These tumors, despite their benign behavior, share some atypical histological features with nevi found in other anatomic sites like the genital and acral regions, globally designated as nevi with site-related atypia. Moreover, in children and adolescents, rapidly growing conjunctival nevi show sometimes worrisome histological patterns in association with a prominent inflammatory infiltrate that may lead to diagnostic problems. In this paper we describe a juvenile compound nevus characterized by marked melanocytic atypia and severe inflammation, which can be considered a rare case of juvenile conjunctival atypical nevus. The final diagnosis relied on morphological and immunohistochemical characterization of the large epithelioid melanocytic cells, and on the results of FISH analysis. Among conjunctival tumors, melanocytic lesions represent 53% of all excised conjunctival lesions . Nevi arHere we report a case of juvenile conjunctival nevus, whose histology was uncommonly atypical, not only in the subepithelial area, but also deeply within the lesion, thus raising the suspicion of malignancy. This was an entity that has, so far, drawn little attention in the literature. Consequently, accurate morphological and immunohistochemical studies were performed to render a final diagnosis of atypical nevus, and pertinent FISH analysis gave interesting results to support that it was of a benign nature.A thirteen-year-old female patient was admitted at our institution with a bulbar juxtalimbal conjunctival pigmented lesion Figure . She undFISH probes were used on four loci: RREB1 at 6q23, 6 centromere, MYB at 6p25 and CCND1 at 11q13, . FISH analysis of the lesion did not show genetic aberrations, which allowed for a diagnosis of atypical compound nevus Figure .In this report we present a challenging case of conjunctival compound nevus in a young female patient. The atypical histological features that characterize the lesion were what made this case peculiar. The lesion could be included in the spectrum of atypical lesions associated with the concept of “site specific atypia”, but this approach is not fully convincing, in part due to the severe inflammation - like a host reaction to malignancies - that was present in our case. Moreover, we observed nests of atypical large cells at the base of the nevus that showed no maturation activity, hence, the differential diagnosis with melanoma became the main diagnostic problem. The features that could have ruled out the diagnosis of melanoma were the sharp circumscription of the lesions and the lack of mitotic activity in the substantia propria.In general, the patient’s young age and the cystic nature of the lesions are consistent with benign behavior, so that the vast majority of these cases are diagnosed as inflamed juvenile conjunctival nevi , taking As far as our case is concerned, the rarity of cystically dilated glands, the marked atypia of the lesional cells and the focal pagetoid spread, suggesting, per se, worrisome histological findings, were in keeping with the diagnosis of atypical nevus. Ki-67 findings were not significantly increased if compared to normal conjunctiva . In addiThe interest of this particular case relies on the differential diagnosis between atypical benign nevic lesions and melanomas in the conjunctiva, using a multi-level evaluation of morphologic, immunohistochemical and in situ molecular findings.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no conflict of interest.CC conceived of the study, participated in its design and drafted the manuscript. MM participated in the design of the study. MP carried out the FISH analysis. DM participated in the design of the study and drafted the manuscript. LM participated in the design of the study and drafted the manuscript. VC participated in the design of the study and drafted the manuscript. All authors read and approved the final manuscript.


Primary pleural angiosarcoma is a rare and clinically aggressive tumor. Patients usually present with chest pain, dyspnea, hemoptysis and/or cough. Radiologic studies reveal diffuse pleural thickening and pleural effusion with or without mass lesion. The clinical and radiological features both resemble those of mesothelioma, and its definite diagnosis requires careful histologic examination. However, frequent epithelioid feature and immunoreactivity to cytokeratin in primary pleural angiosarcoma further complicate the pathologic diagnosis. The use of proper immunohistochemical stains is often needed to support endothelial differentiation in the tumor cells and to exclude metastatic carcinoma and mesothelioma. We report the case of a 49-year-old male patient with primary pleural angiosarcoma, who presented with initial hemothorax, followed by a rapid progress to an inoperable status. Angiosarcoma is an uncommon malignant tumor of endothelial differentiation. It accounts for about 1% of all soft tissue malignancies and most commonly arises in skin, soft tissue, breast, liver, bone and spleen [Primary pleural angiosarcoma (PPA) is a rare occurrence. Since its first description in 1943, only 39 We describe herein a case of PPA, to highlight its aggressive clinical behavior and the diagnostic pitfalls.A 49 year-old-male patient presented with intermittent right chest pain for one month. The pain progressed with exertional dyspnea. He had a 10-year history of asthma under regular medical treatment and was an ex-smoker  who quit 10 years ago. He did not have any history of asbestos exposure or tuberculous infection. In physical examination, breathing sounds were decreased at the right lung. Chest radiography and computed tomography revealed right-side loculated pleural effusion with pleural thickening but without mass lesion  Figure . InfiltrPPA is an aggressive and rapidly fatal disease. Only 39 cases have been reported in the literature-22 afterThe effusions are usually bloody. Cytologic examination of the pleural effusion is rarely helpful in making the diagnosis. In the seven cases with available cytologic examination results,,19,20,22The histologic features show malignant spindle and/or epithelioid neoplasm with areas of vasoformative nature, such as vascular spaces lined by atypical tumor cells and intracytoplasmic lumen containing RBCs. Epithelioid features were mentioned in the majority of cases 72.5%) and constituted variable proportion of the tumors % and con,17-19. TImmunohistochemical stains have an important role in differential diagnosis. Expression of at least one of the endothelial markers including CD31, CD34, factor VIII and FLI-1, is required to confirm the diagnosis of angiosarcoma. Among them, CD31 is considered to be the most sensitive and specific . PositivThe etiologic factors in most cases of PPA are still unknown. Some case reports from Japan indicated the relationship with tuberculous pyothorax n = 11), ,15,21 wh, ,15,21 The treatments of angiosarcoma include surgical excision, radiotherapy and/or chemotherapy. However, the clinical course is usually rapidly fatal, regardless of treatment modalities. Seventy percent of the patients died of disease within 7 months Figure . The proIn conclusion, PPA is a highly malignant disease, which may mimic mesothelioma clinically, radiologically and even pathologically. The diagnostic pitfalls include mesotheliomatous growth pattern with diffuse pleural involvement, biphasic histomorphologic pattern and immunoreactivity to cytokeratin. An accurate diagnosis requires careful pathologic examination to identify the evidence of endothelial differentiation aided with immunohistochemical stains.Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journalPPA: primary pleural angiosarcoma; RBC: red blood cells.The authors declare that they have no competing interests.YCK participated in drafting the manuscript and literature review. JMC and KMW were responsible for acquisition of clinical data, follow-up information and the surgery (KMW). CLF, JSC and CLC participated in making the histopathological diagnosis, conception of the idea and revising the manuscript. All authors have read and approved the final manuscript.


Introduction. We report a rare case of unicystic ameloblastoma (UA) of mandible which showed multilocular radiolucency on the left side of mandible on radiographic examination which is very unusual, and the majority of the cases of UAs till date has been reported of unilocular radiolucency. On histopathological examination, an odontogenic cystic lining that proliferates that intraluminally resembling ameloblastomatous epithelium was observed, leading to a definitive diagnosis of unicystic ameloblastoma. Case Presentation. A 42-year-old male patient presented with a swelling on the left side of the mandible extending from 33 to 36. Radiographically, it showed a multilocular radiolucent lesion resembling odontogenic cyst; however, the final diagnosis was made on histopathological ground with the inclusion of radiological and clinical features. Conclusion. It can be concluded that at present, histopathologic examination is the most sensitive tool for differentiating between odontogenic cysts and UAs. However, both clinical and radiologic findings share equal contribution to the final diagnosis. Ameloblastomas are benign tumors whose importance lies in its potential to grow into enormous size with resulting bone deformity. They are typically classified as unicystic, multicystic, peripheral, and malignant subtypes . A solid Unicystic ameloblastoma (UA) represents an ameloblastoma variant, presenting as a cyst . In 1977, Robinson and Martinez first used the term “unicystic ameloblastoma” (UA) for such lesions , but it Five to 15% of all ameloblastomas are of the unicystic type. Cases associated with an unerupted tooth show a mean age of 16 years as opposed to 35 years in the absence of an unerupted tooth. The mean age is significantly lower than that for solid/multicystic ameloblastoma. There is no gender predilection [Six radiographic patterns have been identified for UA, ranging from well-defined unilocular to multilocular ones. When the radiographic appearance is divided into the two main patterns, unilocular and multilocular, there is a clear predominance of a unilocular configuration in all studies of UA where this feature has been evaluated, especially in cases associated with impacted teeth .A 42-year-old male patient presented with the chief complains of swelling on the left side of the mandible since 1 month. On intraoral examination, solitary, oval swelling measuring 4 × 2 cm in size seen on the left side of the mandible extending from 33 to 36 was noticed . The sweHistopathological examination demonstrated cystic lumen lined by nonkeratinized stratified squamous epithelium showing prominent basal cells with hyperchromatic nuclei which is polarized . The supThe term unicystic ameloblastoma has been described as an ameloblastoma developing within the lining, lumen, or wall of a cyst as well as an invasive ameloblastoma that has a single cystic space rather than multicystic spaces . UnicystVarious contradictory theories about the development of UAs have been proposed . While sSome cases are asymptomatic, sometimes presenting as a swelling of the posterior mandible. More than 90% of cases involve the mandible, usually the posterior region. Up to 80% are associated with an unerupted mandibular third molar. The lesion presents radiographically as a well-corticated unilocular pattern, often pericoronal radiolucency .The unilocular pattern is more common in the unicystic variant than the multilocular one, especially so in cases associated with tooth impaction .Unicystic ameloblastoma may mimic other odontogenic cysts clinically and radiographically. Moreover, the histologic distinction between UAs and certain nonneoplastic odontogenic cysts can be difficult . It appeSince 1925, many had reported the development of ameloblastoma within the walls of odontogenic cysts, and the most commonly cited was the dentigerous cyst . There hIn present case, the lesion presented as a localised swelling in the mandible and multilocular radiolucency on radiographic examination, which resembled a solid multicystic ameloblastoma or keratocystic odontogenic tumor (KCOT), and was difficult to diagnose clinically and radiographically. The final diagnosis was made on the basis of histopathological examination and also by the correlation of clinical and radiological features.It can be concluded that at present, histologic examination is the most sensitive tool for differentiating between odontogenic cysts and UAs. However, both clinical and radiologic findings share equal contribution to the final diagnosis. This case also highlights the importance of careful examination of the entire specimen and the usefulness of deeper sections in diagnosis of unicystic ameloblastoma. Thus, it is of utmost importance to correlate the histopathologic findings with clinical and radiographic features to achieve at a correct definitive diagnosis as all such lesions may have prognostically different biologic behaviours and the final diagnosis may alter the therapeutic decision significantly.


While intestinal tumors are rare, small intestinal lipomas are even more uncommon benign neoplasms. They are usually asymptomatic, but lipomas larger than 2 cm may become symptomatic due to obstruction, bleeding, or intussusception. In this paper, US and CT findings of a lipoma located in the terminal ileum and causing ileocecal intussusception were discussed. We report a case of small bowel lipoma that became symptomatic due to intermittent obstruction episodes and ileocecal intussuception. If the diagnosis of intestinal lipoma had been made absolutely as in our case, they should be removed surgically in elective conditions. Small intestinal tumors are rare, accounting for 1-2% of all gastrointestinal tract tumors . ComputeWe described a rare case of symptomatic ileal lipoma associated with ileocecal intussuseption and reviewed some aspects of diagnosis and treatment. 39-year-old women was admitted to our emergency clinic with one month history of colicky intermittent abdominal pain and continuous since last 24 hours. Abdominal examination revealed right lower quadrant pain with rebound tenderness. Laboratory findings were unremarkable. In her clinical history, she had been admitted to our hospital again for a day with complaint of nonspecific right lower quadrant pain one month ago. During the stay in our hospital the complaints of the patient had been regressed with nonspecific therapy and she had been sent to home. When early findings, which had been registered in our hospital PACS system, re-examined; a 25 × 20 mm mass close to the ileocecal valve consistent with lipoma was detected on abdominal CT performed during this period Figures . Any obvGastrointestinal lipomas are benign tumors that can occur anywhere along the gut in the small bowel. The most common site for lipoma in the small bowel is the ileum . IntestiAdult intussusception is a rare disease that constitutes approximately 5% of all intussusceptions and accounts for 1% of all adult intestinal obstructions. 3 to 20 per 100.000 of hospital admissions was due to intussusception in adults , 6, 7. ADue to the nonspecific and intermittent nature of the symptoms, and difficulty with the examination of the small intestine, preoperative diagnosis is usually difficult , 5. ImagThe treatment for small bowel lipomas depends on the clinical manifestations and size. It is not clear whether asymptomatic small lipomas require any intervention, but conservative treatment is often indicated . SurgicaIn conclusion, intussusception is a common complication of intestinal lipoma. We demonstrated a lipoma, located in the terminal ileum, later which caused ileocecal intusussception by US and CT. Intestinal lipomas are benign tumors in which definite diagnosis can be made by their specific appearences on CT. Lipomas should be removed with minimal invasive surgical operation when they are first identified due to possible complications. After the development of complications such as intussusception, resections involving large segments of bowel may be required in emergency conditions.


Unicystic ameloblastoma (UA) is a benign epithelial odontogenic tumor of the jaws that commonly occurs in 2nd and 3rd decade of life. In fact, this entity is rare in children under 12 years of age. It is characterised as a distinct variant of ameloblastoma, exhibiting a less aggressive behaviour and a lower rate of recurrence than solid conventional ameloblastoma. There are very few reported cases of UA occurring in children below five years of age. The purpose of this case report is to describe a case of UA involving the crown of an unerupted maxillary second premolar in a 3 year old girl. The pathogenesis, clinical appearance, radiographic presentation, histological findings and management of the tumour have also been discussed. Ameloblastoma is one of the most common benign odontogenic tumours, accounting for approximately 1% of all tumours and cysts of the jaws and 10% of all odontogenic tumors . UnicystA 3 year-old girl reported to the outpatient department of Maulana Azad Institute of Dental Sciences, New Delhi, India, with the chief complaint of swelling over left side of jaw since one and a half months. Extraorally, a diffuse swelling of about 2-3 cms in size was noted on the left maxilla. The lesion extended anteriorly up to the ala of the nose and posteriorly up to 2-3 cm in front of tragus. The superio-inferior extent of the swelling was from the floor of the orbit to the ala tragus line. Buccal and lingual expansion was seen intraorally. The swelling was bony hard and non tender on palpation. All primary teeth were present.Panoramic and occlusal radiographs revealed a well defined radiolucency adjacent to the upper left deciduous canine. Axial CT sections showed an expansile, well corticated cystic lesion involving partially formed maxi-llary left premolars Fig. .With these findings, a provisional diagnosis of dentigerous cyst was made and the lesion was enucleated under local anaesthesia.The gross specimen received was a cystic sac measuring 3.5x3x2.5 cms along with partially formed canine and first premolar. The cystic cavity showed forming 2nd pre molar embedded within the wall of the cyst. Multiple mural nodules were noted in the opened cystic sac  variant and rarely as multilocular radiolucency in case of non – dentigerous variant. It is often associated with an unerupted tooth and ranks next to dentigerous cyst as the most frequently occurring pathological pericoronal radiolucency.Leider et al proposed three pathogenic mechanisms of evolution of UA :1) Reduced enamel epithelium associated with a developing tooth undergoes ameloblastic transformation with subsequent cystic development.2) Ameloblastomas arise in dentigerous cyst or other types of odontogenic cysts in which the neoplastic ameloblastic epithelium is preceded temporarily by non-neoplastic stratified squamous epithelial lining.3) Solid ameloblastoma undergoes cystic degeneration of ameloblastic islands with subsequent fusion of multiple microcysts and develops into a unicystic lesion.Since the present case was associated with a developing permanent teeth, the reduced enamel epithelium attached to them may have undergone ameloblastic transformation lending support to the first hypothesis. However, there is not a solid proof of this origin, as there are several UA that are not related to unerupted teeth and therefore the diverse hypothesis should be viewed with caution.Histopathologically, UA was classified by Ackerman as  :Type 1 - unilocular, unicystic lesion lined by epithelium.Type 2 - plexiform variety.Type 3 - invasive islands of ameloblastomatous epithelium.Type 3a- islands not connected to cyst liningType 3b-islands connected to cyst lining.Another histopathological grouping by Philipsen and Reichart  has alsoFollowing this, the published present case falls under 1.2 subgroup.Unicystic ameloblastoma is generally considered to be a less aggressive tumor compared to the solid variant. However, UA showing intraluminal and intramural proliferation histologically should be considered an aggres-sive lesion and treated in a manner similar to a solid ameloblastoma . The occAlso, the management of ameloblastoma in a young patient becomes challenging due to concerns about facial growth . Therefo


We report two cases of extraperitoneal compression of the intra-abdominal space resulting in abdominal compartment syndrome (ACS) with overt renal failure, which responded to operative decompression of the extra-peritoneal spaces. This discussion includes patient presentation, clinical course, diagnosis, interventions, and outcomes. Data was collected from the patient's electronic medical record and a radiology database. ACS appears to be a rare but completely reversible complication of both retroperitoneal hematoma (RH) and rectus sheath hematoma (RSH). In patients with large RH or RSH consideration of intra-abdominal pressure (IAP) monitoring combined with aggressive operative drainage after correction of the coagulopathy should be considered. These two cases illustrate how a relatively benign pathology can result in increased IAP, organ failure, and ultimately ACS. Intervention with decompressive laparotomy and evacuation of clot resulted in return to normal physiologic function. The influence of raised intra-abdominal pressure (IAP) known as intra-abdominal hypertension is recognized as having effects on nearly all aspects critically ill patient physiology , 2. The With an aging population and increasing use of anticoagulant and thrombolytic therapies, spontaneous hematoma formation within the extra-peritoneal abdominal spaces  are increasingly being recognized. Anatomically these spaces are contiguous and massive bleeding within one often communicates with the other justifying there consideration as an extra-peritoneal hematoma (EPH). Although IAH/ACS are classically thought to arise from increases in the peritoneal volume from edematous viscera, distended lumen, iatrogenic packing materials, and resuscitative ascites , extra-pA 79-year-old female presented with nephrotic syndrome and underwent a right renal biopsy which confirmed Minimal Change Disease. Two days following the biopsy she developed hypovolemic shock with a hemoglobin level of 38 g/L and severe lactic acidosis. After resuscitation she underwent a CT scan revealing a large right RH . The pathttp://www.traumacanada.org/Default.aspx?pageId=829763). The retroperitoneal clot measured approximately 2.5 L. Postoperatively her kidney function returned to normal and ventilator support was no longer required.Her operative therapy was staged as an initial decompressive laparotomy resulting in improved IAP, ventilation, and kidney function. Two days later the patient was taken back to the operating room for removal of the retroperitoneal clot and abdominal wall closure , limited precedents exist to support both operative intervention and evacuation of the hematoma after correction of the coagulopathy. The first known description of the ACS secondary to a rectus sheath hematoma was reported by O'Mara and colleagues in 2003 . They noPatients who develop RH/RSH are typically elderly and/or suffering from multiple comorbid conditions that discourage aggressive therapies. Despite this, clinicians should recognize the potential of these extra-peritoneal conditions to restrict abdominal wall compliance and compress the peritoneal space thus reducing intra-abdominal volume and inducing severe IAH. In our experience both RH and RSH may induce overt ACS requiring staged decompressive laparotomies. Both patients developed ARF as a result of increased IAP. The abdominal wall release and removal of the hematoma in both cases resulted in reversal of the shock state and return of completely normal kidney function. Thus, we believe that any patient with RH or RSH warrants vigilant measurement of the IAP. Further, the recognition of IAH should mandate an aggressive management approach , 31, 36.In conclusion, ACS appears to be a rare but completely reversible complication of both RH and RSH. Therefore, despite this infrequency, patients with large RH or RSH should have IAP monitoring, and aggressive operative drainage after correction of the coagulopathy if ACS is recognized. The cases presented herein illustrate how a relatively benign pathology can result in increased IAP, organ failure, and ultimately ACS. Management with a decompressive laparotomy and evacuation of clot results in return to normal physiologic function.


Small bowel obstruction is rarely caused by bezoars concretions formed from undigested foreign material in the gastrointestinal tract. An important cause of bezoars is phytobezoars, formed from vegetables or fruits. A four-year-old boy presented to our emergency department with symptoms of acute intestinal obstruction. Upright plain abdominal radiography revealed multiple air fluid levels. Ultrasound showed no abnormalities, and because of worsening symptoms computed tomography of abdomen was performed. It showed intraluminal obstruction of the terminal ileum. Exploratory laparotomy revealed a phytobezoar consisting of undigested rhubarb. The mass was milked through the large bowel and out the anus. Although rare in humans, bezoars are a well-documented cause of small bowel obstruction and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction may require surgical treatment. Bezoars are concretions of swallowed hair, fruit vegetables fibers, or similar substances, found in the alimentary canal . AlthougA four-year-old boy presented to our emergency department with a history of abdominal pain, distension, and vomiting, for the preceding 12 hours. He had no history of prior abdominal surgery, melena, weight loss, or change in bowel habit. His abdomen was soft but diffusely tender. Bowel sounds were increased and his rectum was empty on digital exam. Physical exam was otherwise unremarkable and complete blood count was normal. Upright plain films of the abdomen revealed multiple air-fluid levels and there was no free air in the abdomen or air in the bowel wall. An ultrasound exam was performed that showed no evidence of intussusception. The child received intravenous fluids but continued to vomit and to help define the cause of his suspected acute small bowel obstruction, an abdominal CT scan was performed. It showed dilated loops of jejunum and proximal ileum. Multiple cylindrical filling defects, folded in on themselves and producing the appearance of obstruction, were visualized in the lumen of proximal ileum . There wThis is the first case report of rhubarb causing a bezoar leading to intestinal obstruction. Rhubarb is a group of plants growing from short, thick rhizomes . They haThe diagnosis of small bowel obstruction is based on a detailed clinical history, meticulous examination, and laboratory and radiological findings starting with plain abdominal films, progressing to abdominal CT if necessary . BezoarsAlthough rare in humans, bezoars are a documented cause of small bowel obstruction and should be considered when intraluminal bowel obstruction occurs. Bezoars are mostly seen in childhood and are well documented in postgastrectomy cases . Various


Calcifying fibrous pseudotumor is a rare benign soft-tissue lesion composed of fibrous tissue with abundant hyalinized collagen and dystrophic and often psammomatous calcifications. The cause of the disease is unclear but, usually, complete resection of the well-circumscribed tumor is sufficient to avoid recurrence of the disease. Here, we report an unusual case of this rare tumor that presented as two lobulated lesions in the calf muscle.The patient was a 17-year-old Japanese girl who noted a hard mass in her left calf. Magnetic resonance imaging revealed two well-demarcated lobular masses in the soleus muscle, and the tumor was significantly enhanced by contrast medium. Preoperative differential diagnoses included soft-part tumors composed of fibrous tissue. However, making a definite diagnosis was impossible because a lobulated shape is rare for fibrous tumors. Biopsy demonstrated that the mass was a benign tumor composed of collagen-rich, hyalinized fibrosclerotic tissue. We performed marginal resection of the two nodules, including the fibrous tissue that connected them. Immunohistochemistry was positive for factor XIIIa and negative for anaplastic lymphoma kinase-1. These findings were helpful to distinguish calcifying fibrous pseudotumor from inflammatory myofibroblastic tumor. There was no sign of recurrence at 30 months after surgery.To the best of our knowledge, this is the first case of bilobular calcifying fibrous pseudotumor that developed in an extremity. As described in the previous literature, simple excision was sufficient for the treatment of calcifying fibrous pseudotumor with two lobules. Fetsch  in 1993 . Calcify in 1993 . Histolo in 1993 . Here, wA 17-year-old Japanese girl noted a painless mass in her left calf. Seven months later, because the mass gradually increased in size, she visited our department. Our patient had no history of major traumatic injury. There was no family history or relevant medical history. Physical examination revealed a 3 cm × 3 cm hard, mobile, tender mass in her soleus muscle. No Tinel-like sign was elicited. Blood examination, including inflammatory response, was negative.Plain radiographs did not reveal any abnormal shadow. Magnetic resonance imaging (MRI) revealed two well-demarcated lobular masses in her soleus muscle Figure . T1-weigBecause the tumor was considered benign, simple excision of the mass was performed two months after the biopsy. At the time of excision, two masses were found in her soleus muscle. There was no feeding vessel and no hemorrhage originated from the tumor. On gross examination, the lesions were found to be solid, lobular, well-circumscribed, non-encapsulated, and gray-white masses Figure . The twoMicroscopically, the lesion was composed of hyalinized collagen fibers with fibroblasts. Psammomatous calcifications and infiltration of inflammatory cells were observed Figure  and 2D. Our patient was discharged without having experienced any postoperative complications. She could walk without any pain or functional disability. At 30 months after surgery, there was no evidence of recurrence.Calcifying fibrous pseudotumor is a rare, benign, tumor-like lesion characterized histologically by fibrotic proliferation, infiltration of inflammatory cells, and dystrophic and/or psammomatous calcifications ,5. The let al. noted that ALK positivity is often observed in IMT but absent in CFPT [et al. reported a molecular study of seven cases of gastric CFPT and addressed the issue of immunoglobulin G4 and the lacking recurrence in contrast to soft tissue counterparts [et al. showed diffuse staining for factor XIIIa in CFPT, in contrast to focal staining in IMT [Pathological differentiation of CFPT from IMT is sometimes problematic because spindle cells, inflammatory cell infiltration and calcification are common in both entities. Some literature has proposed that CFPT is a sclerosing end-stage of IMT . Immunoh in CFPT . Chromos in CFPT . Recentlterparts . Factor g in IMT . They alIn conclusion, we report the first case of bilobular CFPT in an extremity. Immunostaining for ALK and factor XIIIa was useful to differentiate between CFPT and IMT. Bilobular CFPT can be successfully treated by marginal resection.Written informed consent was obtained from the patient's parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.NS and SN performed the assessment and treatment of the patient and wrote the manuscript. MY and YA participated in the treatment of the patient, including surgery. KT, MH, SKi, and SY carried out the histological study. SKo designed the study and drafted the manuscript. All authors read and approved the final manuscript.


Pseudomyxoma peritonei is a rare progressive disease. Patients commonly present with a picture of acute appendicitis or with increasing abdominal girth. We present a case of a 71 year old man who presented with right iliac fossa pain, fever and vomiting. His abdominal examination revealed right iliac fossa mass which was confirmed radiologically. Diagnostic laparoscopy showed jelly like material along with a right iliac fossa mass. The aspirate was negative for malignancy initially. Due to persistance and progression of his disease he underwent right hemicolectomy. Histopathological diagnosis showed moderately differentiated adenocarcinoma of the cecum Duke’s C2. Pseudomyxoma peritonei (PMP) is a poorly understood condition affecting both sexes equally, with an increasing incidence with age. It is chThe quantity and distribution of the tumor can be determined by redistribution phenomenon. PreoperaThis is a case of a 71 year man who is known to have coronary artery disease, hypertension and atrial fibrillation and is on medications. He presented to the emergency department of King Fahd Hospital of the University with localized right iliac fossa pain which was associated with fever, nausea and vomiting. There was no change in the bowel habit and there was no mucus or blood in his stool, he also didn’t have any urinary symptoms. He denied any history of weight loss. His past history was significant for cardiac catheterization, right inguinal hernia repair, upper GI endoscopy and frequent admissions for uncontrolled atrial fibrillation. Systemic review was unremarkable. The physical examination revealed an ill looking patient with slight tachycardia and low grade fever. His respiratory and cardiovascular systems were within normal limits.The abdomen revealed a right iliac fossa mass measuring 8 × 6 cm firm, fixed, tender, not pulsatile and no skin changes over it. There was no organomegaly or palpable lymphadenopathy.Laboratory investigations showed leucocytosis of 13.6 with neutrophilia.The carcinoembryonic antigen (CEA) 54.1 (0-3ng/ml) was elevated, other laboratory investigations including Alpha-fetoprotein (AFP) were within normal limits.Abdominal sonography showed minimal fluid collection in the subhepatic area and a complex mass in the right iliac fossa. CT scan of the abdomen and pelvis with double contrast showed a heterogeneous soft tissue mass on the medial aspect of the cecum and ascending colon with central necrosis . DiagnosA fixed mass was seen in the area of the cecum, the appendix was not visualized. The patient had an uneventful post diagnostic laparoscopy and he was discharged upon his request. The histopathology evaluation confirmed the presence of areas of mucus, focal hemorrhage and calcifications with fibrofatty tissue but no clear evidence of malignancy. The patient presented 3 months later to the emergency department with right iliac fossa pain similar to the previous attack but it was more severe. He was looking ill, febrile and tachycardic. The laboratory test showed leucocytosis with neutrophilia. Repeated CT scan revealed an increase in the size of the mass. The patient agreed on surgical intervention. Intraoperatively the mass was found involving the terminal ileum and attached to the posterior abdominal wall. Complete excision of the mass was achieved followed by right hemicolectomy . The patPMP is a rare progressive disease, characterized by the production of copious amounts of mucinous fluid that gradually fills the peritoneal cavity, resulting in the so called ‘jelly belly’ abdomen. The firsDue its rarity and the small number of published cases, the pathological origin and the ideal management of this condition is a subject of debate.This condition is thought to originate from appendiceal adenoma which occludes the lumen of the appendix followed by gradual distention of the distal part with mucus and epithelial cells till its ruptures. The location and quantity of mucinous tumor within the abdomen and pelvis is characterized by a redistribution phenomenon that accumulates along the absorptive area of peritoneal fluid e.g greater omentum and diaphragm. In contrast the visceral peritoneum of the small bowel are seeded sparsely.8The massive accumulation of tumor cells within the greater omentum contributes to the increase of the abdominal girth which is one of the common presentations.In some instances the appendiceal distention and rupture, result in bacterial contamination and the patients present with symptoms of acute appendicitis.It’s worth mentioning that the literature contains sporadic cases of PMP in association with tumors of GI, lung, breast, pancreas, gallbladder, bile duct, fallopian tubes, ovaries, and urinary bladder.Recent immunohistochemical findings have added strong support to the theory that most tumors associated with PMP originate from the appendix.Due to the different pathological terms PMP is considered as a clinico-pathological entity characterized by mucinous ascites and non-invasive mucinous implants with a characteristic distribution. It contains histologically benign mucinous epithelium derived from an appendiceal mucinous adenoma which were labeled as ‘disseminated peritoneal adenomucinosis’ (DPAM), whereas similar cases with malignant histological features, were classified as ‘peritoneal mucinous carcinomatosis’ (PMCA). These peritoneal mucinous carcinomatosis with intermediate or discordant features were labeled as (PMCA-I/D).PMP is a subclinical event which is usually diagnosed at laparoscopy or laparatomy for appendicitis or ovarian tumor. The most likely explanation is that the appendix may be repeatedly decompressed by perforation and resealing. The most commonly recorded symptoms are abdominal pain resembling acute appendicitis in 27%, distension or mass in 23%. In rare et al.[Imaging studies before surgery is highly desirable, since a preoperative diagnosis allows the operation to be planned well and performed accordingly. Plain films are generally considered unhelpful for the diagnosis but the CT scan is widely employed to establish the diagnosis and extent of PMP. The mucinous material appears heterogeneous, scalloping of the liver, spleen and mesentery with central displacement of bowel loops and occasional calcifications. Sugarbaker et al. used CT The peritoneal aspirates typically contain predominantly mucus and few cells and the mucus stains positively for periodic acid–Schiff, astra blue, mucicarmine and alcian blue. It is impossible to assess the sensitivity and specificity of aspiration cytology in the diagnosis of PMP, hence, its value in clinical practice remains uncertain. Elevated tumor markers such as CEA level, CA19-9 and CA125 indicate advanced disease, and may rise in association with recurrent disease.et al.[et al.[In the past the treatment consisted of repeated debulking surgery which is not curative but aims to resect gross disease and limits mucus production and accumulation. Sugarbaker et al. advocateet al. These prl.[et al. There arl.[et al. in additIn the Mayo clinic series, survival was significant higher in patients who received intraperitoneal chemotherapy than those given systemic chemotherapy. RecentlyRecurrence of the disease may take years to develop or become symptomatic. Surgical reintervention is usually difficult because adhesions and fibrosis greatly increase the risk of unintentional enterotomies with subsequent leaks and fistulae formation. it is however, widely accepted that recurrences should be investigated vigorously and treated with further surgical debulking, with or without adjuvant chemotherapy, in the expectation that many patients will enjoy substantial additional survival and free of symptoms.et al.[In the Mayo Clinic series, the mediet al. reportedRecurrent disease occurs on the bowel surfaces and it is associated with intense fibrosis and adhesions leading to intestinal obstruction and obstructive jaundice, which are often the cause of death in PMP. Metastaset al.[In the Mayo Clinic series, median set al. the survPMP is a rare and heterogeneous disease. Its pathological origin is uncertain and ideal treatment is a subject of debate. Mucinous adenocarcinoma of the cecum can mimic this condition and add to diagnostic difficulties. The role of diagnostic laparoscopy in such doubtful cases is valuable. The management requires an accurate preoperative assessment and diagnosis. Recent application of immunocytochemistry and genetic analysis using polymerase chain reaction have made major contributions to the debate.


Glioblastoma multiforme is a highly malignant primary brain tumor that shows marked local aggressiveness, but extracranial spread is not a common occurrence. We present an unusual case of recurrent glioblastoma in 54-year old male that spread through the scull base to the ethmoid and sphenoid sinuses, to the orbita, pterygomaxillar fossa, and to the neck.A 54-year old male underwent left temporal resection because of brain tumor of his left temporal lobe. Operation was followed by external beam radiation combined with temozolomide. The tumor recurred eight months after first surgery. The patient developed swelling of left temporal region, difficult swallowing and headache. MRI of head showed recurrent tumor, which invaded orbita, ethmoid and sphenoid sinuses, nasal cavity, pterygomaxillar fossa.The patient died ten months after initial diagnosis of glioblastoma multiforme, and two months after his second operation.The aggressive surgical operation helped to downsize the tumor mass as much as possible, but did not prolonged significantly the life or improved the life quality of the patient. The current literature is reviewed, and the diagnostic approaches as well as therapeutic options are discussed. Glioblastoma multiforme is a highly malignant primary brain tumor. The median survival with therapy is approximately 9-12 months [We report an exceptional case of glioblastoma multiforme spreading extracranially to the orbita, ethmoid and sphenoid sinuses, nasal cavity, pterygomaxillar fossa, and neck.A 54-year old Caucasian male presented to Department of Neurosurgery complaining of severe headaches, dizziness, and dysarthria that lasted for 2 weeks. His personal and family history was unremarkable, and his Karnofsky score was 90. Upon admission MSCT showed a hypodense lesion in the left temporal lobe. After initial analysis MRI of the head was scheduled, which showed a ring-enhancing lesion in the left temporal lobe.Figure  We prefoThe patient received radiotherapy in daily factions of 2 Gy given 5 days per week for 6 weeks, for total 60 Gy plus continuous daily temozolomide (75 mg per square meter of body-surface area per day). Following with the six cycles of the adjuvant temozolomide therapy (150 to 200 mg per square meter for 5 days).Three months after operation control MSCT showed no signs of tumor. Eight months after the first operation MRI was performed and revealed a tumor that involved middle cranial fossa with extension to the left orbita, ethmoid and sphenoid sinuses, nasal cavity, and pterygomaxillar fossa Figure . The patDespite malignant nature of glioblastoma multiforme, extracranial metastases are rare . GlioblaIn summary, the extra cranial spread of glioblastoma multiforme is a rare occurrence. In this report we presented unusual case of extra cranial spread of glioblastoma multiforme after resection and concomitant radiotherapy with chemotherapy. The tumor showed aggressive clinical behavior after standard treatment in very short period of time. The recurrent tumor extended to the orbit, ethmoid and sphenoid sinuses, and to the pterygomaxillar fossa. During second surgery we could observe the adherent brain tumor mass to the temporal dura. The tumor destructed the floor of the skull base; the dura mater was absent from the floor of the skull base. The pathological findings revealed invasion of the bone of the skull base, and underlying masticator muscles in the infratemporal fossa. Due to intraoperative and histological findings we believe that the tumor spread with direct invasion of the dura and underlying scull base and mastication muscles. In the later stage of disease tumor showed angioinvasion. Aggressive operation can downsize the tumor mass but the life quality may not be improved significantly.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.MRI: magnetic resonance imaging; MSCT: multi slice computed tomography; WHO: World health organizationAll authors declare that they do not have any financial or non-financial competing interests in relation in relation to this manuscript.DT collected the data, analyzed data and wrote the paper, DC gave conceptual design and edited the paper, SL gathered pathological pictures and interpreted them, IT supervised and edited the paper, GG wrote the paper, AZ supervised the paper end edited the paper. All authors read and approved the final manuscript.


Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst. When the cyst is multilocular and located at the molar ramus area, it may be confused to ameloblastoma. Lots of cases have been reported in the literature where OKC is associated with the nonvital tooth. So trauma could be one of the reasons in inducing this cyst. In our case, it was in the anterior region at the periapex of nonvital tooth having traumatic occlusion. Hence, the diagnosis of radicular cyst was made and endodontic treatment was done. Odontogenic Keratocyst (OKC) was first described by Philipsen in 1956. It is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible . The cliA 25-year-old male patient was referred to a private dental clinic by a dermatologist to rule out any dental cause for a nonhealing extraoral sinus in the submental region . PatientIt was decided to do the root canal treatment for the nonvital tooth. After complete oral prophylaxis, rubber dam applied. Following access cavity preparation, necrotic tissue was removed, working length determined, and cleaning and shaping of the canal was done. Calcium hydroxide intracanal medicament was given for two appointments in an interval of one week. Later obturation was done with lateral condensation of gutta-percha. But lesion did not show the sign of regression even after three weeks. Hence periapical surgery was decided.Before the surgery, to know the extent of the lesion, as it could not be made out in intraoral radiograph, an OPG was advised. Surprisingly, orthopantomograph revealed a large radiolucent area in the anterior region of the mandible crossing the midline. It was extending from right premolar region to left premolar area. One more radiolucent area was seen in the left third molar region, which was extending halfway through the ramus, associated with impacted third molar. Cystic radiolucency was seen in the maxillary right and left third molar area also. Here, right third molar tooth was having dilacerations and was horizontally placed along the crest of the alveolar bone. Left maxillary third molar was vertically impacted. Right maxillary canine and right mandibular third molar too were impacted . Since pPatient was referred to an oral and maxillofacial surgeon who performed surgical enucleation of the cystic lesions. Histopathology revealed parakeratotic cystic lining of 6–8 cell thickness with corrugation. The palisading appearance of the basal cells was evident, thus the lesion is confirmed to be OKC . The patThe odontogenic keratocyst is derived from the remnants of the dental lamina with a biologic behaviour similar to a benign neoplasm. Because of this aggressive nature, recently World health organization used the term “keratocystic odontogenic tumor” to describe this cyst , 2. It is named keratocyst because the cystic lining produces keratin. The cyst occurs in any age group, but most commonly seen in the second and third decades of life with male predilection. There are no characteristic clinical manifestations. The more common features are pain, soft tissue swelling, expansion of bone, drainage, and paraesthesia of the lip or teeth . Our casRadiographically, most OKCs are unilocular with scalloped margin when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst. When the cyst is multilocular and located at the molar ramus area it may be confused to ameloblastoma. The septa present in ameloblastoma are coarse and curved; originate from the normal bone trapped within the tumor. Hence these septa have honeycomb or soap bubble appearance which is not seen in OKC. In odontogenic myxoma, septa present are thin, sharp, and straight. A simple bone cyst has similar scalloped margin, but this margin is delicate and not distinct –5. In ouThe odontogenic keratocyst may occur due to traumatic implantation or down growth of the basal cell layer of surface epithelium or reduced enamel epithelium of the dental follicle. Nohl and Gulabivala reported two cases of OKCs, and in their first case, tooth associated with OKC had history of trauma twenty years ago . Our casMultiple OKC occur with some frequency. Many times, it is associated with NBCCS. However, at other times cyst is independent of syndrome. The recurrence rate in these patients is higher may be because, as the number of keratocysts in an individual has, probability of recurrence is higher. As the number of keratocysts increases in an individual, the rate of recurrence also increases . In our OKCs should be one of the differential diagnoses for the periapical radiolucencies which are not responding following the initial endodontic therapy. The clinical, radiographic, and histopathological correlations are essential for proper patient treatment and followup. This will avoid the further complications, since OKCs are highly aggressive, have high recurrence rate, and are associated with NBCCS.


We present a 13-year-old child who admitted with a dull right upper quadrant pain that started 3 weeks before her referral. Several medications were given but they did not change the intensity and the frequency of the pain. Her physical examination was nonspecific except for slight right upper quadrant tenderness. The imaging studies revealed a sewing pin perforating the stomach and gallbladder. The patient was treated with a successful operation, and no postoperative complications were observed. To our knowledge, this is the first case of a sharp foreign body gallbladder perforation in a child. Ingestion of foreign bodies (FB) is a common problem during childhood, alerting the family but having relatively low complication rates. While most of these objects leave the alimentary tract without a complicating course, sharp objects may perforate the viscera and present as acute abdomen , 2. We rA 13-year-old girl was admitted to our clinic for intermittent blunt abdominal pain presenting mostly after the meals. The pain was consistent and did not relieve with medications. The physical examination was notable only for slight right upper quadrant (RUQ) tenderness. The biochemical and hematological values were within normal limits. On abdominal X-ray, a radio opaque image was seen. With the deepened history, we learned that the patient has swallowed a sewing pin about three weeks prior to her admission. She was interned due to the location and long stay of the pin for further evaluation. An abdominal ultrasound revealed a 38 mm FB perforating the stomach from antrum and lying over the gallbladder of its superior pole. The 30 mm part of the pin was outside the stomach, and gallbladder wall was edematous (13 mm). We planned and performed laparotomy on the same day. During the exploration, stomach and the surrounding tissues were observed to be adherent to each other with marked tissue edema, and serous fluid was oozing from the area Figures . DissectAlthough the ingested FBs are common and alerting problems of childhood, most of them pass the alimentary tract without any sequel. Sharp materials such as fish bones, chicken bones, and needles in contrast may cause complications up to 35% of the cases, such as appendicitis, irreducible inguinal hernia, intussusception, pancreatitis, hepatic abscess, and duodenocolic fistula , 2. During the transit through the alimentary tract, foreign bodies can migrate to any abdominal organ, but perforation of the stomach and migration to the gallbladder is extremely rare. Only one case of fishbone in a 67-year-old man was observed in the gallbladder without any fistula in the stomach. The case was managed with laparoscopy, and cholecystectomy was performed . n = 22) while the remaining were duodenum, transverse colon, sigmoid, and appendix. The most common symptoms were found to be epigastralgia, vomiting, fever, nausea, and jaundice. The suffering period of the patients differed from 1 day (toothpick from duodenum to the both lobes of the liver) to 1 year (a needle in the right lobe of the liver).In a successful review of Santos et al. in 2007, concerning the adult cases of gastric perforation and hepatic abscess formation, 40 patients were identified [The perforation of the luminal organs of the abdomen mostly ends up with peritonitis and acute abdomen, necessitating the urgent surgical intervention. A delay in the diagnosis of such a condition results in sepsis and death. In minority of the cases, such as ours, the body isolates the pathology, enclosing the area with organ walls and omentum, creating an encapsulated zone of inflammation. The management of gastrointestinal FBs still bears debates. In a guideline for the management of ingested FBs and food impactions reported in 2011, Ikenberry et al. described a myriad of swallowed sharp-pointed objects. Chicken and fish bones, straightened paperclips, toothpicks, needles, bread bag clips, and dental bridgework ingestions have been associated with complications –11. It iA detailed history and wisely planned imaging are the crucial steps in FB ingestion in children. As presented in our case, the child may have forgotten or be frightened and trying to hide or may even be unaware of the condition. Any disturbing examination findings accompanying a chronic abdominal discomfort should lead the surgeon to imaging modalities in a stepwise fashion, starting from X-rays. Although we preferred open surgery, laparoscopic approach may also be encouraged in acute and less inflamed cases because it enables direct assessment of the intraperitoneal cavity and organs.


Primary adenocarcinoma of thymus is extremely rare.HLA locus in chromosomal region 6p21.32.This is a case of primary adenocarcinoma with intestinal differentiation and focal mucin production in the thymus. Thymic cyst was associated with this tumor. Intestinal differentiation was confirmed by immunohistochemical stain with positivity for CDX-2, CK20, villin, MOC31 and focal positivity of CK7. Array comperative genomic hybridization (CGH) analysis showed a complex pattern of chromosomal imbalances including homozygous deletion at the This rare tumor shows a similar genetic aberration with other studied thymic epithelial tumors. Primary thymic carcinomas are very rare tumors. The most common histologic subtypes are squamous cell, adenosquamous/mucoepidermoid, basal cell, large cell undifferentiated, adenocarcinoma, carcinoma with adenoid cystic carcinoma-like features, lymphoepithelioma-like, clear cell, and sarcomatoid carcinomas . PrimaryA 28 year old woman presented with neck and right upper extremity pain accompanied by dyspnea of two years duration. Chest X- ray revealed mediastinal widening Figure A. Chest The mediastinal biopsy showed a moderately differentiated adenocarcinoma with a desmoplastic and necrotic stroma Figure C. ScatteHLA-DR5 locus in chromosomal region 6p21.32 seemed to be homozygously deleted . The experimental procedures were performed according to the protocols provided by the manufacturers. Slides were scanned with the G2565CA Microarray Scanner (Agilent) at a scan resolution of 5 μm. Signal intensities from the generated images were measured and evaluated with Feature Extraction 10.10.11 and Agilent Genomic Standard Workbench Edition 6.5.0.58 (AGW6.5) software (Agilent) applying the Aberration Detection Method-2 (ADM-2) algorithm with a threshold of 6.0. It showed a complex karyotype with multiple gains and losses. Part of the “Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.”Metastatic neoplasms to the mediastinum account for most of epithelial cell neoplasms. The second most common tumors are thymoma and thymic carcinoma. Primary adenocarcinoma is very rare in mediastinum, so before considering this diagnostic entity, most prevalent tumors such as metastatic adenocarcinomas, germ cell tumors and malignant teratomas must be ruled out ,3-5,7,8.Immunostains are an important tool in the study of mediastinal tumors. For instance CD5 is a leukocyte marker expressed on differentiating thymocytes. It is said to be useful in differentiating thymic from non-thymic carcinomas ,7,8. CauThe exact origin of thymic adenocarcinoma is not clear. Glandular differentiation is rarely seen in ultrastructural studies of normal thymic epithelial cells . Also, iReview of the literature on thymic adenocarcinoma is shown in Tables In our case the adenocarcinoma was associated with a large benign thymic cyst with columnar epithelium. It showed no dysplastic change.Most of the patients with thymic adenocarcinoma do not have any chief complaint (41%). In symptomatic group, the most common presenting sign is chest pain (0.17%). Other rare signs are cough (0.05%), dyspnea (0.05%), and shoulder pain (0.05%). Weight loss is a rare sign in this tumor (0.05%). Anterior mediastinum is the most common location (79%) followed by right, left, substernal and pretracheal mediastinum (each below%1). Prognosis cannot be accurately evaluated due to low incidence rate of thymic adenocarcinoma. Some patients underwent surgical resection (15 cases), chemotherapy (12 cases) or radiotherapy (19 cases). Clinical outcome showed local recurrences (2 cases), metastatic disease 3 cases) and death due to surgical complication or disease (9 cases). According to Table  cases anHLA-DRB5-locus in chromosomal region 6p21.32 was homozygously deleted, showing similar genetic aberrations with other thymic epithelial tumors.In our case, the HLA- locus in chromosomal region 6p21.32 confirmed by CGH array. It is associated with a benign thymic cyst. This is the first genetic study on a primary thymic adenocarcinoma (mucinous type), which shows a similar genetic aberration with other thymic epithelial tumors. We suggest adding genetic study to clinicopathologic and imaging workup for confirmation of diagnosis of a primary thymic tumor.This primary adenocarcinoma of the thymus with intestinal differentiation shows homozygous deletion of part of the No conflict of interest is declared, and source of funding is Dr. Daneshbod Laboratory.YD, MM, MR and AS were involved in diagnosis, conception, design, acquisition of data, analysis and interpretation of data and were directly involved in drafting and revising the manuscript. IN and RS were participated in the array CGH, analysis and interpretation of data and revising the manuscript. PB reviewed this case and confirmed the diagnosis as well as extensively revised the paper. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6890/13/17/prepub


Adnexal cancers are in fifth place among the tumors with the highest mortality in the female population. The aim of the present study was to evaluate the accuracy of Multi-detector computed tomography (MDCT) on a 64-multislice CT scanner in the detection and differentiation of adnexal masses stages.During the present prospective study, 95 women with a primary diagnosis of ovarian mass in base of clinical examination and ultrasonographic findings underwent preoperative evaluation by a 64-slice MDCT with a section thickness of 0.6 mm, 50% overlap and reconstructed images. Afterward, results of MDCT were compared with surgical and histopathological findings, and the sensitivity, specificity, positive and negative predictive value and accuracy were determined.The mean age of patients was 48.63 ± 13.93 years. MDCT diagnosed 25 (26.3%) masses to be benign and 70 (73.7%) to be malignant . The sensitivity and specificity of MDCT in determining local extension was 72.2% and 93.4% respectively. And the sensitivity and specificity of MDCT in determining peritoneal seeding and liver extension was 81.8% and 93% respectively. Estimated stage was significantly agreed with the surgical (Cohen's Kappa (κ) = 0.891) and histopathological findings (κ = 0.858).MDCT is a highly sensitive and specific diagnostic method in evaluation of adnexal masses and successfully stage the tumor in consistent with surgery and histopathology. Malignancies of the female reproductive system are among serious causes of mortality and morbidity, and adnexal cancers are in fifth place among the tumors with the highest mortality in the female population . While tPutting together with a thorough observation, physical examination and characteristics of the mass will give valuable information about its nature ,6. AfterComputed tomography of abdomen and pelvic can depict the masses as well as probable local or regional invasions. Additionally, it can differentiate gastrointestinal tract, urinary tract and reproductive malignancy from each other using contrast materials. Multi-detector computed tomography (MDCT) makes multiplanar evaluation of pelvic and abdominal structures available as well as two or three dimensional illustrations . FurtherAlthough the diagnostic accuracy of spiral CT and its axial views for nature and extension of the adnexal masses were reported , the preFrom May 2007 to March 2009 all women with the primary diagnosis of adnexal mass who were referred for further evaluation by MDCT imaging and underwent surgical resection and histopathologic examination, were included in this study. The mass extensions to pelvic, abdominal organs or peritoneum, existence of ascitis and lymph nodes involvement have been evaluated by MDCT, surgical studies and histopathologic examinations. This study has been approved by the Ethics Committee of Tabriz University of Medical Sciences. A written informed consent was obtained from all participants.All MDCT studies were performed using a 64-multislices MDCT system  in Tabriz Imam Khomeini Hospital (Parsian Center). Image scanning parameters were as follows: rotation time 1 second, table speed 15.4 mm/rotation, reconstruction interval 0.6 mm at Kernel H20, 120 kV/260 mAs, acquisition time 9s.MDCT images were obtained from the abdomen and pelvic, covering the area from the diaphragm to the symphysis pubis . All scans were done with a standard protocol using the triple phase. Precontrast scan of the upper abdomen; arterial phase using the Automatic Bolus Tracking System; portal phase yielded with a delay of 60 s after the arterial one. The contrast medium  was administered at a dose of 1.5 mL per kg, with a variable flow rate of 3-4 mL per second through the antecubital vein of the right arm.To facilitate the differentiation of calcified peritoneal implants from bowel loops, 500 ml of water was administrated 30 min prior to the examination. Although it may be difficult to recognize small peritoneal implants and distinguishing them from bowel loops, a careful evaluation of multiplanar reformatted (MPR) images usually enables this differentiation. All patients were fixed during MDCT examination to prevent motion artifacts.The MDCT studies were interpreted at a workstation by an experienced radiologist  using Maximum Intensity Projection (MIP); MPR and volume rendered images (VRI).An expert surgeon (E. O. S.) reported surgical results and described involvement of pelvis, lymph nodes and peritoneum. An experienced pathologist (A. D.) examined all the resected specimens with no knowledge of the MDCT or surgical findings. The surgical and histopathological findings were considered as a control for the evaluation of MDCT findings in adnexal mass.P value was less than 0.05.Statistical analyses were performed by SPSS software package for windows version 13.0 . Results are presented as mean ± standard deviation (SD). The sensitivity, specificity, positive and negative predictive value for MDCT were calculated in comparison with surgical and histopathological findings. The Fisher exact test and Pearson correlation tests (Cohen's kappa (κ) values ) were usDuring the study period 95 women with a primary diagnosis of ovarian mass  were included in the study. The frequency of pathologic findings reported by MDCT, surgery and histopathology are demonstrated in Figure Table The disagreement in staging of the tumor between MDCT and surgery was found in 12 cases  is considered the primary imaging modality for the assessment and characterization of adnexal masses. But, although the reported sensitivities of the technique are high (85-100%), the specificities are variable (50-100%) ,16. SeveTsili et al. reported the sensitivity of the16-slice MDCT to be 90% and accuracy of 89.1% for detecting malignant tumors in patients with an adnexal mass . HoweverThe sensitivity, specificity, positive and negative predictive value and accuracy of CT has some potential limitations which are the topic of today researches to be improved. The sensitivity of CT for detecting peritoneal metastasis is reported about 85-93%, while it decreases to 20-25% when the metastasis is lesser than 1 cm in diameter . This maResults of MDCT imaging were compatible with histopathological findings in 84.6%. When there was a different MDCT mostly under-estimated the stage of the tumor. Accuracy of MDCT was higher in advanced stages compared to earlier stages (I and II). This maybe explained by high capability of MDCT to illustrate peritoneal seeding and involvement of abdominal visceral organs. Similar results have been reported by Tsili et al. about the compatibility between results of MDCT and histopathological evaluations  which isThis study concludes that despite the possibilities of overstaging and understaging the adnexal masses, MDCT provides accurate information on detection, differentiation and staging of adnexal tumors and allows planning therapeutic approach.CT: Computed Tomography; MDCT: Multi-Detector Computed Tomography; MPR: Multiplanar Reformatted; MIP: Maximum Intensity Projection; VRI: Volume Rendered Images; US: Ultrasound; MRI: Magnetic Resonance Imaging.The authors declare that they have no competing interests.All the authors in this manuscript have read and approve the final manuscript. MGS: Conception and design, and manuscript writing. MKT: The MDCT studies and manuscript writing. EOS: Surgical results. AD: Pathological examinations. AA: Data analysis and manuscript writing.


Colorectal cancer is a rising problem, as the incidence increases with age. In most cases the goal of treatment is oncological resection followed by adjuvant chemotherapy in order to optimize the survival. In this case report we present a 93-year-old patient with a sigmoid carcinoma inside an irreducible inguinal hernia, which was diagnosed prior to surgery. We chose to perform a sigmoid resection through an oblique inguinal incision as a safer alternative to laparotomy. Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females. It is estimated that over 1.2 million new cases and 608.700 deaths have occurred in 2008 [In most cases of CRC, the primary goal is curative treatment. This means a radical resection and, if necessary, adjuvant chemotherapy.In CRC, as the incidence increases with age, there is a peak of 350 cases/100.000 individuals above the age of 80 . This evInitial common symptoms in patients presenting with colon cancer are abdominal pain, change in bowel habits, melaena, and general weakness . OccasioWe present a 93-year-old man with a sigmoid carcinoma in a left-side irreducible inguinal hernia, which was diagnosed prior to surgery and was resected through a standard oblique inguinal incision.μg/L. An abdominal computed tomography (CT) scan revealed an inguinal hernia-containing tumour (A 93-year-old man with a medical history of hypertension, left bundle branch block, and macular degeneration was admitted to the emergency department because of rectal bleeding and abdominal pain. Physical examination revealed a nontender, irreducible mass in the left groin . Rectal g tumour . A colonConsidering age, vitality, and associated peroperative risks of this patient, our team of gastrointestinal surgeons held the opinion that a low anterior resection would be too much of a burden and it was decided to perform a tumour resection through a standard oblique inguinal incision. Peroperative findings were a large left-sided inguinal hernia, which contained the sigmoid colon with the spotted tumour . ResectiHistological examination of the specimen revealed a radically resected, moderately differentiated adenocarcinoma with invasion in the subserosal fat. None of 9 lymph nodes was tumour positive. No adjuvant treatment was given.In the case reported above, a sigmoid resection was performed through the inguinal canal in order to avoid a laparotomy, minimizing surgical risks. Unfortunately, the performed resection could not be considered optimal from an oncological point of view, as the lymph node yield was less than 12. Although it minimizes the surgical risk during operation by avoiding a laparotomy, one can wonder if this risk reduction has benefits over a suboptimal oncological treatment. For example, Steele et al.  found anIn stage II or stage III colon cancer, the survival rates in patients receiving adjuvant chemotherapy can be up to 16% compared to patients without adjuvant chemotherapy , 9. The In conclusion, we resected a sigmoid carcinoma in a hernia sac through a standard oblique incision in a 93-year-old patient. Therefore surgical risks were minimized and the patient could be discharged relatively short after operation. Although the specimen was oncologically not fully satisfying, we consider the current evidence too small to justify more invasive surgery in order to achieve a potentially oncologically better resection in this group of vulnerable patients.In our opinion, a resection of a sigmoid carcinoma in an irreducible inguinal hernia through an oblique inguinal incision can be an attractive alternative for the very old patients.


Osteomas are asymptomatic and rare slow growing bony tumors in temporal bone, and should be taken into account in differential diagnosis of the osteolytic solitary skull lesions. Sometimes is associated with pain and functional loss. Only a few cases have been reported.We describe a case of an osteoid osteoma of the temporal bone (mastoid) in a 31-year-old woman presenting as painful solitary tumor of calvarium and its management. The resection of whole bony tumor was performed using the retroauricular approach. Pathologic evaluation revealed the osteoid osteoma. Although osteoid osteoma of the temporal bone is rare, it should be taken into account in differential diagnosis of the osteolytic skull lesions. Treatment is indicated for symptomatic osteomas or cosmetic reasons.  Magnetic resonance image (MRI) reveals typically low signal intensity on T1- and T2-weighted images with contrast enhancement . Here, we report a rare case of osteoid osteoma presenting as a painful solitary skull lesion.Osteoid osteoma is a benign skeletal disorder, and new bone forming tumors located within bones or developing on them. They are often asymptomatic, and are incidentally found on radiological investing- ations. Osteomas are frequently found in the frontal-ethmoid region ,2. In thThis 31-year-old woman presented with a painful scalp lesion on the left mastoid, 2 cm in diameter. She had no specific medical history, and her general condition was good. She experienced severe headache of abrupt-onset 1 month ago, and noticed a newly developed scalp tenderness on the left mastoid region. Findings from physical examination were normal except for a tender scalp lesion on the left temporal region. She was neurologically intact. Routine laboratory data, including serum calcium, phosphorus, and alkaline phosphatase, were within the normal limits. Brain computed tomography scans showed approximately 2.5 cm sized, lobulated, osteolytic lesion over the right temporal (mastoid) bone . During the operation, an reddish lesion was attached to the bone, and had completely eroded the outer and inner tables of skull. At the margins of the lesion, the skull was thickened and gritty in an area of 1 to 1.5 mm around the lesion . En-blocHistopathological examination confirmed an osteoid osteoma . She wasOsteoma is a slow growing benign mesenchymal osteoblastic tumor formed by mature bone tissue. Osteoma is prone to grow from the outer table of the cranium, jaw and paranasal sinuses . Excludi We reported a rare case of an osteoid osteoma of the temporal bone (mastoid) in a young woman with severe retroauricular pain. Although osteoid osteoma of temporal bone is an infrequent benign tumor, it should be included in the differential diagnosis of an osteolytic temporal lesion. The suspected diagnosis is based on the clinical findings and CT. Surgical removal is indicated when growth of the osteoma causes distressing symptoms or cosmetic issues. The prognosis of the mastoid osteoma may be considered to be good in cosmetic and curative aspects when it is completely excised.


Primary tumours of the middle ear are much less commonly encountered in clinical practice than non neoplastic lesions. Middle ear adenocarcinoma is a very rare, locally invasive neoplasm assumed to arise from the middle ear mucosa. Because the natural course and clinical behavior of this neoplasm are far from established, the sporadic reports of such cases continue to provide basis for better understanding.A case of low grade adenocarcinoma of the middle ear is described in details with regard to its clinical presentation, radiological findings, histopathological, immunohistochemical and ultrastructural findings. The tumour recurred four times. As a consequence of their rarity, middle ear neoplasms may be difficult to classify, for both clinicians and pathologists  . Middle A male patient presented at age 24 with a mass in the right middle ear extending to the external auditory meatus. He underwent surgery and the mass was diagnosed as a simple polyp. One year later he presented with a recurrent bleeding mass. The mass was re-excised and the surgeon informed him that it was adherent to the facial nerve and the patient ended up with a facial paralysis. The mass was diagnosed as a middle ear adenoma. The patient was free of symptoms for 5 years when he presented with a recurrent reddish mass in the previous mastoid cavity filling it completely and peeping through the Eustachian tube. The mass was completely excised in September 2000 and the biopsy revealed a middle ear adenoma.The patient was followed up and was free until 2003 when routine MRI showed a huge mass extending behind the mastoid cavity into the posterior cranial fossa. The previous mastoid cavity was free of recurrence. A posterior fossa craniotomy was performed and the mass partially excised as it was extremely bloody and adherent to the cerebellum and brainstem. The biopsy revealed it to be a middle ear adenocarcinoma. The patient received post-operative radiotherapy on the remnant and repeat follow-up MRI revealed it to be stable. In 2005 a follow-up MRI was ordered for recurrent headaches and revealed a large mass in the middle cranial fossa above the tegmen. The previous middle ear and mastoid cavities were still free of recurrence. The mass was excised by a middle fossa craniotomy and the last biopsy revealed an adenocarcinoma as well. The patient has no family history of similar conditionHistologically the tumour cells are arranged in islands, cords or form glandular spaces. The latter contain brightly eosinophilic secretory material. Tumour cells are cuboidal or oval with finely granular eosinophilic cytoplasm and centrally placed cytologically bland nuclei. Figure Immunohistochemistry revealed that the tumour cells are positive for keratin Figure , vimentiAs epithelial tumors as a group are rarities in the middle ear, epithelial tumours of the middle ear of variable degrees of aggressiveness have been considered together in several reports -5. MoreoThe differential diagnosis of this tumour include papillary adenocarcinoma (aggressive papillary tumor) of the middle ear which has a papillary-to-glandular appearance and may produce a colloid-like substance and resemble papillary carcinomas of the thyroid. It has been suggested that this may be the same tumor as low grade adenocarcinoma of endolymphatic sac origin, which has locally extended into the middle ear. These tumors are immunohistochemically positive for cytokeratin, epithelial membrane antigen, and S100 protein. In the present case the tumour showed no papillae, and it remains to be verified whether similar tumours can originate from the middle ear. Paulus etal. 1999  describeEvery individual case of middle ear adenomatous tumor requires a detailed clinical and radiological workup. All cases should be managed aggressively with an attempt at tumor removal. Regular follow-up with sequential radiology is essential.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of written consent is available for review by the Editor- in- Chief of this journal.The author declares that they have no competing interests.The author is responsible for data collection, and interpretation, literature search and manuscript preparation. She read and approved the final manuscript.


Lung carcinoid tumor and low grade glioma are two uncommon malignancies.We report the case of 24-year-old man who presented with respiratory disease. Imaging investigations showed a right lung tumor and histological analysis confirmed a typical carcinoid tumor. As part of initial staging, brain MRI revealed an asymptomatic right frontal lesion. First, a right pulmonary lobectomy was performed without adjuvant treatment. In second time, brain tumorectomy was performed. Histological examination confirmed the diagnosis of low grade glioma (LGG). The patient remained in complete remission 2.5 years after the initial diagnosis.This is the first case reporting the association between LGG and lung carcinoid tumor, while no association between LGG and a systemic tumor have been published to date. Association of lung carcinoid tumor with other malignant diseases has been reported but remained uncommon. Only minimal data support a potential molecular common origin.This exceptional association may be fortuitous. However, their concomitant diagnoses suggest a potential association between both rare diseases. A genetic susceptibility remains possible. Carcinoid bronchopulmonary tumors represent approximately 1 to 2% of all lung neoplasms. Low grade glioma (LGG) are rare, diffuse, slow-growing, primary neuroectodermal tumors that occur in the central nervous system. In this report, we present the first association between LGG and lung carcinoid tumor. We also performed a comprehensive review of the literature on the association between LGG or carcinoid tumor, and systemic malignancies.A 24-year-old man presented in September 2009 with respiratory symptoms including cough and hemoptoic expectorations, without altered general status. Past medical history was restricted to Oto-Rhino-Laryngological viral infections without smoking, alcohol, or asbestos exposure. Clinical observation was not relevant with normal respiratory and neurological examinations. Thoracic radiography showed a mass in the right lung. Computed tomography (CT) confirmed a lung tumor (56 mm) in the right superior lobe associated with mediastinal lymph node involvement without visceral metastasis. First, lung fibroscopy was performed. It was complicated by massive hemoptysis. Histological analysis concluded a diagnosis of typical carcinoid tumor. Positron emission tomography was moderate positive  and octreoscan presented an intensive fixation for lesions previously described on the CT scan Figure. Both exLung surgery consisted of a right superior lobectomy with a resected tumor that measured 5 cm. Lymph node involvement was restricted to one of the 16 explored nodes. Definitive histology confirmed a typical carcinoid tumor pT3N1M0 R0 (Stage IIIA). After multidisciplinary consultation no adjuvant treatment was indicated.2 per day, five days per week, during 6 weeks) was performed. At present, patient is routinely follow-up and complete remission is maintained 2.5 years after the initial diagnosis.On subsequent surgery, gross total resection of the brain tumor was performed. Anatomopathologic examination concluded a diagnosis of grade II oligoastrocytoma. Further immunohistochemical and molecular analyses identified expression of p53, lack of MGMT (O(6)-methylguanine-DNA methyltransferase) promoter methylation, absence of IDH (Isocitrate Dehydrogenase) mutation and no amplification of EGFR . Using Fluorescence In Situ Hybridization technique, no 1p19q codeletion was detected. An adjuvant treatment with radiotherapy (60Gy) and concomitant temozolomide . Oligoastrocytomas exhibit a mixed phenotype in which some tumor cells show astrocytic differentiations while others show oligodendroglial differentiations. No assoAssociation of carcinoid tumors with other malignant diseases is uncommon. Rare isolated cases have been reported with association between carcinoid tumors and other carcinomas (gastric, renal, colorecTwo molecular analyses showed correlation between LGG and carcinoid tumors. The first reported that astrocytomas could share N-CAM-related antigens with small lung carcinomas. This biological observation could support a relationship or potential common origin between neural and neuroendocrine tumors. A seconOurs is the first case reporting the association between low grade glioma and lung carcinoid tumor. The occurrence of these tumors might be an as yet undescribed association that is more than fortuitous. A genetic susceptibility remains possible.Written informed consent was obtained from the patient for publication of this report and any accompanying images.The authors declare that they have no competing interests.ET acquired and analysed data and drafted the manuscript. MB, CV, AG, OC, PV partyicipated to the acquisition of data. OC helped to draft the manuscript. AM supervised this case report, participated in the acquisition of data and helped to draft the manuscript. All authors read and approved the final manuscript.


To report the effectiveness of non-invasive management of congenital eversion of the eyelids, a rare condition associated with serious socio-psychological consequences.Three neonates with congenital eversion of the eyelids and secondary conjunctival chemosis and prolapse were managed with 5% hypertonic normal saline, lubricants, antibiotics, and padding. Complete eye opening was achieved by the 10th day of presentation and the condition resolved.Non-invasive management of congenital eyelid eversion was found to be effective with no need for surgical management. All health care workers should be informed that this condition is amenable to conservative treatment if started early, so that prompt referral for expert management can be offered. Congenital eyelid eversion is a rare entity which usually presents at birth and more commonly involves the upper eyelid. It may be described as a condition in which the eyelid is completely turned out and is usually associated with swelling, conjunctival prolapse and chemosis. It was first reported by AdamsCongenital lid eversion can be due to infections, inflammation and birth trauma; or may be associated with systemic anomalies such as Down syndrome.6Patients may be treated medically with hyperosmotic agents, antibiotics and patching; or surgically by applying temporary tarsorrhaphy using mattress sutures.4Our first patient was encountered after twelve years of ophthalmology practice in Osun State, Nigeria and has already been reportedThe aim of the current case series is to highlight effectiveness of a noninvasive treatment approach instead of the invasive method which is still widely practiced in some parts of developing countries. We also discuss the socio-psychologic aspects of the disease, its etiopathogenesis and treatment options.A 3 day-old male neonate was brought to medical attention by his parents who complained of inability to see his eyes since birth, mucopurulent discharge and excessive tearing . The babThe baby was slightly febrile  and without jaundice. Ocular examination revealed a purulent discharge, moderate conjunctival injection and massive chemosis in both eyes . Both upA diagnosis of bilateral congenital lid eversion with possible neonatal sepsis was made. Pediatricians were consulted and the patient was treated as a case of neonatal sepsis with intravenous cefuroxime. The eyes were treated with tobramycin ointment, padding with 5% hypertonic saline-soaked gauze dressing and frequent application of methylcellulose gel. By the eighth day of admission, the chemosis resolved , the eyeA 4 day-old boy  presenteThere was no history of fever or convulsions and pediatric assessment revealed no abnormalities. The left upper lid was everted with gross conjunctival injection and chemosis, but there was no discharge. Mild upper lid eversion, and mild conjunctival injection and chemosis of the right eye were also present. Both globes were otherwise normal.The left eye was treated with tobramycin ointment, methylcellulose gel and padding with gauze dressings soaked in 5% hypertonic saline. The right eye was treated with only tobramycin ointment. The left upper lid needed to be repositioned twice. Complete resolution was achieved by the tenth day of admission . DilatedA 4 hour-old male neonate was referred from a private hospital immediately after birth to the emergency room of our eye clinic with fleshy protrusion of the lids and inability to open both eyes since birth . PregnanPediatric assessment revealed no abnormality. Ocular examination revealed bilateral everted upper lids, exposed and chemotic conjunctiva covering the eyeballs and tense lids, but normal cornea and anterior chamber depths in both eyes.The parents refused admission on financial and social grounds; he was therefore treated on an outpatient basis. Treatment consisted of daily eye cleansing, application of gauze dressings soaked with 5% hypertonic saline over the chemotic conjunctiva, chloramphenicol ointment, and padding. During follow up, he developed a mild serous discharge and ciprofloxacin eye drops were commenced every two hours. Ten days later, the baby achieved complete eye opening in both eyes . DilatedCongenital eyelid eversion is reported to be very rare; nonetheless we were confronted with 3 cases within a period of 3 years. This may confirm the reportedly higher incidence of this entity in Africans.Several factors have been implicated in its pathophysiology including orbicularis oculi hypotonia, birth trauma, vertical shortening of the anterior lamella or vertical elongation of the posterior lamella of the eyelid with failure of the orbital septum to fuse with the levator aponeurosis, absence of an effective lateral canthal ligament and lateral elongation of the eyelid.10Venous stasis during delivery may also cause marked chemosis and prolapse of the conjunctiva, leading to eversion of the eyelids.In this report, only one patient had manifestations of neonatal sepsis. In the remaining two subjects, no condition was detected which could be attributed to the problem, as similarly reported in cases by previous authors.It has been suggested that a careful history should be taken stressing on information on pregnancy and labor, and signs or symptoms of vaginal infections in the mother. A pediatrician’s assessment of the child is very important, firstly to ascertain patient health, and to rule out associated congenital anomalies or other conditions such as Down syndromeThe role of grand multiparity and post maturity on the occurrence of this condition has been questioned by earlier work in NigeriaDaily eye cleansing was performed to keep the external eye clean of any discharge, which is thought to originate from edematous lid tissues.The mechanism by which the 5% hypertonic saline-soaked gauze dressing worked could be explained as follows: the hypertonicity allowed movement of fluid from edematous tissues through the semipermeable conjunctival membrane by the process of osmosis;The socio-psychological aspects of this condition can be serious. In Nigeria, the patient’s face is usually completely wrapped up at presentation, and naming ceremonies are usually postponed until there is significant resolution and satisfactory eye opening. By doing so, the mother protects herself from disgrace, shame and embarrassing comments.In summary, congenital eyelid eversion can be treated conservatively. The goal of management is to prevent dessication of the exposed conjunctiva, reduction of conjunctival edema and spontaneous reversion of the lid. The patients described in this report were managed by topical lubrication, antibiotics and application of 5% hypertonic saline to the chemotic conjunctiva. We have illustrated the need for early successful repositioning of the eyelid by a conservative method rather than an invasive approach to break a cycle leading to increasing lid edema, conjunctival chemosis and eversion. A normal anatomical outcome with good cosmetic results can be effectively achieved using topical lubrication, antibiotics and application of 5% hypertonic saline. This method is highly recommended because it is inexpensive and non-invasive. It is important that all health care workers be aware of this condition so that prompt referral for expert management can be offered. Reassuring the parents should be considered of importance in the management of this condition.


In 1809, Johann Friedrich Meckel described the embryology of a small bowel diverticulum, which now bears his name. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, with a prevalence ranging from 1% to 4% of the population. The majority are clinically silent and are incidentally identified at surgery or at autopsy. The lifetime risk of complications is estimated at 4%, with most of these complications occurring in adults. It is these cases that can cause problems for the clinician, as the diagnosis can be elusive and the consequences extremely serious.We present the case of a 68-year-old Caucasian man with axial torsion of a Meckel's diverticulum around its base, a rare complication. He presented with acute, severe abdominal pain, and a clinical diagnosis of perforated acute appendicitis was made. Laparotomy revealed a torted Meckel's diverticulum with distal necrosis and perforation, which was resected. His recovery was uncomplicated, and he was discharged to home six days post-operatively.Torsion is an extremely rare complication of Meckel's diverticulum. Its presentation can be elusive, and it can mimic a number of different, more common intra-abdominal pathologies. Imaging appears to be an unreliable diagnostic tool, and the diagnosis is usually made intra-operatively. Factors pre-disposing these patients to axial torsion of Meckel's diverticulum include the presence of mesodiverticular bands, a narrow base, excessive length, and associated neoplastic growth or inflammation of the diverticulum. The importance of searching for a diseased Meckel's diverticulum at laparotomy in appropriate circumstances is highlighted. Once identified, prompt surgical excision generally leads to an uncomplicated recovery. Johann Friedrich Meckel first described the embryological origin of congenital diverticulum of the mid-gut in 1809 . It is tMD is invariably found on the anti-mesenteric border of the ileum, with 90% located within 90 cm of the ileocecal valve . Its sizMD is more often diagnosed in men, as they are more prone to complications . The mos3/μl, and a high C-reactive protein level at 208 mg/L. The patient had normal renal function and a normal hemoglobin level. An abdominal radiograph revealed dilated small bowel loops, and a clinical diagnosis of perforated acute appendicitis was made. No other pre-operative investigations were carried out, and following fluid resuscitation, a laparoscopy was performed.A 68-year-old Caucasian man presented to our hospital with acute, severe abdominal pain. An examination of the patient revealed that he was septic and had a distended abdomen with rebound tenderness in the hypogastrium and the right iliac fossa. His rectal examination was unremarkable. His blood test revealed a raised white cell count, 15.4 × 10Laparoscopy revealed purulent fluid within the pelvis. The appendix could not be visualized, but the peri-appendicular region appeared normal. The laparoscopy was converted to a laparotomy. Surgical exploration revealed a torted MD with distal necrosis and perforation. The necrosed tip of the diverticulum was adherent to the adjacent mesentery Figure . The appThis case report presents the unusual case of torsion of MD. By reviewing the previous literature, we aim to identify the possible etiology, main clinical features, appropriate investigations, and operative management associated with this variant.The etiology of axial torsion of MD remains unclear. On the basis of the available literature, we have identified several risk factors. Although primary neoplasms arising within MD is rare, representing less than 1% of cases , they maPain is always a presenting feature of a torted MD but is more frequently localized to the right lower quadrant . Pain duBecause of its various forms of presentation and unreliable imaging, torsion of MD is frequently misdiagnosed. Special investigations appear to have little value in the diagnosis of acute MD complications. Abdominal radiographs are usually normal but may reveal an ileus or perforation . Less coAppendicitis is the main pre-operative diagnosis, while other diagnoses include small bowel obstruction, acute cholecystitis, and liver abscess ,18,20. MThe management of symptomatic MD is surgical resection. A wedge resection of the MD is generally carried out, and occasionally some ileum is resected by end-to-end anastomosis . DivertiIn summary, this case report describes a patient with torsion of MD. Imaging appears to be unreliable in the detection of torted MD, and the diagnosis is usually made intra-operatively. Major risk factors for torsion appear to include an increased size of the MD with a narrow base, potentially compromising blood supply and leading to gangrene, the presence of a fibrous mesodiverticular band, and the rare presence of neoplasm. The importance of suspecting MD pathology in the differential diagnosis and its confirmation at laparotomy has been highlighted. Once identified, prompt surgical excision generally leads to an uncomplicated recovery.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.JS was the surgical senior house officer who diagnosed the case. AS performed the literature search. Both authors were involved in the writing of the report.