing – review & editing: Yue Wang.


Cavernous lymphangioma often occurs in the head, neck, trunk, and extremities of infants and children, and it is rare to cause a small intestine intussusception in adults. In this case, a 32-year-old woman presented with abdominal pain, vomiting, and a 5 cm × 5 cm abdominal mass on the left side of the abdomen. Laboratory tests showed anemia and CT showed small intestinal intussusception. After conservative treatments, her symptoms disappeared. However, 18F-FDG PET/CT suggested malignancy and her symptoms reappeared after eating something. Segmental jejunal resection was performed and pathology showed submucosal cavernous lymphangioma. At the 1-year follow-up, the patient was asymptomatic. Then this paper reviewed the literature on small intestinal cavernous lymphangioma in adults and found that this is the first English case report of intussusception caused by a jejunal submucosal cavernous lymphangioma in an adult. Current problem is that adult intussusception and intestinal lymphangioma are difficult to diagnose preoperatively. Imaging techniques such as tomography and PET/CT aid in the diagnosis of these benign lesions. Surgical resection was considered to be the required treatment and seems to have had no recurrence in adults according to the literature. Intussusception caused by small intestinal cavernous lymphangioma in adults is rare. The etiology of intussusception in adults is often benign polyps, Meckel's diverticulum, malignant lesions, or idiopathic lesions, which account for approximately 1%–5% of mechanical intestinal obstruction and are malignant in up to 77% of cases . LymphanA 32-year-old woman presented with abdominal pain and vomiting for 10 days, with a history of cesarean sections in 2015 and 2017, without family history of gastrointestinal tumors.Vital signs remained stable and within normal ranges. Abdominal examination revealed tenderness and a 5 cm × 5 cm abdominal mass on the left side of the abdomen, without signs of peritoneal irritation.9/L, Neutrophil percentage was 87.4%, Hemoglobin was 10.3 g/dl, Amylase was 141 U/L, and D dimer was 630 ng/ml. Tumor biomarkers were not known. Contrast-enhanced CT of the abdomen showed possible small intestinal intussusception of the left-sided upper abdomen. There was the presence of fat within a loop of the jejunum which suggested intussusception with a jejunal lesion and a small amount of pelvic fluid . Microscopically, cysts were identified in mucosal lamina propria and submucosa layers (hematoxylin-eosin staining). The endothelial cells were partially positive for D2-40, CD31, CD34 , desmin,The patient was hospitalized for 11 days after surgery. At the 3-month follow-up, the abdominal CT looked the same as the one after partial bowel resection. At the 1-year follow-up, the patient was asymptomatic, her hemoglobin was normal and the gastrointestinal endoscopy showed smooth duodenal mucosa.From 1940 to 1961, Viar reviewed 9 lymphangiomas in 52 cases of mesenteric cysts, mostly in the ileum and mesentery . HanagirThe authors searched Pubmed, Clinical Key, and Web of Science for English literature and CNKI, WAN FANG, and CQVIP for Chinese literature from inception up to January 1, 2022, for “lymphangioma” and “small intestine” as keywords. Patients under 18 years old were excluded, and those whose pathology showed “cavernous lymphangioma” were included. There were 23 cases in English literature from 1961 to 2021 –33. WomeThe etiology of lymphangioma is unclear. Congenital lymphangiomas arise from abnormal embryonic development of the lymphatic system with gradual accumulation of lymph. In adults, lymphangiomas may develop secondary to lymphatic duct injury caused by infection, tumor, surgery, trauma, or radiation . We repoClinical presentation is nonspecific. It may be asymptomatic. Sometimes the mass grows slowly and aggressively, encasing and compressing the surrounding organs causing symptoms, and sometimes complications cause acute abdominal disease: torsion, intussusception, or rupture of cystic structures leading to acute peritonitis or intestinal obstruction. Invasion of the intestinal wall can cause gastrointestinal bleeding .Preoperative diagnosis is difficult. However, endoscopy, ultrasound, CT, MRI, and PET/CT can help us. Patients with chronic black stools or abdominal masses can have lesions detected by endoscopy, and the development of small intestinal endoscopy is very helpful, while for patients with acute abdomen are difficult to use endoscopy. The septa in a cystic mass are usually more accurately delineated by ultrasound than by other techniques. But the accuracy of preoperative ultrasound localization and diagnosis is low . On CT sMost patients undergo surgical resection of the lesion and part of the small intestine, and pancreaticoduodenectomy is performed for lesions involving the head of the pancreas , 29. In In summary, we report a rare adult case with jejuno-jejunal intussusception caused by a small intestine cavernous lymphangioma. Most of the cases are under 50 years old, men, Asian, and located in jejunum. Preoperative diagnosis is difficult, but CT, ultrasound, and PET/CT are helpful. Surgical resection is a good curative method without a case of recurrence reported in the literature. The final diagnosis of cavernous lymphangioma will be made by histological examination.The patient was uninterested in follow-up or learning about the condition. She had the same abdominal pain after exercising when she was 14 years old. But there was no abnormality on gastroscopy and the pain disappeared soon. However, the pain existed for 10 days without eating anything. She was particularly impressed that she had many CT scans, but the diagnosis was not verified. She hoped the doctor would confirm the diagnosis as soon as possible so she could feel easy.


Pure ovarian neuroendocrine tumors are very rare. Herein, we present a young Iranian woman with a pure primary ovarian neuroendocrine tumor.A 26-year-old female presented with chronic abdominal pain and progressive constipation and was referred to the emergency room. Imaging findings confirmed a mass in the right adnexa. Following the resectional surgery of the ovarian mass, histopathological and immunohistochemistry results disclosed a mixed type of primary ovarian neuroendocrine tumor. The patient did not experience tumor recurrence afterward. Due to the rarity and low prevalence of primary pure ovarian neuroendocrine tumors, the histopathologic diagnosis should be confirmed by an immunohistochemistry study. Carcinoid tumors (CT), recently known as neuroendocrine tumors (NETs), derive from neuroendocrine cells show capability for secreting a variety of neuropeptides, causing clinical symptoms. NETs usually originate from the gastrointestinal or respiratory tract and rarely from other organs, including ovaries, and generally account for less than 0.5% of all malignancies . NeuroenOvarian NETs are rare, accounting for less than 5% of all NETs and 0.1% of all ovarian tumors . The preOvarian NETs most commonly appear as a unilateral adnexal mass in patients around 50 to 70 years of age and represent a carcinoid syndrome episode . CarcinoRadiologically, ovarian NETs commonly appear as solid cystic masses , 9 and cWe report a rare primary pure ovarian NET in a 26-year-old Iranian woman suffering from chronic abdominal pain and chronic progressive constipation as a scarce symptom of carcinoid syndrome. She was admitted to the emergency room with acute abdominal pain due to the torsion of the ovary, despite the small size of the tumor. Before enrolling the patient in this study, participant consent was obtained, and all applicable international, national and/or institutional guidelines were followed.The patient was a 26-year-old woman, with a history of two pregnancies with the outcome of two live children, without any family history or personal risk factors for malignancy. She suffered from chronic abdominal pain with chronic progressive constipation for six months and was admitted to the emergency of Kosar academic hospital  in April 2018, with a chief complaint of lately intensified abdominal pain in the right lower quadrant region, accompanied by nausea and anorexia. A tender pelvic mass in the right adnexa was palpated. Nevertheless, appendicitis was ruled out by specific physical examinations.Sonographic studies showed a right adnexal mass, measured 64 × 54 ×54 millimeters. In computerized tomography (CT) scan, a well-defined solid cystic mass was seen in the right adnexa, M: 63 ×53 ×53 mm, with echogenic foci inside the solid part and no invasion of the surrounding tissue were detected. Subserosal leiomyoma was considered as the most likely possibility in differential diagnosis. Laboratory studies showed exclusively mild leukocytosis, while other laboratory studies, including thyroid and parathyroid gland tests and serum levels of Ca, P were within normal limits. Tumor markers were within normal limits, including CA125, CEA, CA19.9, LDH, BhCG, Inhibin B and AFP. In the past medical history, the colonoscopy studies had shown no pathologic findings (performed due to 6-month history of constipation).During surgery, torsion of the right adnexal mass was observed, and the received specimen was an intact gray ovaloid mass in appearance, M: 6×5×5 cm . The cutThe Ki67 index was less than 3%, and granular cytoplasmic immunoexpression of CgA and nuclear expression of PAX8 were detected . The surWe reported a new case of pure primary ovarian NET in a 26-year-old woman, a neoplasm emerging mostly in five or later decades of life and rarely in young adults , 2, 12. Constipation is a very uncommon symptom of carcinoid syndrome and is rarely seen in patients with ovarian NET , 14. DueIn imaging studies, ovarian NETs may appear in different forms, such as a pure form, a solid mass with small cysts, a nodule within a mature teratoma, a mucinous cystadenoma, or even within a Brenner tumor , 3. In tThe histomorphologic diagnosis of the mass was a mixed type of pure primary ovarian NET, known as a non-prevalent type . In thisPrimary pure ovarian NET is a very rare type of ovarian neoplasms. The initial clinical presentations may be very diverse and unspecific, necessitating a complete assessment and follow-up of each patient, especially those with progressive symptoms, to make an early and reliable diagnosis. To exclude secondary ovary involvement, histopathologic diagnosis should be confirmed by the IHC studies. Today, it is challenging to establish diagnostic criteria for grading ovarian NETs. Data accumulation of more cases will indeed provide other experiences.The authors declared no conflicts of interest. No source of funding.


Mucosal prolapse syndrome is also known as solitary rectal ulcer syndrome. It may either presents as an ulcer or polyp, which could mimic other pathological lesions such as juvenile polyp, hyperplastic polyp, adenomatous polyp, polyp related inflammatory bowel disease and adenocarcinoma. It can pose as a diagnostic challenge to both the surgeons and pathologists due to the overlapping gross and histological features. The characteristic histological features of mucosal prolapse syndrome are fibromuscular obliteration of lamina propria and splayed hypertrophic muscularis mucosae. It can occur in a wide range of ages, including children and teenagers. Rectal bleeding is one of the common presenting symptoms. Here, we described two cases of mucosal prolapse syndrome presented as rectal polyposis and provide a discussion on its histological differential diagnosis. Mucosal prolapse syndrome (MPS) is a condition with confusing terms and histological features. It is historically called as solitary rectal ulcer syndrome, even though it is not always solitary, not always in the rectum and not always an ulcer. The incidence of MPS is approximately 1 in 100,000 with young adult predominant. The proposed pathogenesis of SRUS is due to excessive straining which results in high intrarectal pressure and ischaemia. The anterior rectal mucosa is forced into the closed anal canal due to contracting/non-relaxation of puborectalis muscle, leading to congestion and oedema, forming ulcer or polyp. It may present clinically with bleeding, mucus discharge, abdominal pain, tenesmus, feelings of incomplete defaecation and constipation [The gross appearance of either an ulcer or polyp may be mistaken as malignancy to the surgeon. It can be diagnostically challenging to pathologists due to its varied histological appearances. It could mimic other pathological lesions such as juvenile polyp, hyperplastic polyp, tubular adenoma, serrated adenoma, adenocarcinoma, pseudomembranous colitis and inflammatory bowel disease . Polyp i3/µL . There was no history of bleeding tendency and his platelet count was 274 × 103/µL. Examination of the rectum showed multiple polyps on the mucosal surface which was confined to the rectum and extend to the distal surgical margin. Altemeier proctosigmoidectomy was performed.An 18-year-old man presented to the emergency unit with one-week history of daily and persistent rectal bleeding. He also noticed a prolapse mass with berries-like surface from the anus, associated with pain. He did not have constipation. He was mildly anaemic with haemoglobin level of 12.8 g/dL. Other laboratory investigations showed total protein level of 69 g/L , albumin level was 43 g/L , globulin level was 26 g/L , and the albumin to globulin ratio was 1.7 . The white cell count was 5.8 × 10Gross examination revealed approximately 42 polyps on the mucosal surface A. The la3/µL , platelet count level was 243 × 103/µL , c-reactive protein level was 0.14 mg/dL , total protein level was 75 g/L  and albumin level was 42 g/L .A 62-year-old lady with systemic lupus erythematosus presented to our hospital with intermittent watery rectal discharged for the past few years, which became worsened one-month ago. It was associated with constipation and occasional rectal bleeding. Ten years ago, there was a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy. Proctoscopy revealed a pedunculated rectal polyp and grade 4 external haemorrhoid. Polypectomy was performed. Laboratory investigations showed haemoglobin level of 11.3 g/dL , white cell count was 6.1 × 10The rectal polyp measured 2.0 cm × 1.5 cm × 1.3 cm. Microscopically, the polyp consisted of irregularly spaced tubular crypts with focal dilatation, separated by hypertrophied muscularis mucosae, and granulation tissue cap. It was focally covered by squamous epithelium. Some of the glands demonstrate serrations . These fWeigert Van Gieson  was used for the staining of elastic fibers. Tissue blocks were sectioned at 4 µm thickness and the tissue slides were incubated with 10 drops of periodic acid solution for 5 min. This was followed by rinsing in distilled water. After that transferred Weigert’s solution into a Coplin Jar, immersed the slides in the jar, covered it, and incubated for overnight. Then, rinsed the slides in distilled water. Subsequently, incubate the slides with 10 drops of acid differentiation buffer for 10 min. This was followed again with rinsing with distilled water. After that, put on the slides 5 drops of Weigert’s iron hematoxylin (solution A) and add 5 drops of Weigert’s iron hematoxylin (solution B) and incubated for 10 min. Then, blue it in running tap water for 10 min. Lastly, put on the slides 10 drops of Van Gieson’s Picrofuchsine and incubated for 7 min. The slides were then rinsed for 2–3 s in distilled water, dehydrate and cover-slipped with mounting medium. TP-XCAM4K8MPA  camera mounted on an Olympus microscope BX41  was used to obtain the figures of H&E and EVG staining in this study.MPS was first described by Cruveilhier in 1892 as four unusual cases of rectal ulcers . It is aThe second case showed the typical histological features of a mucosal prolapse syndrome with cystically dilated glands, some of them demonstrate intraluminal serrations, villiform surface, exudate on the mucosal surface simulating pseudomembrane, and thickened and disorganised muscularis mucosa see . AdditioOne of our cases occurred at the age of 18 years. It has been reported MPS can developed in children and young adults. Thirumal and colleagues described 24 cases of MPS between the age of 5 to 11 years. All of them presented with rectal bleeding and about 8% had rectal polyps .The histological mimics of MPS with polyp can be divided into those with (1) granulation tissue and (2) glands with intraluminal serration. The differential diagnosis of MPS with polyp containing granulation include juvenile polyp and benign inflammatory polyp in inflammatory bowel disease. While the differential diagnosis of MPS with polyp demonstrating glandular intraluminal serration includes hyperplastic polyp and serrated adenoma .Juvenile polyp (JP) is a hamartomatous malformation that can be sporadic or hereditary (juvenile polyposis syndrome). Similar to MPS, juvenile polyp can be single or multiple, with presence of granulation tissue and prominent dilated crypts. In contrast to MPS, surface erosion in JP is not common. There is no prominent muscularis mucosa. JP may have prominent inflammatory infiltrates and may involve other part of colon .Benign inflammatory polyp is often related to inflammatory bowel disease. Similar to MPS, it may be single or multiple, with surface erosion or ulceration and granulation tissue, and crypt distortion or dilation. In contrast to MPS, it may have heavy acute and chronic inflammatory infiltrates with cryptitis and crypt abscess. Benign inflammatory polyp can be located anywhere in the colorectum.Both hyperplastic polyp and serrated adenoma demonstrate glandular intraluminal serrations or saw-tooth appearance, which can also be seen in MPS. However, hyperplastic polyp and serrated adenoma lack other features observed in MPS, like surface ulceration and granulation tissue. In addition, these polyps can be located anywhere in the colorectum. MPS may also be mistaken as adenocarcinoma due to displacement of crypts in the muscularis mucosa and submucosa .The histological diagnosis of MPS could be challenging due to various mimicry. However, the diagnosis can be made with careful identification of its classic histological features. These 2 cases demonstrated some of the spectrum of the histological changes in MPS with polyps. If diagnosis is difficult, we suggest performing a few deeper sections and an elastin stain to demonstrate elastin fibers in the lamina propria. Sometimes the excision is too superficial and the muscularis mucosa is unable to determine, then a comment of repeat biopsy of deeper tissue could be helpful.


The leukemic phase of ALK‐positive anaplastic large cell lymphoma (ALCL) is reported to have a poor prognosis. We, herein, report a rare case of the common type of ALK‐positive ALCL complicated by lactic acidosis. The present case indicates that the leukemic phase of ALCL should be considered in a peripheral blood smear when abnormal lymphocytes are detected, as urgent chemotherapy may rescue life‐threatening LA in the leukemic phase of ALK‐positive ALCL. These findings suggested the leukemic phase of malignant lymphoma complicated by lactic acidosis (LA). Computed tomography showed neither lymphadenopathy nor hepatosplenomegaly. She was hospitalized the same day and started on continuous hemodialysis. However, her laboratory findings of the next day of admission were WBC count, 42,540/μL; abnormal lymphocytes, 29.0%; LDH, 5719 U/L; blood pH, 7.317; HCO3, 10.8 mmol/L; and lactic acid, 88 mg/dL. She started chemotherapy consisting of etoposide, doxorubicin, cyclophosphamide, vincristine, and prednisone (EPOCH) under continuous hemodiafiltration. LA improved after the first cycle of EPOCH therapy.A 47‐year‐old woman visited our hospital with a chief complaint of a low‐grade fever and an inability to move due to fatigue. Her laboratory findings were white blood cell (WBC) count, 21,370/μL; abnormal lymphocytes, 12.0%; lactate dehydrogenase (LDH), 2836 U/L; blood pH, 7.295; HCOMay‐Giemsa staining of a peripheral blood smear revealed small to medium‐sized abnormal lymphoid cells Figure . The cytThe patient underwent chemotherapy consisting of brentuximab vedotin, doxorubicin, cyclophosphamide, and prednisone after the first cycle of EPOCH therapy. However, severe headache developed, and the central nervous infiltration of her lymphoma was detected by a lumbar puncture. Papanicolaou staining and May‐Giemsa staining of a cerebrospinal fluid smear revealed abnormal lymphoid cells, and the phenotype was found to be positive for CD4 and CD30. She was started on alectinib and, thereafter, her central nervous symptoms rapidly improved.Although ALK‐positive ALCL is associated with a favorable prognosis among peripheral T‐cell lymphoma, the leukemic phase of ALCL is reported to have a poor prognosis, especially due to early death.Noriharu Nakagawa: Writing – original draft. Masahide Yamazaki: Writing – review and editing.The authors received no specific funding for this work.The authors declare no conflicts of interest in association with the present study.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Traumatic abdominal wall hernia is defined as protrusion of bowel or an abdominal organ through a disruption of musculature and fascia following a severe blunt trauma. We report a case of a patient who had a delayed presentation of a traumatic, superiorly located paralumbar hernia months after the initial admission. The most common causes of this rare phenomenon are motor vehicle collisions (MVC) followed by handlebar injuries, motorcycle accidents and falling . TAWH maet al. . Seventyet al. , 2. TAWHWe present a case of a 27-year-old female with a history of an MVC that presented with abdominal pain and nausea for 2 days. Three months prior, she was the restrained driver when her car was hit on the driver’s side. X-ray imaging demonstrated a left hemothorax, left open fractures of the humerus and a left proximal femoral fracture. Computed tomography (CT) yielded a left apical pneumothorax, bilateral pulmonary contusions and a left-sided pelvic retroperitoneal hematoma. Along with surgical fixation for her fractures, she was admitted into the surgical intensive care unit (SICU) for monitoring. She was discharged 1 month later with no complications. She presented 2 months later with abdominal pain. CT scans suggested a partial small bowel obstruction (SBO). She was admitted, treated with bowel rest and was discharged 9 days later.During her last admission, she experienced lower abdominal pain with nausea for 2 days. The abdomen was soft, obese with mild tenderness and guarding on palpation without rigidity or a hernia. CT scans suggested ileitis, omental adhesions, SBO and an inferior lumbar hernia. She underwent laparoscopic surgery for the ileitis, omental adhesions and repair of two mesenteric defects, while the lumbar hernia was opted to be handled electively; however, she did not desire additional surgery.TAWH arise from increased abdominal pressure, shearing forces and/or blunt forces on the abdomen, which cause a disruption of abdominal wall musculature and fascia. Blunt force results in the disruption of the abdominal wall muscles and fascia, allowing subcutaneous herniation of abdominal viscera through the defect, while the elasticity of the skin allows it to remain intact .Lumbar hernias are rare, with 300 reported cases in English literature, 66 of which were traumatic lumbar hernias . They caFat stranding is a common finding in late-onset TAWH. On CT, this appears as well-defined linear areas of increased attenuation caused by omental infarct, ischemia, perforation or infection . In delaIn June, the patient’s CT imaging demonstrated a left posterolateral muscular defect of the fascia and external and internal obliques 2a. FolloFigs 1b and Traumatic lumbar hernias are due to high energy blunt traumas to the abdomen, particularly restrained drivers in MVCs due to shearing forces and/or increased intra-abdominal pressures. This is one of the first descriptions in literature showing a progression with imaging studies of how these hernias develop. In most cases, they are found at the time of admission. In our patient, we believe the delay in presentation may be due to an initial muscular and fascial defect of the abdomen, which was worsened by severe muscle atrophy from a prolonged hospital course. Additionally, our patient had a superior lumbar hernia, which is an uncommon presentation. CT evidence of fat stranding and muscular defect may have been an early indicator for delayed traumatic lumbar hernia.None declared.None.


Splenic abscess is a rare infection that may develop from a multitude of causes. There are several different microorganisms implicated in pathological formation including Staphylococci, Streptococci, Salmonella, and Escherichia coli. Antibiotics are the first line of therapy in treatment with eventual surgical intervention. It is imperative to have surgical intervention performed due to increased rates in mortality with only medical management. However, specific treatment guidelines in the management of splenic abscess have been unclear due to the low number of documented cases. We report the case of a splenic abscess in thirty-year-old female two months following an appendectomy. The goal of this case report is to help provide additional context into management and treatment options for splenic abscess using literature review. Splenic abscesses are uncommon infections with a reported incidence of 0.05-0.7% . One of The diagnosis of a splenic abscess is often diagnosed through clinical suspicion. The triad of fever, leukocytosis, and left upper quadrant pain are only present approximately one-third of the time in patients with a suspected splenic abscess . TherefoWe present the case of a 30-year-old female who had undergone a laparoscopic appendectomy two months prior for confirmed appendicitis. Her past medical history was significant for chronic kidney disease, diabetes mellitus, and hypertension. One month following the appendectomy, she was evaluated in the local emergency department due to reports of persistent abdominal pain. Radiological findings ordered during that visit included an MRI without contrast, which demonstrated a lobulated area with a high T2 signal within the spleen which extended from the superomedial aspect to the posterior mid-spleen. Initially, this was suspected to be a splenic infarct due to the rarity of a splenic abscess. She was discharged with antibiotics and advised to follow up as needed.The patient presented again to the emergency room two months after her appendectomy with a chief complaint of left upper quadrant and chest wall pain for two days. CT abdomen/pelvis without contrast demonstrated progression of hypodensity in the spleen Figure .The study was limited due to the patient’s inability to tolerate IV contrast. It did not fit a classical radiologic picture of a splenic infarct; therefore other diagnoses were considered. Due to the clinical history and left upper quadrant pain, fever, and leukocytosis, the diagnosis of a splenic abscess was suspected. The patient was taken to the operating room after providing consent and underwent an open splenectomy. Laparoscopic intervention was not performed due to surgeon preference given the rural setting of the hospital it was performed at. During the operation, the entire spleen was found to be ischemic. Dissection of the spleen resulted in back bleeding from the upper spleen, and spillage of pus into the abdominal cavity was noted. Proper hemostasis was obtained, and cultures were procured. Cultures were positive for Escherichia coli and negative for anaerobic growth.Pathology report demonstrated a spleen weighing 296 grams, measuring 12.5 x 8.5 x 6 cm. Peripherally on the diaphragmatic surface, yellow adipose tissue was approximately 5 x 2 cm in dimension. Adhered to that segment, was a light gray softened and necrotic surface tissue with a 5.5 x 2.5 cm dimension. Central to the peripheral hilar surface was a superficial decortication with 8 x 5 cm of red-brown tissue. Sectioning demonstrated softened and friable tissue beneath the area of light tan surface discoloration. The remaining parenchyma presented a solid and homogeneous dark pink-red appearance within the central portion beneath the focal disruption on the diaphragmatic surface. An example of splenic abscess is provided (Figure It was suspected that the abscess resulted from bacteremia secondary to appendicitis. The patient was seen for follow-up in the clinic two weeks later and recovered without postoperative complications from the surgery.Splenic abscess is a fatal condition when left untreated. Prompt recognition using known risk factors is critical in diagnosis. It is uncommon for immunocompetent patients to develop a splenic abscess . TherefoDue to the rarity of presentation, diagnosis and treatment guidelines have not been well established. Improper diagnosis of splenic abscess can result in a high mortality rate, extending beyond 70% . HoweverDue to the infrequent presentation of splenic abscesses, there are no specific guidelines regarding the diagnosis and treatment, and the best mechanism of management is still undecided. More information is needed to enhance the interpersonal management of splenic abscesses and to strengthen the evidence-based care provided to patients.


Desmoid tumors most commonly occur in the anterior abdominal wall in approximately 50% of cases and are locally aggressive. We describe a case of a 38-year-old lady who was investigated as a case of gastrointestinal tumor. Post-operative immunohistochemistry staining showed the presence of a synchronous desmoid in the abdominal wall and proximal ileum. Wide local excision remains the gold-standard of treatment with pharmacotherapeutics and radiotherapy serving as adjuvant or palliative treatment options. These most commonly occur in the anterior abdominal wall in approximately 50% of cases.Our report describes a 38-year-old male who presented to us with an abdominal lump, noticed 6 months prior. The lump was gradually increasing in size and was more prominent during exercise. He also noted early satiety since the last 2 months, but denied weight loss, nausea or vomiting. The history was also insignificant for hematemesis, hematochezia or melena. On examination, the patient wasn't pale, icteric, edematous or dehydrated. No cervical lymph nodes were palpable. Abdomen was soft, without tenderness or visceromegaly. There was an approximately 6x8cm firm, fluctuant, fixed mass in the mid upper abdomen, without any skin changes suggestive of inflammation, which became more prominent on raising the legs.The patient underwent an ultrasonogram, which revealed a well-defined hypoechoic lesion about 8x 5cm in the subhepatic and 6 x 5cm lesion in the right pelvic lesion with minimal vascularity and minimal ascites. The patient further underwent a CT scan of the abdomen, which showed two well defined soft tissue lesions within the abdominal and pelvic cavity .The abdominal mass was well defined, oval, ~76 x 109mm showing heterogeneous post contrast enhancement, without calcification or cavitation. The mass was noted to lie in between the greater curvature of stomach and liver with loss of fat plane with anterior abdominal wall, stomach and liver. Another lesion in the pelvic cavity was ~59 x 67mm on the right side at the level of the pelvic brim with similar findings. Differential diagnoses provided were gastrointestinal stromal tumor, nerve sheath tumor, soft tissue sarcoma and desmoid tumor.With normal preoperative investigation, the patient underwent exploratory laparotomy, resection of the lumps and primary anastomosis .Intra-op findings revealed a 7 x 8 x 4cm lump attached to the muscular layer of the abdominal wall, extending up to the peritoneal layer, without any intraperitoneal extension. Another lump 10 x 8 x 6cm was noted to be arising from the proximal ileum, which was mobile and not invading the serosa of the small bowel. Post-op immunohistochemistry was reactive for SMA, b-catenin and vimentin, consistent with features of desmoid tumor .One month post-operatively the patient underwent colonoscopy, which did not reveal any signs of polyposis. On subsequent follow up visits the patient is doing well.4 they are usually thought to be locally invasive but non-metastasizing.5 Most cases occur sporadically, with most cases having mutation in the beta-catenin pathway, in the gene CTNNB1.6 They usually arise in the mesentery or retroperitoneum, when intraabdominal.3 Desmoid tumors have also been associated with familial adenomatous polyposis (FAP), usually caused by a mutation in the APC gene when abdominal. These arise in the female patient, during or after pregnancy, and usually following abdominal trauma. The most affected age group is 15 to 50 years of age.3Although the cell of origin of desmoid tumors is not clearly defined, it is suggested that desmoid tumors arise from mesenchymal progenitor cells.7 Initially, the pathogenesis was obscure, but recently they have been described as arising from the interstitial cells of Cajal, primarily within the stomach in the muscular layer (50-70%), and small intestine (20-30%).8 Most of the cases of GIST have been attributed to mutations in the tyrosine-protein kinase KIT, or cluster of differentiation 117 (CD117), encoding proto-oncogene named c-KIT.9 Histologically it is difficult to differentiate the two, as both have characteristic proliferation of spindle cells.3 The differentiation is done by use of immunohistochemistry, which usually notes expression of CD1 1 7 marker more weakly in fibromatosis compared to GIST. Further differentiation can be done with the detection of b-catenin and APC mutations in favor of desmoid tumors.One of the most common differential diagnosis is the more commonly encountered gastrointestinal stromal tumor (GIST). The most common sarcoma, or mesenchymal tumors, of the gastrointestinal (GI) tract are gastrointestinal stromal tumors, or commonly referred to as GISTs.11 Positive margins or incomplete surgical removal can lead to recurrence of the tumor, hence caution is advised during debulking surgery.1 Abdominal wall tumors seem to have a better prognosis than the ones presenting at the extremities.11 Adjuvant therapy comprises of radiation therapy, which has also been applied as a definitive therapy, hormonal or nonsteroidal anti-inflammatory drug (NSAID) therapy , and anthracycline-based chemotherapy regimen.11 Anthracyclines may be combined with methotrexate, vinblastine and cisplatin.11The gold-standard for treatment of fibromatosis is by wide local excision, and reconstruction of the defect.As it is a rare disease, it is vital to consider desmoid tumor as a differential for anterior abdominal wall mass. Thus, it can be difficult to differentiate between intra abdominal fibromatosis and gastrointestinal stromal tumors. The only available means of differentiation at present is the use of immunohistochemistry staining. However, excision with wide surgical margins should form the mainstay of treatment of such tumors, regardless of certainty of diagnosis.


Granular parakeratosis (GP) is a rare, idiopathic, and self-limiting cutaneous disorder. It clinically presents as erythematous to brown hyperkeratotic or scaly papules that can coalesce to form plaques. If GP is suspected clinically, histopathological confirmation is adequate for diagnosis. Several treatment modalities were tried with varying success, but none was consistently efficacious.Given the rarity of GP and the variety in its clinical presentation and management, we report a case of a self-resolving infra-abdominal GP. Our patient is a 47-year-old female who presented with a one-week history of asymptomatic, multiple, linear, horizontal, brown, hyperpigmented scaly papules in the infra-abdominal fold. She had a three-year history of applying almond oil and Sudocrem Antiseptic Healing Cream®. Histopathology showed the retention of basophilic keratohyalin granules within the area of parakeratosis in the stratum corneum, which is consistent with GP. She was discharged on emollients, and on follow-up one month later, her lesions completely resolved.In conclusion, GP is a rare cutaneous disorder characterized by hyperkeratotic plaques or papules typically on intertriginous areas. The natural history of the disease may vary from spontaneous resolution to a waxing and waning condition. In addition, given how uncommon the disease is and its variable etiologies and course, definite management is yet to be established and a standardized treatment recommendation is lacking. Granular parakeratosis (GP) is a rare, idiopathic, and self-limited cutaneous disorder. It was first described by Northcutt et al. in 1991, as an axillary eruption with a unique histopathological finding and termed “axillary granular parakeratosis.” Since then, it has been described in other intertriginous and non-intertriginous body parts, eliminating the word “axillary” . MultiplA 47-year-old woman presented to our dermatology clinic with asymptomatic skin lesions on the abdomen for almost a week. She was obese with a body mass index (BMI) of 39. Her medical and surgical history was unremarkable. She mentioned applying Sudocrem Antiseptic Healing Cream® in combination with almond oil on her body folds for almost three years prior to the appearance of the lesions. Upon examination, there were multiple, brown, hyperpigmented, scaly, flat-topped papules in a linear horizontal configuration in the infra-abdominal fold Figure . A threeThe patient was given emollients with no intervention. Upon follow-up a month later, the skin lesions had completely spontaneously resolved almost 20 days after the initial appearance. Three years later, there was no recurrence.Multiple theories exist on the possible etiology of GP . The iniClinically, GP can be confused with other disorders, especially those affecting the folds like Hailey-Hailey disease, erythrasma, and retention hyperkeratosis among others. In addition, it can be present in association with conditions like tinea corporis but not any systemic diseases . PatientWith high clinical suspicion, a skin biopsy is required for histopathological diagnosis . In addiManaging patients with GP can be challenging since responses to treatments have been inconsistent . A wide In conclusion, GP is a rare cutaneous disorder characterized by hyperkeratotic plaques or papules typically on intertriginous areas. The natural history of the disease may vary from spontaneous resolution to a waxing and waning condition. In our case, the patient had a spontaneous resolution in less than a month. Her obesity and application of topical preparations were possible contributing factors to the condition. In addition, due to the rarity of the disease and the variable etiologies and course, definite management is yet to be established and a standardized treatment recommendation is lacking.


The first case of synovial sarcoma was published in 1893. The disease is a type of primary malignancy of the soft tissues. It is a rare and aggressive neoplasm of unknown tissue origin, characterized by strong metastatic potential and poor prognosis. The present case of a 64-year-old male patient with pain and swelling in his right shoulder and progressive loss of movement demonstrates an uncommon location for the neoplasm. Magnetic resonance proton-density fat-suppressed turbo spin-echo sequences show a heterogeneous mass in the right shoulder. The lack of homogeneity in the signal has been described in medical literature as the “triple sign” and is represented by low, intermediate, and high signal intensity areas through the neoplasm. Visible serpentine vessels spread through the tumor. There was a visible metastatic disease in the regional lymph nodes and metastatic foci in the adjacent bones. Pathological analysis of the tumor confirmed the diagnosis of biphasic synovial sarcoma. An oncological committee advised chemotherapy and radiotherapy. More prominent magnetic resonance imaging findings in synovial sarcoma that may facilitate the diagnostic process are the inhomogeneity and “triple sign” in proton density and T2 sequences, multilobulated tumors, septa, irregular borders, serpentine vascular channels, engagement of the adjacent bones and bone marrow, and involvement of the joint synovia. Primary synovial sarcoma (SS) was initially described in medical literature in 1893 and represents a malignancy of the soft tissues The presented uncommon case was of a 64-year-old male patient with pain and swelling in his right shoulder. The pain started several months before the imaging examination. The patient did not recall any accident or trauma. The patient was not vaccinated against COVID-19. Initially, he took pain relief medications with little to no effect. He tried immobilizing the shoulder and some alternative medicines with no result, such as herbal compress. Around 2 months after the initial complaints, the patient experienced swelling in his right shoulder, which began to grow. A few weeks later the soft-tissue mass almost doubled in size, he could no longer raise his arm above the shoulder. The patient consulted an orthopedist and was directed to the Department of Oncological Imaging. A magnetic resonance imaging (MRI) of the right shoulder was performed. Before scanning, the patient's arm was almost immobile during the physical examination, and there was a large soft tissue mass in the right shoulder. The tumor was red to purplish in some regions, rigid, and uneven on palpation. During the MRI, the patient experienced severe pain. Although pain relief medication was introduced before the scan, some of the images have motion artifacts due to uncontrollable shaking of the limb during the image acquisition phases.Proton-density fat-suppressed turbo spin-echo (PD_FS_TSE) MRI sequences show heterogeneous formation in the right shoulder A-C.  chromosome , which validates the suspected MRI diagnosis of SS C.Because of the size and intraarticular location of the neoplasm and the presence of metastatic disease, the treatment plan for the patient was decided by a multidisciplinary oncology committee. The decision was to perform “sandwich” therapy initiated with 3 courses of chemotherapy followed by radiotherapy and another 4 courses of chemotherapy. Before the last chemotherapy course, a staging CT scan and MRI of the shoulder will be performed. Depending on the response to the treatment, surgical excision of the prime tumor could be planned.Synovial sarcoma is a rare neoplasm with a poor long-term prognosis. It is an aggressive neoplasm that is characterized by monophasic or biphasic differentiation. A pathognomonic sign is a translocation of the t chromosome  to create and express the SYT-SSX fused gene In conclusion, we can say that the most common MRI findings in synovial sarcoma are the inhomogeneity and “triple sign” in PD and T2 sequences, the presence of multilobulated neoplasm, septa, serpentine vascular channels, affecting the adjacent bones, and bone marrow, and involvement of the joint synovia. T1 sequences were not indicative of synovial sarcoma.Written patient consent for publication has been obtained.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee of Medical University Plovdiv number 132/01.02.2022, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.A.G. is responsible for the conception of the work, data collection, data analysis, and interpretation. A.G is also responsible for drafting the article. D.T. and V.A. are responsible for data analysis. L.C. and T.K. are responsible for critical revision of the article and final approval of the version to be published.All research data supporting this publication is included in the article.


Choroid Plexus Carcinomas (CPC) are rare malignant brain neoplasms of choroid plexus epithelium, with a tendency to occur in infants and children, especially those who are under two years of age. The Main symptoms of CPC include nausea, vomiting, headache, irritability, blurred vision, and seizures. Few studies discuss the therapeutic methods to treat this tumor. However, most of these studies confirmed the poor prognosis of it.A two-year-old girl presented with a headache due to head trauma, normal consciousness, GCS 15/15, and without intracranial hypertension symptoms. Computed Tomography (CT) has shown a large heterogeneous lesion in the region of the right lateral ventricle. Magnetic resonance imaging (MRI) showed a large poorly-defined mass in the right lateral ventricle with mild dilatation of the ipsilateral lateral ventricle, and midline shift and marked edema surrounding it. In this case, the mass has been discovered by accident. The histological diagnosis was choroid plexus carcinoma (WHO grade 3), curettage of the right lateral ventricle was performed.CPC is a serious condition with a poor prognosis. Early diagnosis and appropriate approaches are required in order to reduce mortality and morbidity rates. •Diagnosis difficulties of Choroid Plexus carcinoma make it an important case.•Correct diagnosis is often delayed, resulting in a poor prognosis.•CPC should be present in the diagnosis of atypical brain tumors, especially in children and their atypical symptoms.•An early and accurate diagnosis of the lesion can improve the prognosis and maintain the patient's quality of life. There are two main types, malignant and benign, classiﬁed as choroid plexus carcinoma (CPC) and choroid plexus papilloma (CPP), respectively .CPC represents about 17–30% of all choroid plexus tumors with a tendency to arise in patients younger than two years in comparison with adults ,3. CPC iCurrent treatment strategies range from total gross surgical resection alone to a combination of surgical, radiological, and chemotherapy for both CPC and CPP; however, the medical literature recommends total surgical resection for children with CPC ,5.We report a new case of choroid plexus carcinoma diagnosed in a 2-year-old girl in which the clinical outcomes were described.2A two-year-old girl presented to the emergency department complaining of headache due to head trauma, with no seizures, no vomiting, and no loss of consciousness. Her physical examination showed increased head size, GCS 15/15, and jerky gait.Computed Tomography (CT) has shown a large heterogeneous lesion with irregular margins, and perilesional edema in the region of the right lateral ventricle, with marked midline shift that compresses the opposite lateral ventricle .Fig. 1CoMagnetic resonance imaging (MRI) showed a large poorly-defined lesion in the right lateral ventricle which appeared to be hypointense on T1 images and hyperintense on T2 images. The mass also showed strong heterogeneous gadolinium enhancement, with mild dilatation of the ipsilateral lateral ventricle, and with midline shift and marked edema surrounding it . ThroughThe histological examination showed a conspicuous papillary pattern, with tumor cells arranged in dense sheets. Frank features of anaplasia were also presented, including nuclear atypia, cellular pleomorphism, increased mitotic activity, focal necrosis, and stromal calcifications .Fig. 3ThImmunohistochemically, the tumor cells were negative for glial fibrillary acidic protein (GFAP), synaptophysin, and epithelial membrane antigen (EMA). The ki67 was more than 60%.The histological diagnosis was choroid plexus carcinoma (WHO grade 3), curettage of the right lateral ventricle was performed.This case report has been reported in line with the SCARE Criteria .3Choroid plexus tumors (CPTs) are exceptionally uncommon. They make up less than 4% of all brain tumors in childhood. CPTs are divided into Choroid Plexus Papilloma (CPP) and Choroid plexus carcinoma (CPC) which is rarer and classified as highly invasive tumor according to the classification of the World Health Organization (WHO grade III), accounting for 1% of all CNS tumors ,8. The fThe tumor arises from the epithelium of the choroid plexuses. The average age of the tumor onset in childhood is in the third year . The latThe etiology of the tumor is not yet clear, but it is believed that a mutation in the TP53 gene which causes Li-Fraumeni syndrome has a strong association with the malignancy incidence. The basis of this claim is that half of the malignant tumor cases are associated with a mutation in this gene, and unfortunately with a worse prognosis .The manifestations and signs of the tumor are similar to any intracranial mass, where intracranial pressure increases and neurological symptoms appear, including headache, vomiting, and nausea. Symptoms and signs can be distinguished in an infant as we note increased head circumference, bulging fontanelles, splayed cranial sutures, and neurological delay ,9. What Histological studies revealed increased mitotic figures and nuclear pleomorphism. Moreover, Russell and Rubinstein established specific criteria for an accurate histological diagnosis, including clear invasion of adjacent neural tissue with an ill-defined pattern of growth, loss of papillary architecture (at least in the invaded areas that are associated with mitoses), varying nuclear size, and chromatin content, and cellular pleomorphism.Immunohistochemically, positive markers of CPC include cytokeratins, vimentin, S100, and transthyretin. Glial fibrillary acidic protein is also positive for CPC, but only in 20% of the cases. CPC is negative for epithelial membrane antigen in general ,9,11.Due to the rarity of CPC cases, there is no established protocol approved yet to treat CPC. However, gross total resection is the most accepted treatment, because it improves prognosis, despite the high risk of surgery due to hemorrhage issues and tumor infiltration which results in increased morbidity and mortality chances. About 40–75% of CPC cases applied surgery as a treatment method. The adjuvant therapy is still controversial. In some cases, chemotherapy was applied prior to surgery in order to reduce the tumor's vascularity. Radiation treatment has risks that could not be expected in the pediatric population, as they are the most affected sample by the tumor .The prognosis of CPC is poor in general, as the tumor grows rapidly and has an average survival of 2.5–3 years approximately, and recurrence is common and occurs when malignant infiltrates grow rapidly ,9.Metastases are apparent at presentation in less than a quarter of cases and are located in areas of tumor infiltration (CSF pathways) .In conclusion, CPCs are rare tumors that emerge in the lateral and fourth ventricles and affect early childhood patients in most cases. Diagnosis is directed by Radiological examinations and confirmed by both histological and immunohistochemical studies. There are no completely approved treatments, but surgery remains the best approach. CPCs have a poor prognosis and recurrence is common.4As the patient is a child of two years of age, the consent was obtained from the patient's parents.Not commissioned, externally peer reviewed.N/A.N/A.Kutaiba Alali, Mahmoud Wereekia, and Najeeb Sakkal did the surgery. -Mohammed Moutaz Alshaghel, Wafik Mayo, and Najeeb Sakkal wrote the manuscript.Authors declare that there is no conflict of interest.Name of the registry:Unique Identifying number or registration ID:Hyperlink to your specific registration (must be publicly accessible and will be checked):Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Mahmoud Wereekiadr.kutaiba90@gmail.coms.


The artery of Percheron (AOP) is a variant of the posterior cerebral circulation where a single branch of either posterior cerebral artery supplies both paramedian territories of the thalami. A stroke of the AOP has become a neurodiagnostic conundrum due to its relative rarity and vague symptoms, and, hence, a missed opportunity for recanalization treatment. The classical presentation of AOP stroke is the triad of altered mental status, vertical gaze palsy, and memory impairment.Here, we describe a retrospective case review of a 59-year-old male presenting with confusion and slurred speech with subsequent symptoms such as blepharospasm and bradyphrenia. The initial computed tomography of the head failed to recognize the bilateral thalamic infarct which was established on day three on brain magnetic resonance imaging. Because the patient was out of the therapeutic window for thrombolysis, dual antiplatelet therapy was started. The patient made a rapid recovery to near-baseline function and was discharged to rehab services.This case is unique with the clinical presentation of both blepharospasm and bradyphrenia being rarely found in the literature. The shared insult to the basal ganglia-thalamocortical circuits may have caused both symptoms. Physician awareness of these subtle findings can increase awareness, earlier diagnosis, and treatment of bilateral thalamic lesions and AOP strokes. Artery of Percheron (AOP) has a prevalence ranging from 7% to 11%. Among the general population, AOP infarct accounts for 0.1-2% of all ischemic strokes and 4-18% of all thalamic strokes. Patients most commonly present with a triad of altered mental status, vertical gaze palsy, and memory impairment. Bilateral thalamic acute infarcts are often not diagnosed in a timely fashion as they are rarely seen on initial computed tomography (CT) of the head or are incidentally found on magnetic resonance imaging (MRI) of the brain . However2 99%, and body mass index 27.12 kg/m². He answered questions after prolonged pauses with a generalized paucity of facial expressions. Blepharospasm was present, and his visual acuity was 20/40 bilaterally. The remainder of his neurologic examination was unremarkable. He denied alcohol use, recreational substance abuse, any recent illnesses, and recent travel out of state or out of the country.A 59-year-old male with hypertension and hyperlipidemia, non-compliant with medication, was brought to the emergency department with confusion, forgetfulness, slurring of speech for 14 hours, and one episode of urinary incontinence. The initial vitals were blood pressure (BP) 130/84 mmHg, pulse 58 beats per minute, temperature 36.6°C, respiratory rate 18 breaths per minute, SpOA stroke code was called for acute change in mentation. He was evaluated as having a National Institutes of Health Stroke Scale score of two, and a stroke workup ensued. CT of the head was performed Figure . AlthougCT angiography of the head and neck, axial view Figure  and coroLevetiracetam 2 g load and 1 g every 12 hours, dual antiplatelet therapy, acetylsalicylic acid 81 mg once daily orally, and clopidogrel 75 mg for one month were recommended. Transthoracic echocardiogram, electroencephalogram, routine blood testing, and urinalysis, including toxicology screen, were within normal limits. On day three, MRI of the head diffusion-weighted imaging Figure  and T2 fThe acute bilateral thalamic infarcts were attributed to an AOP stroke. The patient made a rapid recovery to near-baseline functionality within four days with the only persisting symptom being bradyphrenia, which showed notable improvement by day seven prior to discharge.Thalamic infarcts were first described by Dejerine and Roussy in 1906 . In 1973The definition of blepharospasm is eyelid heaviness; tension around the eyes; chronic, persistent eyelid spasms; and frequent blinking, which may lead to total closure of eyelids and obstruction of vision. Blepharospasm is considered a dystonic movement disorder and is commonly attributed to basal ganglia disorders but may be caused by thalamic lesions .The pathophysiology of blepharospasm in thalamic lesions is poorly understood. Thalamic lesions can injure the pallidothalamic fibers in transit to the ventrolateral and ventro-anterior nuclei , which mBilateral thalamic injury in areas such as the paramedian territories cause decreased arousal and impaired learning and memory which may contribute to bradyphrenia . BilaterThe combination of blepharospasm and bradyphrenia in this patient, although rarely found in the literature, may be explained by the shared insult to the basal ganglia-thalamocortical circuits.High suspicion should be maintained with acute changes in cognition and new onset of subtle findings such as blepharospasm and bradyphrenia as symptoms of a bilateral thalamic lesion. Physician awareness of these symptoms can lead to earlier diagnosis of bilateral thalamic lesions and diagnosis of AOP strokes, earlier initiation of treatment, and better recovery for patients.


Perineal epidermoid lesions are uncommon, with only a few research papers accessible on the subject. Because these lesions are varied in origin and can range from benign to malignant, it can be difficult to tell them apart. A wide variety of lesions are evaluated in the differential diagnosis of perineal cystic lesions, however perineal epidermoid cyst is uncommon. An epidermoid cyst is a benign ectodermal congenital abnormality. Epidermoid cysts can be found all over the body, however, they are uncommon in the perineal area.We discuss a case of a perineal epidermoid cyst in an adult female presenting to the general surgery department with painful perineal swelling. The patient was advised for an ultrasound (US) and MRI for further evaluation and the findings are reported. EC(s) are benign tumors that usually affect the scalp, face, neck, back, and chest. It is usually asymptomatic when small in size and evolving, but these can become symptomatic as a result of secondary infection or when it grows to a size that displaces or causes a mass effect on the surrounding anatomical tissues . EpidermCT and MRI enable inspection of the entire intestinal wall layer as well as the perirectal tissue, making it easier to describe these abnormalities further. MRI has a strong radiologic diagnostic value since it can accurately show the perineal architecture. As a result, MRI has been largely employed to investigate perineal cystic lesions .A 45-year-old female patient presented to consult the department of general surgery with complaints of pain in the perianal region for three years. The symptoms had acutely worsened in the past week. There was no history of trauma to the patient. On local examination, there was a mild subcutaneous bulge in the natal cleft region. There was no evidence of a local rise in temperature or redness on inspection. The patient was advised of high-frequency soft tissue ultrasonography of the perianal area.On ultrasonography of the perianal area, there was a well-defined cystic lesion with internal echoes within the subcutaneous plane. The patient was further advised to MRI pelvis in view of the complete evaluation of the lesion and to understand its extension.Subsequently performed MRI showed a well-defined thin-walled, peripherally enhancing signal intensity lesion that was hyperintense on T2WI/STIR and isointense on T1WI measuring approximately 9.0 x 4.0 x 3.4 cm (AP x TRANS x COR) Figure . The lesThe patient was later advised for FNAC (fine needle aspiration cytology) which showed components of keratin Figure . The patEpidermal cysts are keratin-rich and linked with stratified squamous epithelia. The mitosis of epidermal cells within the closed cavitation of the dermis is involved in the pathophysiology of epidermal cysts. Men are nearly twice as likely as women to have epidermoid cysts. They can occur at any age; although, statistically it is most common in the third to fourth decades of life. Epidermal cysts usually occur on the face, head, neck, and torso; perineal involvement is rare. Only a few cases of unanticipated intra-cystic bleeding and epidermoid cyst malignancy have been described in the literature ,7.US is often the initial modality of choice in evaluating masses in the perianal region. Selected soft-tissue lesions can be diagnosed based on certain clinical and imaging features. Epidermoid cysts are rather common on ultrasonography, but they may have a non-specific and hazy appearance, and variable imaging features require additional imaging. Ultrasound is useful for determining the anatomic position and proximity to neighboring structures, and features like echogenicity, size, and margination can be routinely seen . EpidermBoth CT and MRI are utilized to identify epidermoid cysts and define the surgical removal procedure. CT is useful for confirming the diagnosis of a large epidermoid cyst, but not for small epidermoid cysts. On CT, a well-encapsulated mass of heterogeneous densities can be detected, which reflects a mixture of fat and keratin .The MRI findings of epidermal inclusion cysts are influenced by the cyst's maturity, compactness, and the amount of keratin it contains . EpidermMRI is one of the best investigations of choice to evaluate perineal lesions, which helps in understanding the nature as well as the extent and involvement of the adjacent soft tissue with its fine resolution. Epidermoid cysts that have not ruptured typically show well-defined mass lesions with low signal intensity, some bright foci on T1-weighted MR images, and high signal intensity on T2-weighted MR imaging.


Gynecologists are familiar with procidentia, a severe form of pelvic organ prolapse (POP) that includes herniation of the anterior, posterior, and apical compartments of the vagina, through the introitus. Usually, women with POP present with concerns of something coming out of the vagina, heaviness, discharge through the vagina, urinary complaints, and, rarely bowel, complaints. Intestinal obstruction secondary to procidentia is a rare complication and is seldom reported in the literature. We report one such case where an elderly woman presented with the primary concerns of constipation, retention of urine, and multiple episodes of vomiting. Clinical history revealed that herniated tissue protruding outside the vaginal introitus was reposited inside the vagina two days ago. Clinical examination and investigations were suggestive of intestinal obstruction, secondary to the reposition of procidentia. Exploratory laparotomy revealed gangrene of the terminal ileum. Right hemicolectomy with ileo-colic anastomosis was done, which saved the woman’s life. Reposition of the prolapsed uterus was thought to be the probable reason, leading to obstructed and gangrenous small bowel. As this case illustrates, the chronology of symptoms and signs and progression of disease should be appropriately interpreted to diagnose and manage such potentially life-threatening conditions. Pelvic organ prolapse (POP) is defined as the descent of pelvic organs into the vagina from their normal anatomical position, as a result of the weakness of supportive structures such as ligaments and pelvic fascia . The terA 50-year-old-female, with long-standing, complete procidentia was referred to the surgical unit of a rural hospital in central India during emergency hours. She was a fourth para, having two living children and all four childbirths had taken place vaginally, at home. She was a farmer by occupation and presented to the ED in the month of March 2020 during the period of strict lockdown in India for the coronavirus disease 2019 (COVID-19) pandemic. She had concerns about retention of urine and pain in the abdomen for 24 hours and a history of something coming out of the vaginal introitus for 10 years. Before the acute event, she was relatively all right, and over a period of 12-24 hours, she had retention of urine and associated severe generalized abdominal pain. Thus, she reported to casualty at midnight in spite of the lockdown restrictions and ongoing pandemic. Clinical examination showed that she had third-degree uterine descent, cystocele, rectocele, and eversion of the vagina. A decubitus ulcer was present on the anterior wall of the vagina  revealed an empty and ballooned distal rectum. The examining finger was unstained with feces. There were centrally located, multiple air-fluid levels, dilated small bowel shadows, and loss of gas in the pelvis on plain X-ray abdomen Figure .All these features were suggestive of small bowel obstruction. Exploratory laparotomy was performed by a team of surgeons and gynecologists. Intraoperatively, we found that the uterus was enlarged up to 10-12 weeks pregnant uterus size and dense adhesions were present between the rectum and isthmic region of the uterus Figure .Adhesiolysis and total abdominal hysterectomy with bilateral salphingo-oophorectomy were performed by careful dissection. The gynecologist performed the hysterectomy and handed the procedure over to the surgical team. A 20 cm length of the small bowel, from 5 cm proximal to the ileocecal junction, was found to be gangrenous Figure .Due to the vicinity of the gangrenous segment to the ileocecal junction, a right hemicolectomy with ileo-colic anastomosis was done. The woman recovered well postoperatively and was discharged after 10 days. The histopathology report of the excised tissue was suggestive of wet gangrene of the ileum.POP is a well-tolerated, benign, gynecological problem found in women and has site-specific symptoms. It does not warrant treatment unless it is symptomatic. Procidentia, a chronic condition, is complete herniation of the uterus, out of the vaginal introitus along with anterior and posterior vaginal walls. Rural women often postpone seeking medical assistance in spite of having longstanding procidentia, resulting in further complications. Kumari et al. reported that more than half of the subjects in their study did not obtain any treatment for uterine prolapse and among those who did, some waited more than 10 years before consulting a doctor while many did so only more than one year after the onset of prolapse . Bang etIn the present case too, the woman did not seek medical attention for almost 10 years and presented with acute symptoms of urinary retention. Constipation is the common symptom associated with POP, specifically in posterior compartment prolapse (rectocele). In the present case, there was acute development of constipation, which was associated with episodes of vomiting, which forced the treating team to think of an alternative diagnosis. The findings of this case illustrate the importance of meticulous clinical examination in a common scenario like POP to rule out other underlying serious, surgical conditions like bowel gangrene. Though constipation may be common in POP, full-blown small bowel obstruction is extremely rare. Few cases of small bowel obstruction associated with post-hysterectomy POP and enterocele have been documented in the literature . HoweverThis case illustrates that counseling every patient for post-procedure observation is important, and there should be close monitoring, especially when the bladder or bowel is handled either directly or indirectly. Adequate attention should be rendered to symptoms, their progression, and chronology. High suspicion for “acute abdomen,” with prompt follow-up and rapid and relevant investigations, is recommended in patients presenting in emergency settings. A multidisciplinary approach is imperative in such complicated cases. Procidentia is a long-term disease and many women prefer to seek the opinion of family physicians for minor symptoms related to it. It is suggested that family physicians should be aware of the rare but lethal complications of procidentia so that prompt referral can be done and the associated morbidity and mortality can be reduced.