Desmoid tumors are characterized by indolent growth, progressive invasion of surrounding tissues and a high rate of relapse. We present the case of a desmoid tumor rising from the trapezius of a young woman. Following resection, we performed a functional reconstruction using an innervated gracilis free flap. A desmoid tumor (DT), also known as desmoid-type fibromatosis, is a rare benign neoplasm characterized by monoclonal growth of fibroblasts with the progressive invasion of soft tissues, a high rate of recurrence following treatment and the inability to metastasize. It can occur in any part of the body, with those arising in the limbs and trunk portending the poorest prognosis .Active surveillance is now considered by most authors the best way to deal with asymptomatic disease . On the A 34 years old woman was admitted to our institute for a soft palpable mass localized in her left trapezius. She complained about localized discomfort and pain that interfered with her daily activities. In order to better characterize the nature of the mass and its anatomical boundaries, an MRI  was perfWe discussed with the patient the possibility of a watchful follow-up before considering surgery. She opted for surgery in the first place, which we considered a reasonable choice in consideration of the symptoms she complained about.Under general anesthesia, we performed an en-bloc resection of the mass with macroscopic margins of resection of about 1 cm. The mass was located in the upper third of the trapezius at the base of the neck, thus resection would involve the neuromuscular hilum leading to paralysis of the muscle, a condition seen after neck dissections with the sacrifice of the spinal accessory nerve . FunctioThe upper third of the trapezius was resected en-bloc with the overlying skin including the scar from the previous biopsy. The spinal accessory nerve was prepared as close to the muscle hilum as possible and so were the transverse cervical vessels. The right transverse musculocutaneous gracilis free flap was transferred to the defect. The vascular anastomosis was performed end to end between the transverse cervical artery and vein and the gracilis pedicle. Neurorraphy was performed end to end between the spinal accessory nerve and the obturator nerve. The flap survived completely and the post-operative period was uneventful.Three months following surgery the gracilis muscle recovered its contractility, as demonstrated by the follow-up EMG. After rehabilitation, the patient regained full range of motion and was able to go back to her daily routine, including swimming, her favourite hobby, without any restriction six months postoperatively. Pain and discomfort disappeared completely.Supplementary Videos 1–3).After 9 months, to improve the cosmetic result and obtain a more attractive contour of the neck area, a skin expander was implanted in the subcutaneous region adjacent to the flap and progressively inflated until enough skin was gained in order to replace the flap island and reduce dimensions of the scar. Three months later the flap’s skin was resected and the resulting defect was covered with the expanded skin. The final aesthetic result was satisfying, consisting of just one linear eutrophic scar of about 7 cm. After a 7-year follow-up based on MRI and clinical evaluations, no signs of recurrence were observed . A 10 yeThe desmoid tumor usually presents as an indolent, asymptomatic, growing mass. Diagnostic workup usually begins with imaging, with MRI being the mainstay. The suspicion of DT is then confirmed by core biopsy and is based on the detection of nuclear accumulation of b-catenin protein caused by activating mutations in the b-catenin gene .Given the wide spectrum of clinical presentations and variable progression of the disease, treatment should be tailored to each patient; options encompass surgery, radiotherapy, medical therapy and isolated limb perfusion, the latter being reserved for DT of the extremities.In recent series, up to 50% of asymptomatic patients had no progression of disease at 5 years and in 20–30% of the regression of disease was observed . Hence, Selection of the best treatment option should be based on tumor location, dimensions, age and functional necessities of the patient. Surgery is still considered the first-line approach for intraabdominal DT ,6 while Since the morbidity of upper trapezius palsy following neck dissection with spinal accessory nerve sacrifice is well known, we sought a functional restoration of the upper trapezius by means of an innervated gracilis free flap ,14. AdeqThe innervated gracilis free flap represents a great choice for functional reconstruction of small and medium defects of trapezius muscle following tumor resection. The availability of muscular innervated tissue with minimal donor site morbidity, allows the surgeon to perform radical resection with greater disease-free margins and better control of disease without concern about reconstruction options. However, the rarity of the disease and the related prognosis requires more evidence to outline a defined therapeutic and reconstructive algorithm.Click here for additional data file.


Pancreaticoduodenectomy represents a major surgery for tumors located at the pancreatic head and the ampullary/periampullary region. This complex procedure is associated with a high morbidity rate. Many surgical techniques have been proposed in order to reduce mortality rates, although post-procedure complications represent a current problem. Different imaging findings and complications may appear depending on the surgical technique used. Hence, radiologists should be familiarized with them to distinguish normal findings from real complications. The most challenging scenarios are represented by abdominal fluid collections, and tumor recurrence, that may frequently mimic normal postsurgical changes. MDCT represents the first-line imaging modality after pancreaticoduodenectomy.Most challenging complication diagnoses are pancreatic fistula and tumor recurrency.Additional angiographic-CT phase is recommended when vascular complications are suspected.MRI with gadoxetic-acid is recommended to detect hepaticojejunostomy stenosis and biliary fistula.DWI helps differentiate local recurrence form postsurgical changes when CT is inconclusive.Pancreaticoduodenectomy is a major surgery for tumors located at the pancreatic head and the ampullary/periampullary region, and represents the only curative procedure available to date for this group of diseases. This complex procedure has been associated with a high morbidity rate . Due to The aim of this article is to review the main pancreatic, gastric and bilioenteric reconstruction techniques used after a pancreaticoduodenectomy, illustrating the normal imaging findings and their complications.Pancreaticoduodenectomy consists of two phases: the resection phase that involves the resection of pancreatic head, duodenum, gallbladder, distal bile duct and proximal jejunum, with or without pylorus preservation, followed by the reconstruction phase with the creation of three anastomosis: pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy (Whipple procedure) or duodenojejunostomy  Fig. 1)1).Fig. 1Computed tomography (CT) represents the main imaging modality in postsurgical assessment of pancreaticoduodenectomy due to its capability to explore the whole abdominal cavity with a high spatial resolution and short acquisition time. For routine post-surgical follow-up, we suggest a non-contrast phase to depict high density findings  and a portal venous phase (60–70 s delay) including the pelvis for a global assessment. Positive oral contrast agent is routinely used for postsurgical intestinal anatomy distinction, specially the efferent limb and gastroenteroanastomosis. Protocol should be based on clinical findings during a complicated postoperative period, with an abdomino-pelvic non-contrast phase for hemorrhagic fluid detection and an additional CT-angiographic phase if vascular complication is suspected. In cases of abdominal collection, a late phase after three minutes may improve its distinction. The use of neutral oral agents, such as water, is not recommended as bowel loops may mimic a collection.In order to improve imaging surveillance quality, magnetic resonance imaging (MRI) should be considered an additional method to CT for several reasons. Firstly, it is well known that MR provides a higher pancreatic and hepaticojejunostomy evaluation, especially when MR cholangiopancreatography (MRCP) or hepatobiliary contrast agents are used . SecondlPancreatic–enteric anastomosis represents the most challenging anastomosis during the surgical procedure and leads to most post-procedure complications . There aDifferent metaanalyses show there is no significant difference between PJ and PG anastomosis in terms of pancreatic fistula, mortality or morbidity , 7. AlthHepaticojejunostomy is usually located 20–30 cm distal to PJ. It may be difficult to find due to jejunal limb collapse. Pneumobilia is a normal postoperative finding that helps to identify it, as well as using the hepatic hilum as a landmark . When positive oral contrast agent is used, sometimes reflux to the afferent limb may occur, so it can fill the anastomosis and helps to recognize it. The use of coronal plane reconstructions is recommended for a better visualization. MRCP and MRI with gadoxetic acid are the most useful methods to assess permeability Fig. .Fig. 4HeGastrojejunostomy allows reconstitution of the digestive tract. Depending on the primary pathology and the surgeon's choice, it can be performed with resection of the gastric antrum (classic Whipple procedure) or with pylorus preservation (pylorus preservation procedure). This anastomosis is usually located in the left upper quadrant. The use of a positive oral contrast agent is essential to digestive tract reconstruction assessment, allowing delineation of marked change in mucosal pattern in gastroenteric anastomosis and pylorus identification, when preserved Fig. .Fig. 5GaChild type reconstruction. Another popular intestinal reconstruction technique is the Roux-en-Y type, in which a jejunal loop is constructed in order to make the pancreaticojejunal and biliodigestive anastomosis. This jejunal loop is called afferent or biliodigestive limb. In our institution, a Roux variant known as Machado type is used, which allows to reduce morbidity and mortality in case of pancreatic or biliary fistula, preserving each anastomosis separately. Intestinal reconstruction techniques are exposed in Fig. Classic procedure includes intestinal reconstruction by an unique jejunal loop where the three anastomoses are performed. This technique is known as In this section, normal postoperative findings of each anastomosis or intestinal reconstruction technique, as well as their complications will be discussed Table .Table 1NDuring the early perioperative period, imaging may show temporary findings related to surgery that should not be misunderstood as tumor recurrence or abnormal inflammatory processes. These findings include fluid, edema and peripancreatic fat stranding, pneumoperitoneum, pneumobilia and pneumowirsung, mild pancreatic duct and/or intrahepatic biliary dilatation, lymph nodes and perivascular cuffing Fig. .Fig. 7NNormal postoperative findings may mimic tumor recurrence. Lymphadenopathy, collapsed loop, perivascular cuffing and pancreatic and/or intrahepatic ducts dilatation represent the major challenges.Lymphadenopathy represents one of the most frequent postoperative findings. Adenopathies are expected to regress within the first six months after surgery, but can sometimes persist for longer periods .Although morphological characteristics such as short axis less than 1cm and oval shape can help identify reactive lymph nodes in the early period, the new-formed or growing nodes should raise suspicion for malignancy  Fig. 8)8).Fig. 8mass-like appearance makes it difficult to rule out recurrence , because it is the main site of complications. The most frequent one is pancreatic fistula (PF), with a global incidence of 4 to 30%. It is associated with increased length of hospital stay and mortality [PF is a clinical diagnosis characterized by the presence of amylase concentration three times higher in fluid collection than in serum, and/or persistence of it 7–10 days after surgery. At CT, it appears as a fluid collection near the PJ Fig. .Fig. 15PWhen a fluid collection is seen near the PJ, it is important to identify whether it is an infected collection. PF usually is expected to resolve by itself, while an abdominal abscess requires drainage. CT features that suggest abscess include heterogeneity within the collection with or without air content, and the presence of an enhancing wall Fig. . NeverthIn order to reduce the risk of PF, a stent in the anastomosis may be placed, depending on the surgeon's criteria. Stent migration is a usual finding, with no pathological significance.Another complication to be aware of is anastomosis stenosis. PJ diameter may be reduced, either due to fibrosis or tumor recurrence. Stenosis predisposes to recurrent pancreatitis episodes, which lead to PJ assessment in order to achieve the etiology Fig. .Fig. 18PBiliary fistula (BF) is a rare complication of hepaticojejunostomy, occurring in 3–4% of all procedures. The presence of a fluid collection adjacent to the anastomosis is a finding suggestive of BF in CT imaging  Fig. 1919.Fig. 1As BF and PF depict similar imaging findings, and the proximity of the anastomosis (PJ and HJ) may not confirm the leak origin, biochemical analysis of fluid is essential for correct diagnosis: high bilirubin levels in fluid confirm BF  Fig. 2020.Fig. 2Stricture is another complication, commonly in late controls. Clinical presentation includes jaundice and cholangitis, in case it is not detected early . As expeThe use of MRI with hepatobiliary-specific contrast agent (gadoxetic-acid) represents a safe and noninvasive option to detect postoperative biliary complications, such as hepaticojejunostomy stenosis and biliary fistula. Biliary excretion of contrast agent on hepatobiliary late phase (20 min) allows demonstration of anastomosis patency by identifying afferent loop filling or contrast leak into a neighboring fluid collection, allowing diagnosis of a biloma Fig. . SometimAs both gastrojejunostomy and intestinal reconstruction are intended to allow return of digestive tract transit after surgery, they are mentioned together.Regarding gastrojejunostomy, delayed gastric emptying (DGE) represents a major complication after pancreaticoduodenectomy. Although it is a clinically diagnosed complication, imaging may suggest the diagnosis and dismiss others Fig. . The pylAnother clinical scenario may be present when afferent limb is partially or completely obstructed, developing afferent limb syndrome. This syndrome is characterized by mechanical obstruction of afferent limb, may be acute or chronic depending on grade of obstruction. Abdominal pain, nausea, vomiting, bacterial overgrowth, diarrhea, malabsorption and undernutrition are its usual clinical presentation resulting in pancreatobiliary disturb Fig. . It is aHemorrhagic complications are infrequent (2–15%), with a high mortality rate . They usDirect vascular injury either from iatrogenic trauma or vascular erosion due to anastomosis dehiscence may develop pseudoaneurysm, which represents a challenging diagnosis with a high potential mortality rate if untreated Fig. .Fig. 27RVascular injury also may determine decreasing blood flow to certain organs with infarct development Fig. .Fig. 28HThe pancreaticoduodenectomy procedure is associated with several postsurgical complications, knowledge of which is essential. Radiologists should be able to depict the principal anatomy landmarks and normal post-procedure findings, as well as imaging findings of each possible complication in order to achieve the correct diagnosis.


Chylous mesenteric cysts represent a subgroup of uncommon, mostly benign intra-abdominal masses often identified incidentally on radiographs. Diagnosis is often challenging because these lesions cannot be reliably distinguished from hematomas or other cystic lesions without direct tissue sampling. In addition, data remains scarce regarding nonsurgical diagnostic and therapeutic options for these cysts. This case describes an endoscopic option for a uniquely located chylous cyst. Mesenteric cysts are a rare GI condition of unclear etiology thought to affect those of all ages . These cA 56-year-old man with end-stage renal disease on dialysis presented for evaluation of a retroperitoneal mass incidentally found on a CT scan. He was referred by his surgeon during the process of renal transplant evaluation. He reported feeling well at the time and denied a history of abdominal pain, distention, back pain, nausea, vomiting, anorexia, or change in weight. The mass was described as a 4.9-cm round lesion with central heterogeneous fat density abutting the distal fourth portion of the duodenum and extending inferiorly just left of the midline near the root of the mesentery Figure . He subsEndoscopic ultrasound (EUS)-guided biopsy/fine needle aspiration (FNA) of the lesion was performed after that. EUS revealed a 4.8 x 4.7 cm round cystic mass adjacent to the distal duodenum Figure . The masThe fluid analysis revealed amylase 128 U/L, carcinoembryonic antigen (CEA) 4.9 ng/mL, triglycerides 41 mg/dL, and a positive qualitative chylomicron screen. Gram stain and culture analysis of the fluid were unremarkable. Pathology revealed fat necrosis and stromal fragments with chronic inflammation. No malignant cells were seen. A repeat CT scan three months later revealed trivial residual cyst fluid.Mesenteric cysts are lesions that develop anywhere in the GI tract mesentery from the duodenum to the rectum, with the majority located in the small bowel mesentery . This raSurgical enucleation, partial excision, drainage, and deroofing have been deemed the ideal therapeutic options up to now ,8. HowevThis case provides renewed data on the endoscopic evaluation of mesenteric cysts located adjacent to the duodenum. To the best of our knowledge, only one other case of EUS-guided diagnosis of a chylous cyst at this particular site has been reported. However, as this intervention is infrequent and not guideline-driven, the durability of EUS drainage and the utility of surveillance cross-sectional imaging are uncertain. Moreover, given the theoretical risk of cyst enlargement, rupture, torsion, and malignancy, it is unknown whether endoscopic drainage offers the same protection against future complications as surgical resection. For example, if the cyst wall is unable to be drained entirely, there may be a reasonable concern that cystic fluid reaccumulation will ensue. Thus, the involvement of an experienced surgeon is advantageous to comprehensive care as surgery may be merited despite endoscopy.


Idiopathic pneumoperitoneum has an unknown etiology despite exploratory laparotomy. However, it may occur without definite abdominal symptoms; thus, adequate management could be in clinical dilemma. We experienced three cases of idiopathic nonsurgical pneumoperitoneum in healthy individuals during a health check-up. Their cases were not accompanied by any relevant etiology or definite abdominal symptoms. All of the three cases exhibited a benign clinical course. The three patients underwent an abdominal computed tomography (CT) scan as part of a health check-up program, which incidentally revealed free air in the right paracolic gutter without evidence of visceral perforation or inflammation. Among the three cases, two patients underwent colonoscopy before abdominal CT, whereas one patient did not. Two cases were completely asymptomatic and were observed without any treatment in the outpatient clinic. Only the third case with minimal symptoms was treated conservatively for a short time. If a small amount of free air typically located in the right paracolic gutter is detected in the absence of perforation during colonoscopy, close observation without unnecessary treatment would be sufficient. Due to increased health concerns and access to medical imaging, computed tomography (CT) scans are occasionally performed after colonoscopy. On postcolonoscopy CT scans, pneumoperitoneum may occur despite the absence of perforation during the procedure. However, pneumoperitoneum does not always correspond to a perforated viscus that requires surgical intervention. Spontaneous or nonsurgical pneumoperitoneum (NSP) may occur due to a variety of intrathoracic, intra-abdominal, gynecologic, and other miscellaneous etiologies . In partA 42-year-old man underwent screening esophagogastroduodenoscopy (EGD) and colonoscopy, which revealed superficial gastritis and normal colonoscopic findings . Room aiA 68-year-old woman underwent screening EGD that revealed atrophic gastritis and had a biopsy at the midbody of stomach. Colonoscopy was not performed. After that, abdominal CT was performed as part of a health check-up program. She had a history of total abdominal hysterectomy decades ago and had no lung disease. We contacted the patient on the third day of the exam since free air was recognized on her CT scan . No immeA 66-year-old woman without any medical history underwent screening EGD and colonoscopy , which rPneumoperitoneum usually indicates a perforated viscus, which requires urgent surgical intervention, but the proportion of visceral perforation as the cause of pneumoperitoneum has substantially been reduced . TherefoPneumatosis cystoides intestinalis (PCI) is a frequent cause of NSP . In addiIn the present cases, we could not identify any clear etiology of pneumoperitoneum radiologically and endoscopically. None of the cases had a history of recent surgery or lung disease or evidence of a perforated viscus, PCI, nor peritonitis. Hence, the present cases were termed as idiopathic NSP.Previously reported cases of benign pneumoperitoneum after colonoscopy differed from the present ones. In the previous cases, the patients had an underlying condition or definite abdominal symptoms that prompted examination via exploratory laparotomy , 9. In tWe present three cases of idiopathic NSP with a benign clinical course. In all three cases, CT scans were performed as part of a personalized health check-up program and not to evaluate symptoms after endoscopy. Therefore, this phenomenon is considered as a coincidence rather than a consequence of endoscopy. Once experienced, these conditions would not be difficult to determine. Otherwise, clinical judgement would not be easy. In particular, if a small amount of free air typically located in the right paracolic gutter is detected in the absence of overt perforation during colonoscopy, close observation would be sufficient without unnecessary treatment or bowel rest.


Case Presentation. In this report, we outline a patient who had a paraurethral tumor with histopathology showing a circumscribed hypocellular lesion with myxoid stroma and abundant vasculature, consistent with the diagnosis of aggressive angiomyxoma. The mass was excised with resolution of symptoms and the patient was advised to continue close follow-up with her gynecologist and endocrinologist to monitor for recurrence.  Aggressive angiomyxomas (AAs) are rare mesenchymal tumors that are histologically composed of myxoid stroma and vasculature. AAs are typically located in the pelvis and perineum and occur more frequently in females of reproductive age.  Due to its rarity, aggressive angiomyxomas are often misdiagnosed as cysts, hernias, lipomas, or cancerous lesions. Although benign, close follow-ups are crucial to monitor for recurrences or metastasis. Aggressive angiomyxoma (AA) is a mesenchymal tumor that is histologically evident by its appearance of myxoid stroma with abundant vasculature . The chaAlthough surgical excision of the tumor is the definitive treatment for AA, complications such as urinary incontinence and sexual dysfunction may occur due to the gynecological procedure . Injury CG is a 31-year-old G1P1 premenopausal female with a past medical history significant for fibroids, who presented to the office for evaluation of a possible pelvic mass that had been present for eight months. She complained of vaginal itching and pelvic pressure with discomfort; however, she denied having vaginal discharge, pain, urinary urgency, urinary frequency, or vaginal odor. MRI performed on 11/15/21 reported a mass that was difficult to localize, possibly along the posterior vaginal wall.Upon closer examination, the mass was noted to adhere to the anterior vaginal wall. All possibilities of urethral involvement were excluded before an attempt was made to drain the mass, which yielded 1 mL of thick gelatinous fluid. The fluid was sent for culture, which resulted in no bacterial growth. Excision in the operating room and marsupialization of the cyst was planned for a later date. Unfortunately, the patient was seen in the emergency department four days later due to worsening pain from the vaginal mass and dysuria. The patient also noted copious brown and purulent discharge with no foul odor over the past day. On physical examination, the patient had a swollen and tender spherical lesion adhered to the left anterior vaginal wall . She wasHerein, we have discussed a case report of paraurethral aggressive angiomyxoma in a premenopausal woman. Angiomyxomas are typically slow-growing, asymptomatic vulvar masses that are sometimes unnoticed in patients for years . There aAAs tend to be misdiagnosed as cysts, hernias, lipomas, or cancerous lesions due to their rarity and cystic mass-like appearance. AAs are most often benign; however, there have been 3 cases reported to date involving evidence of metastasis –6. SurgeDespite possible complications, complete surgical excision with tumor-free margins is the preferred treatment. In cases where surgery is contraindicated, hormonal treatments may be used to slow the rate of growth of the AA . Most AAAggressive angiomyxoma is a rare neoplasm that is often misdiagnosed due to its cystic-like appearance. AAs should be considered as a differential diagnosis when a patient presents with a mass, particularly in the pelvis or perineum. Close observation is crucial to monitor for any recurrences or metastasis.


Myopericytoma is a rare vessel wall tumor, a subtype of hemangiopericytoma that usually develops subcutaneously. Intravascular myopericytoma is a rarer subtype, with only few cases reported in the literature and even fewer with imaging modalities included. We report the case of a 36-year-old man who was referred to our institution with a painless, palpable mass in the right arm and was evaluated with MRI, grey-scale and Doppler-mode ultrasound. Tumor histopathology and imaging characteristics are presented together with the role that each imaging modality played in the management of the patient. Myopericytoma is an uncommon, benign tumor, the most common subtype of hemangiopericytomas . Due to Intravascular myopericytoma (IVMP) is a rare subtype of myopericytoma, that was recognized as a distinct entity by the World Health Organization only in 2002 . There wTherefore, we aim to present an extremely rare location of intravascular myopericitoma, contained within the arterial wall (IVMP) and not the blood vessel lumen as the majority of previously published cases; furthermore, we provide a review of the imaging characteristics all reported IVMP, imaging characteristics of myopericytoma and, last, we discuss and suggest an algorithm for the imaging evaluation of IVMP patients.We report the case of a 36-year-old man who was referred to our institution with a painless, palpable mass in the right arm, close to the right cubital fossa, which had been slowly growing for the past 5 years. The mass was mobile, soft, pulsating and non-tender to touch. No overlying skin or soft tissue changes were noted and the ulnar and radial artery pulses were present.MRI highlighted the vascular origin of the mass, arising from the arterial wall, located above the brachial artery bifurcation, anteriorly to the right medial epicondyle. It was well delineated with circumscribed borders and had T2 hyperintense signal intensity (SI), T1 hypointense SI A and aviUS showed a solid mass surrounding the brachial artery, located in the arterial wall, with a clear delimitation between the internal and external wall of the artery . The masSurgical resection  with a tThe pathology report showed a macroscopic well-defined mass with microscopic features of a vascular nodular proliferation. The mass developed within the arterial wall and had a small extension into the adipose tissue. The tumor was composed of medium-caliber vessels surrounded by myoid cells, well-represented smooth muscular component and hyaline nodules with elongated cells. Immunohistochemistry highlighted a very weak mitosis index of 5–6 per 50 HPF, Ki 67% proliferative index of 5%, positive alpha actin and desmin and negative S100; cytokeratin AE1/3 was inconclusive and CD31 and CD34 were positive at the endothelial level . The finThe patient had not undergone any adjuvant treatment and the follow-up US imaging at 5 years was clear of tumor relapse. We presented a rare case of myopericytoma located within the brachial artery wall, discuss histopathology characteristics and highlight the role of different imaging modalities  in the diagnostic and characterization of this peculiar tumors.Myopericytoma is a vascular tumor originating from myopericytes, with benign behavior in most of the cases. It originates in the cells named “myopericytes” that were relatively recently described (in 1992) as transitional cells between pericytes and smooth muscle cells of blood vessels. They are specialized contractile cells surrounding the endothelial cell layer of small vessels, reason why myopericytoma develops encasing the artery’s lumen.The term “myopericytoma” or “perivascular myoma” was used for the first time in 1998, by Granter et al. to describe classical myopericytoma. In 2002, the World Health Organization (WHO) recognized this tumor as a distinct entity .It may occur in various age groups, reported as ranging from 10 to 87 years; however, most are seen in adults with a median age of 49 years . The mosIntravascular myopericitoma (IVMP) is an extremely rare subtype of myopericitoma, where the tumor is contained within a blood vessel wall, with or without invasion into surrounding structures.We performed PubMed database research using MESH terms as “blood vessel tumor”, “myopericitoma” and also non-MESH terms as “intravascular myopericitoma”, “IVMP” as key words, with 15 papers reported in the English literature, and 10 actually including IVMP characteristics ,17,18,19The first case of IVMP was reported in 2002, by McMenamin et al. as a “long-standing myopericytoma that was entirely located within the lumen of a subcutaneous vein” . Few casOverall, the authors reported solid lump masses of the arms and legs, mouth and orbital area. Patients were symptomatic and followed surgery with histopathology diagnosis. Compared to general myopericitoma which may or may not be painful, all patients with IVMP complained of long-lasting pain. McMenamin et al., suggested the associated intravascular thrombus to be the cause for the pain in these patients .Furthermore, two authors reported US and two MRI features of IVMP. No author reported computed tomography characteristics of the IVMP.Regarding the IVMP characteristics, at US, all masses were well-defined, solid, with internal Color Doppler signal corresponding to internal vascularity. Tumor vascularity was also depicted on MRI, as homogeneous enhancement after contrast administration.An accurate location of the IVMP was reported in cases investigated by US, which was able to highlight the tumor mass within the blood vessel wall. In cases with MRI examination, Mahapatra et al. and Xia et al. concluded that MRI was unable to identify the intravascular origin of the tumor in both cases. In our case, the MRI provided relevant information regarding the exact location of the tumor, within the arterial wall, and helped excluding a potential malignant lesion (homogeneous mass with no invasion into surrounding structures). First possible explanation could be the improvements on MRI sequences (higher resolution and contrast) as the previously reported cases were almost 20 years old; second, the tumor size, as one MRI case failed to located the millimetric tumor within a digital artery of the finger. Thereby, we support the role of MRI could have in characterizing this peculiar tumor masses To the best of our knowledge, there is no available review of the imaging modalities used in the diagnostic diagnose and characterization of myopericytoma, a brief review being available only on breast myopericytoma due to its possible misdiagnosis with breast cancer . AuthorsThe majority of imaging characteristics of the myopericytoma reported in the literature, are represented by case reports. The most frequently affected areas include superficial soft tissue of the distal extremities, followed by head and neck, urinary tract and female genital tract. In most of the cases, authors have focused on clinical, histology and immunohistochemistry findings, and less was reported about imaging characteristics or the role of imaging in their diagnostic.Thus, we expanded our search to include all relevant papers which reported imaging modalities of myopericitoma ,27,28,29On US, all the masses had well-defined margins, hypoechoic echogenicity and homogeneous ecostructure, with internal vascularity exhibited on Doppler modalities.CT showed homogeneous masses on both native and postcontrast sequences, and was helpful in delineating the tumor’s margin and invasion into surrounding structures. Some authors reported myopericytoma as multiple solid masses, with circumscribed margins, within the breast and parotid gland and parapharyngeal spaces ,22.The MRI angiography protocol varies between different vendors, but generally includes post-contrast sequences acquired with thin slices (1–2 mm), which allows multiplanar reformations (MPR) in different planes ,31. NearAs regards to tumor features, MRI was in concordance with US and CT, showing soft-tissue masses, well-defined on both T1 and T2-weighted sequences. The majority of the masses appeared hypointense on T1-weighted and hyperintense on T2-weighted sequences. Enhancement was reported without any further clarifications in terms of the time-intensity curves or homogeneity.The FDG-PET/CT may be used in cases of malignant myopericytoma, for the detection of distant metastatic disease. One author reported a myopericytic lesion of the ear, that was moderately positive for GLUT-1 and identified as being hypermetabolic with intensely increased FDG uptake.Furthermore, we suggest a stratified diagnostic algorithm, based on the available literature, with US as the first line imaging modality, followed by CT and MRI as second-line imaging tools, and least, FDG-PET/CT for selected cases with proved malignancy. .For our patient, US was the second-line imaging modality used to depict and characterize the mass. It helped not only to highlight the mass origin, but also to assess the vessel permeability. The nutritive arterial tumor vessel was well-depicted by the Doppler mode, which suggested an underling tumor process over an arteritis and had an important role in planning the surgery procedure.Further, we opted for MRI because it provides better soft tissue contrast than CT, accurate relations with surrounding structures and may also indicate towards a low- or high-grade tumor. Myopericytoma is a well-defined, circumscribed mass, non-invading into surrounding structures, with avid and homogeneous contrast enhancement. Generally, a spiculated, infiltrating mass with heterogeneous with non-enhanced necrosis areas, are more suggestive of high-grade tumors.Regarding the histopathology, literature showed the possibility that these lesions may be malignant, and highlighted the role immunohistochemistry has in diagnosis these tumors. Some authors suggest that myopericytoma is a unifying term for a spectrum of tumors that show overlapping features with myofibromas. The main differentials should include myofibromatosis, archetypal myofibroma, glomangiopericytoma and myofibroma. However, the most important differentiation to make is against sarcoma, malignant and very aggressive tumor. The authors highlight the importance of the growth pattern in making the final histopathology diagnosis.Furthermore, myopericitoma is positive for muscle-specific actin, SMA, h-caldesmon, and focally for desmin, but is negative for S-100 protein, CD31 antibody, CD34 antibody, factor VIII, human melanoma black 45, and cytokeratin AE1–AE3.Unlike myopericytoma, authors reported IVMP to be negative for desmin . HoweverBiopsy is not indicated in well-defined, benign IVMP, as bleeding can be a common complication. For selected cases with ill-defined borders, where malignancy is suspected, biopsy should be discussed with a multidisciplinary team so that, if performed, the following surgery will include the biopsy trajectory.The treatment of IVMP is surgical excision with vessel reconstruction when needed.Recurrence is a rare but possible evolution, with only 2 cases reported in Mentzel et al. series out of 23 lesions with marginal or incomplete excisions. However, recurrence is more frequently encountered than distant metastasis, reported in 5 cases by McMenamim et al. and 2 out of 54 by Mentzel et al. ,23.Follow-up with US as the first-line imaging tool, may be a good option, relying on MRI if distant metastases are suspected.In conclusion, IVMP are rare subtypes of myopericitoma, with few cases reported in the literature. Immunohistochemistry may be positive for desmin, contrary to previously published papers. US should be used as the first-line imaging modality to detect the mass and asses the blood vessel. MRI is a second-line imaging tool which helps delineate the tumor boundaries related to surrounding structures, as well as planning the surgery. Follow-up US imaging must be considered due to the fact that tumor may relapse.


Although rare, several cases of spontaneous DMD have been reported in the literature, mostly occurring after intraocular surgery. We searched the Pubmed database (1949–2021) for peer-reviewed publications relevant to the topic of spontaneous DMD. Discussion: The pathogenesis of spontaneous DMD is complex and depends on several factors. It can occur due to anatomical anomalies, inflammatory disease, trauma, chemical injuries, and surgical or laser procedures. In most cases, early diagnosis and appropriate management led to resolution.Introduction: We report a case and discuss the clinical characteristics and treatment of spontaneous Descemet membrane detachment (DMD). Case description: We describe a rare case of spontaneous DMD in a patient with prior anterior uveitis and provide a review of the current literature. A 20-year-old woman with a prior history of anterior uveitis presented with vision loss in the left eye. The slit-lamp examination showed corneal edema secondary to DMD, confirmed by anterior segment optical coherence tomography (AS-OCT). The patient underwent an intracameral injection of 20% sulphur hexafluoride (SF Descemet membrane detachment (DMD) was first described by Weve in 1927. It is a separation of the endothelium–Descemet membrane complex from the posterior corneal stroma; most DMDs occur as an uncommon complication of intraocular surgical procedures. The Descemet membrane (DM) is tightly attached to the posterior corneal stroma by a narrow transitional zone of the amorphous extracellular matrix known as the interfacial matrix. Thus, the rupture of the DM leads to penetration of aqueous humor into the corneal stroma and subsequent localized or diffuse stromal edema [Spontaneous DMD has been described as an intra or post-operative complication of other ocular surgeries such as glaucoma, corneal transplantation, pars plana vitrectomy, intracorneal ring segment implantation, radial keratotomy, and cataract. The reported incidence of 2.5% during or after extracapsular cataract extraction and 0.044–0.5% during or after phacoemulsification could be underestimated because most of the DMD occurs in a subclinical fashion ,2,3, butRisk factors for DMD include anatomic predisposition , bleeding from corneal vascularization, intraoperative factors such as clear corneal incisions that might create lateral traction, use of blunt blades for making incisions, inadvertent insertion of instruments between the stroma and DM, entry into the anterior chamber in a soft globe, tight or small incisions as compared to the size of the probe, improper incisions such as shelved or oblique incisions, and accidental injection of substances such as saline, air, antibiotics, or ophthalmic viscosurgical devices (OVDs) between the DM and the posterior stroma.Mackool and Holtz described DMD as planar when there is 1 mm or less of separation between the DM and the overlying stroma in all areas and nonplanar when the DM detachment exceeds 1 mm of separation .Herein, we describe a rare case of spontaneous DMD in a patient with prior anterior uveitis and review the current literature.A 20-year-old woman with a recent (6 months) diagnosis of idiopathic chronic anterior uveitis was referred to our cornea service because of persistent central corneal edema in her left eye. The patient was being treated at another hospital for anterior uveitis, which was treated with topical steroid therapy, but after 3 months, the central corneal edema developed. At the first examination, the best-corrected visual acuity (BCVA) was 20/20 in the right eye and hand movement in the left eye. Slit-lamp examination revealed a normal anterior segment, a clear lens in the right eye, and central corneal edema with an extensive central DMD, posterior synechiae, and dense cataract in the left eye. No signs of active intraocular inflammation were visible through the paracentral cornea. The intraocular pressure was 17 mmHg in the right eye and 20 mmHg in the left eye. No iris atrophy was present. We tried to perform an endothelial cell count, but given the condition of the cornea, the machine was unable to perform it. An AS-OCT scan was performed, confirming DMD in the central cornea. A customized uveitis workup was planned. 6) and an inferior basal iridectomy were performed , 125 mg oral Acetazolamide thrice a day, topical Dexamethasone four times a day (tapering down the dose over ten days), topical Timolol-dorzolamide twice a day, and a topical hypertonic saline solution four times a day. After two months, given the persistent DMD, an intracameral injection of 20% sulphur hexafluoride  arecovery .Although rare, several cases of spontaneous DMD have been reported in the literature, mostly occurring after intraocular surgery. Such cases are mainly related to the mechanical stress exerted on the DM, causing separation along a cleavage plane deriving from the peculiar anatomical and functional interaction between the DM and the posterior corneal stroma .Various clinical features have been described in the corneas of patients suffering from anterior uveitis, including keratic precipitates, iridocorneal adhesions, and band keratopathy . CornealIn the case described in this study, the patient was seen only several months after the diagnosis of anterior uveitis, so we cannot exclude that the DMD may be related to the traction exerted by an inflammatory membrane overlying the endothelium. However, in our opinion, this hypothesis is not strong because of the central location of the DMD; on the contrary, we could expect an inferior detachment due to the gravitational deposition of the inflammatory material. Conversely, the spontaneous DMD could represent the consequence of an acute endothelial dysfunction in a patient with an already existing predisposition to DM detachment. When DMD is localized, it may resolve spontaneously, but a surgical procedure is required when it is significant with severe vision impairment. However, spontaneous resolution depends not only on the size of DMD but also on the state of health of the corneal endothelium.6 and the fibrotic changes of the posterior corneal stroma–DM interface could be related to the underlying inflammation.The lack of adherence after the first bubbling with 20% SFThe management options for a DMD vary from observation to medical or surgical treatment. Several studies reported a spontaneous resolution of corneal edema, most often occurring in localized and planar DMD cases. Medical therapy includes topical steroids and topical saline solution four or more times daily. A mean period for spontaneous reattachment of DMD of 9.8 weeks has been reported , but Ass3F8) and 14–20% sulphur hexafluoride (SF6) [It is preferred to use a surgical approach in cases of nonplanar, extended DMD, scrolled edge, and in patients that are non-responsive to the medical therapy. The gold standard treatment for DMD is descemetopexy with intracameral air/gas. When this fails, an endothelial or penetrating keratoplasty is chosen. The use of isoexpansile gas reduces the need for repeat injections, such as 12–14% perfluoropropane CF8 and 14A few authors described the use of 10–0 nylon sutures for transcorneal suture fixation of DMD, which is usually combined with intracameral air/gas injection. This procedure carries the risk of DM damage and tenting at the site of origin of the DMD . DrainagThe prognosis for reattachment depends on the configuration of the detachment, such as the endothelium health. When medical treatment and/or descemetopexy fail, keratoplasty is the last option. Most of the procedures performed are endothelial keratoplasty or PK. The type of procedure depends on DMD features. The longer the edema lasts, the more likely the corneal stroma will be damaged. In these cases, PK is preferred.There are other causes described in the literature that could lead to DMD, such as chemical trauma, post penetration keratoplasty, and other rare causes. Ocular chemical injury represents 10–22% of all ocular trauma ,6. The sThe cause of DMD after chemical injuries is not well understood. Yuen et al.  observedDue to the presence of hyphema in their cases, Najjar et al.  presumedZhang et al.  hypothesSpontaneous DMD has been reported as a rare complication after PK. Because it is associated with graft edema, it can be misdiagnosed as acute graft rejection or late graft failure. Most of the reported cases occurred in patients with keratoconus ,19,20,21The exact pathogenesis of DMD after PK is not known. Gorski et al.  proposedBecause corneal edema after PK can also be caused by rejection or failure, the diagnosis came later in many cases. The patients were first treated with topical steroids with no results. Hence, it is crucial to perform an anterior segment optical coherence tomography (AS-OCT) to exclude DMD when a graft edema is present. Most spontaneous DMDs after PK cases were treated with one or more intracameral air/gas injections, achieving resolution in several cases. When this treatment failed, the authors chose to perform a new PK or a Descemet’s stripping automated endothelial keratoplasty (DSAEK) procedure. DMD has been reported after glaucoma surgery in patients who often required multiple air/gas injections due to the passage of the gas through the drainage system .The incidence of post-canaloplasty DMD is reported to be 1.1% to 1.6% . The exaLiu et al.  reportedRosetta et al. observed DMD in a patient 20 years after radial keratotomy . The patCases of spontaneous DMD occurred in patients with osteogenesis imperfecta ,28, anteFelipe et al.  proposedIn conclusion, Descemet’s detachments are rare clinical conditions that can be correctly diagnosed by the clinical features and imaging methods such as AS-OCT; the gold standard treatment for DMD is descemetopexy with intracameral air/gas, but when this fails, endothelial or penetrating keratoplasty is chosen.


Rice bodies, a rare finding in clinical practice, are commonly observed in the shoulders and knees of affected individuals. However, they can occur in the wrist as well. Herein, we report a case of a female presenting with painful swelling in the right wrist that lasted with a history of carpal tunnel syndrome, rheumatoid arthritis, and history of median nerve decompression two years ago. A potential diagnosis of infectious diseases and gout was excluded through negative cultures and laboratory findings. X-rays showed no significant findings; however, magnetic resonance imaging revealed findings suggestive of rice bodies that were confirmed by additional proton dense fat-saturated imaging. The mass was then removed by extensive debridement and sent for pathological assessment, which showed multiple nodules containing fibrin and polymorphonuclear cells. The patient did not experience recurrence during the follow-up period. Rice bodies, although rare, can occur in the wrist, and this imposes several challenges associated with their diagnostic and management protocols. Rice bodies are rarely observed in clinical practice; however, they are associated with several diagnostic and treatment challenges. For instance, their occurrence has been reported to be closely associated with several rheumatic and infectious diseases, and multiple hypotheses have been proposed regarding their origin. Although they are commonly located in big joints like the shoulders and knees, rice bodies can also occur in the wrist . Rice boA 73-year-old female patient presented to the orthopedic surgery department  with median nerve palsy and an edematous right wrist with a circumferential mass located in this area. The patient complained of pain at the swelling site for three months, and she reported no prior injury to the wrist or pain before the swelling had occurred. Noteworthy, an informed consent was taken from the patient prior to the conduct of this research. The patient had no prior medical or surgical history except for a history of carpal tunnel syndrome, rheumatoid arthritis (five years prior to the presentation) on hydroxychloroquine medication, and right median nerve decompression two years prior to the current presentation. Physical examination of the right wrist and forearm was carried out, revealing an extensive volar swelling extending from the distal end of the forearm to the wrist Figure . The sweThe initial differential diagnosis included the following possibilities: ganglion cyst, synovial cyst or synovitis, or giant cell tumor. We also put into consideration other etiologies like gout, synovial chondromatosis or abscesses. Cultures revealed no growth of germs of any kind, including tuberculosis. Also given the chronicity of the presenting sign, the possibility of gout was very dim. Radiological assessment showed normal X-rays of the right wrist; however, MRI images revealed a 12x15 cm isointense mass, extending from the distal forearm to the palmar surface of the hand (surrounding the flexor tendons) while passing through the carpal tunnel Figure . This prFollowing a thorough assessment, the decision to remove the rice bodies was reached. Chest X-ray before the procedure was done, and it was unremarkable. A written informed consent was taken from the patient before the operation. An extensive debridement procedure was carried out, where an incision was made over the mass, and a surgical spoon was used to extract the mass in addition to the applied pressure from the sides of the mass (to force the mass of rice bodies out). The extracted rice bodies are shown in Figure Rice bodies are a rare condition that was first reported in patients with tuberculous arthritis. Thereafter, rice bodies have been reported in cases with a wide variety of rheumatic and inflammatory diseases, including but not limited to rheumatoid arthritis, juvenile idiopathic arthritis, and lupus erythematosus. This condition is frequently observed in the following locations: subacromial bursa of the shoulder and the knee. However, the presence of rice bodies in the wrist is less common ,3,4. We In terms of clinical presentation, our case was quite similar to cases observed in the literature, highlighted by a mass that enlarges progressively with time. The presentation is acute (less than six months) ,3,7 in sRice bodies usually originate, histologically, from the amorphous eosinophilic material  in addition to polymorphonuclear cells -17. ThisThe management of such cases differed widely in the literature, but all of them are focused on the removal of the mass either through subtotal synovectomy, debulking synovectomy, or aspiration ,11,12. TRice bodies in the wrist are a rare finding commonly associated with a chronic microinflammation of the synovium either in the context of rheumatoid arthritis or chronic infections. The diagnosis can be made through proper history, physical examination, and intensive radiological assessment. The management of such cases differs widely but focuses on the surgical removal of the mass, with satisfactory results obtained.


Microphthalmia, anophthalmia, and coloboma, fall under the MAC spectrum of ocular malformations. Congenital anophthalmia/microphthalmia is a rare developmental condition. It is due to the almost complete defect of the primary optic vesicle, which leads to an absent or very small eye within the orbit. The birth prevalence of these abnormalities is up to 3 per 10,000 births. The diagnosis is established upon clinical and imaging criteria. Genetic counselling might be challenging due to the wide range of involved genes. A full-term male newborn was referred to our department on the first day of life for ophthalmic examination. Medical history revealed a parental consanguinity. The patient was the third child for both parents. They had a six-year-old daughter with isolated bilateral severe microphthalmia  and a 4-year-old healthy son. Prenatal genetic analysis of both parents and the old daughter did not identify chromosomal abnormalities. Additionally, gestational-acquired infections, maternal vitamin A deficiency, X-rays or drugs exposure were excluded. Upon examination of the newborn, we noticed a firmly closed eyes. The eyelid shape was normal. A gentle pose of the speculum revealed narrowed palpebral fissures and small conjunctival fornices. Both eyeballs, especially the left one, had a very reduced size. Conjunctiva and cornea were barely individualized. Adnexal tissues including the lacrimal canal were identified (C). Further systemic evaluation including transfontanellar and abdominal ultrasound, as well as neurological and urological assessments ruled out associated anomalies. Computed tomography scan of the orbits confirmed the diagnosis of severe bilateral microphthalmia. Rudimentary optic nerves were detected. Extra ocular muscles were within normal limits (D).


We present a case series to evaluate the clinical features of acute leukemia presenting with primary orbital manifestations. We undertook a retrospective case review of primary orbital presentations of acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) over a 10-year period at two hospital sites . Our case series included four patients - two with AML and two with ALL. Patients were young (mean age of four years and five months) at presentation, all with unilateral disease, and presented with orbital signs. Although there was some confusion with the diagnosis at the time of referral, a suspicion of malignancy was made rapidly once ophthalmic review was initiated. All four cases were diagnosed with the assistance of peripheral blood film and bone marrow biopsy, without the need for orbital biopsy. All four cases had resolution of the orbital mass and remain disease-free. Leukemia is the most common pediatric malignancy and is classified according to mode of presentation (acute or chronic) and cell line affected (lymphoid or myeloid) . OrbitalCase 1A boy aged two years and 10 months presented with a two-week history of left upper lid swelling with hypoglobus and proptosis, but no palpable orbital mass  of 1.45x1012/L, hemoglobin (Hb) of 40 g/L, platelets of 131x109/L and neutrophil count of 1.99x109/L  of 16.6 x10The patient was referred to a pediatric specialist unit where he was diagnosed with acute lymphoid leukemia (ALL) with overexpression of cytokine receptor-like factor two following a bone marrow biopsy and started on the UKALL 2003 chemotherapy regimen C . He remains in remission five years post-cessation of chemotherapy with no recurrence of eye symptoms and resolution of orbital mass.Case 29/L, RBC of 2.1x1012/L, Hb of 71 g/L, platelets of 35x109/L, and neutrophils of 1.05x109/L  with RUNX1-RUNX1T1 fusion and commenced on treatment . She remains in remission four years post-cessation of chemotherapy with no recurrence of periocular symptoms and radiographic evidence of mass resolution.Case 3A boy aged four years and 10 months who had a history of left esotropia from the age of two years was noted to have swelling on the nasal aspect of his left lower lid during routine orthoptist assessment, which was present for a two-month period. He was initially treated for left dacryocystitis, but one week later presented to eye casualty following an increase in swelling of the left lower lid.9/L, RBC was 3.44x1012/L, Hb was 40 g/L, platelets were 131x109/L, and neutrophils were 1.99x109/L . He had a negative PET-CT scan after two cycles and negative flow cytometry minimal residual disease post-course one. He remains in complete remission three years post-diagnosis with resolution of the orbital mass.Case 49/L, RBC was 4.97x1012/L, Hb 125 g/L, and platelets were 319x109/L . There was complete resolution of his peri-orbital swelling within five days of starting chemotherapy, and he remains in remission 18 months post-diagnosis.Leukemia can present with ocular findings after systemic diagnosis, as the first presenting sign, or as the manifestation of relapsing disease ,5. OrbitThe laterality of pediatric orbital lesions can help tailor a differential diagnosis. Rhabdomyosarcoma, secondary tumors, and cystic lesions are typically unilateral. The most common bilateral lesions tend to be inflammatory, related to orbital metastasis of neuroblastoma, or myeloid sarcoma . In 1986Orbital biopsies prove to be useful diagnostic procedures in identifying the etiology of space-occupying orbital lesions. In cases of acute leukemia, an orbital biopsy may be required if a diagnosis cannot be made confidently on the grounds of clinical and radiological findings, or when orbital findings are the first presenting complaint. Orbital incisional biopsies carry procedural risks in a complex anatomical space. Core-needle and fine-needle aspiration biopsies have gained popularity as minimally invasive techniques, but in themselves carry the risk of inadequate tissue yield. Our case series demonstrates the synergistic use of clinical and hematological findings to raise the suspicion of acute leukemia and referral to specialist pediatric unit. Non-invasive and inexpensive investigations, such as a full blood count and peripheral blood smear, should be considered first in a work-up before surgical biopsy in the diagnosis of acute leukemia with orbital involvement. In pediatric case series of orbital leukemia, the patients that required an orbital biopsy for definitive diagnosis remain in the minority, ranging from 7.4% to 17% ,11.Although leukemia is the most common childhood malignancy, orbital presentations remain rare but should not be forgotten given the potential consequences. Orbital lesions of ALL are less common than AML but also require prompt diagnosis and treatment. There is generally good survival for both entities, however, orbital manifestations may be associated with worse outcomes. Diagnosis can be achieved without the need for orbital biopsy using hematological and radiological findings. Multidisciplinary collaboration between ophthalmology, hematology, oncology, and radiology is essential.


Because of this, endoscopic resection of such polyps carries a high risk of perforation and management has traditionally been with surgical intervention, which increases the risk of complications. In this series, we present 2 cases of successful excision of an adenomatous polyp located within the lumen of a diverticulum using endoscopic mucosal resection (EMR).Colon polyps arising from diverticula are rare with only a few cases reported to date.A 73-year-old woman presented for a surveillance colonoscopy. During the procedure, a 1-cm polyp was found arising from within a diverticulum in the proximal transverse colon Figure . Then, aA 72-year-old woman presented for a surveillance colonoscopy. During the procedure, an 8-mm, flat polyp was found arising from a diverticulum in the hepatic flexure. After careful inspection, a decision was made to remove the polyp using hot snare EMR. We injected the site of the polyp with ORISE gel, raising the polyp out, making it accessible for EMR. A 10-mm Captivator II snare (Boston Scientific) was used to remove the polyp by the 1-piece snare polypectomy technique using the blend cut mode. Two Resolution Clips (Boston Scientific) were used prophylactically at the site of polypectomy. Pathology revealed tubular adenoma. The patient did not experience any early or delayed complications.1 When detected, endoscopic removal carries a high risk of perforation. EMR has revolutionized endoscopic removal of advanced polyps. Other techniques described in a few case reports include endoscopic band ligation and the use of over-the-scope clips with full-thickness colon resection.5 To the best of our knowledge, this is the first series of cases that demonstrate successful removal of diverticular polyps using EMR without any complications, but more cases are needed to validate this technique as a standard of care. Informed consent could not be obtained from the patient despite several attempts. All identifying information has been removed from this case report to protect patient privacy.Colon polyps that arise from diverticula are very rare.Author contributions: M. Shakhatreh and G. Rapoport reviewed the literature and wrote and edited the article. A. Zamir provided the images, approved and revised the final article for intellectual content, and is the article guarantor.Financial disclosure: None to report.Previous presentation: Case 1 was presented at the American College of Gastroenterology Annual Scientific Meeting; October 23-28, 2020; virtual meeting.Informed consent could not be obtained for this case report. All identifying information has been removed.


Mesenteric pseuodycst is a very rare benign childhood tumor, accounting for less than 1 out of 250,000 hospital admissions. We here report a case of giant mesenteric pseudocyst incidentally detected in a 11-year-old boy with acute appendicitis. He complained of persistent abdominal pain for the past 48 hours. He had a history of intermittent pain for several months. Physical examination showed fever and abdominal pain. Ultrasonography showed large peritoneal fluid related to peritonitis probably of appendicular origin. The patient underwent exploratory laparotomy revealing giant abdominal mesenteric cyst and acute appendicitis. Open resection of the cyst and appendectomy were performed. The diagnosis of uncomplicated acute appendicitis associated with mesenteric pseudocyst was made. Preoperative diagnosis of pseudomesenteric cysts is a clinical challenge. Knowledge is essential and suspicion should be maintained in patients with nonspecific symptoms. Mesenteric cyst is a rare benign tumor. It can be located anywhere in the mesentery from the duodenum to the rectum . More thPatient information: an 11-year-old boy was admitted to the emergency department with persistent abdominal pain for 48hours with vomiting. The patient reported a history of intermittent pain with no specific symptoms for several months. No other relevant history was noted.Clinical findings: on admission, the patient had a fever (38.5°C). Abdominal examination showed a slight epigastric abdominal swelling, abdominal tenderness and pain in the right iliac fossa and epigastric region.Diagnostic assessment: blood tests revealed normal leukocytes count and high levels of inflammatory markers, but no other relevant findings. Abdominal ultrasound showed large peritoneal effusion related to peritonitis of probably appendicular origin. For further assessment, a computed tomography (CT) scan was advised but could not be done due to limited access to emergency care services. The diagnostic hypothesis was complicated appendicitis.Therapeutic intervention: after resuscitation, an exploratory laparotomy was performed. It revealed a giant abdominal unilocular cyst adherent to the mesenteric wall of the small bowel measuring 17cmx12cm and acute appendicitis. We noticed multiple inflamed lymph nodes of different sizes (nt sizes . The patnt sizes . After 5Follow-up and outcome of interventions: the postoperative course was uneventful and there were no significant symptoms and no clinical evidence of recurrence during the 3-month follow-up. Histological examination confirmed the diagnosis of the mesenteric pseudocyst, with inflammatory infiltrate. Fluid cytology was negative for malignancy. The diagnosis of uncomplicated acute appendicitis with mesenteric lymphadenitis was made.Informed consent: written informed consent was obtained from the patient and his parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Mesenteric pseuodycst is a rare type of mesenteric cyst, accounting for less than 1 out of 250,000 hospital admissions . More thClinical presentation includes nonspecific abdominal pain, abdominal distention, change in bowel habit, nausea, vomiting and an abdominal mass. Physical examination is often unremarkable. Complications such as intestinal obstruction, ischaemic bowel, volvulus and peritonitis or haemorrhagic shock secondary to rupture or bleeding into the cyst, rarely occur . In our Mesenteric cysts are very rare benign tumors. Preoperative diagnosis is a challenge due to nonspecific symptoms. In some cases, complications could occur with patent clinical presentation. Abdominal imaging is necessary for preoperative diagnosis. Knowledge is essential, and suspicion should be maintained. Complete resection is the gold standard treatment.


Schwannomas are peripheral nerve sheath tumors. Due to their low incidence, few cases of colorectal schwannomas have been published, which increases the diagnostic challenge. The aim of this case report is to discuss the role of transvaginal ultrasound in different areas than the gynecological disorders, when on hands of properly trained professionals that perform systematized procedures. A 56-year-old woman consulted for postmenopausal genital bleeding. During transvaginal ultrasound, a colonic solid, hypervascularized mass of 23 × 26 mm was visualized. As a result of this incidental finding, the patient underwent a sigmoidectomy, with a final diagnosis of intestinal schwannoma. Transvaginal ultrasound is today one of the most useful and accurate diagnostic tools in the assessment of gynecological disorders. However, the proximity of other pelvic structures makes it possible to evaluate the presence of nongynecological conditions. This fact should encourage gynecologists to systematize the transvaginal ultrasound procedure. Mesenchymal neoplasms affecting the gastrointestinal tract are currently classified into 2 groups. Firstly, gastrointestinal stromal tumors (GISTs), and secondly, a smaller group that includes a wide spectrum of non-specific tumors, such as leiomyomas, sarcomas, lipomas and peripheral nerve sheath tumors They usually present at an average age of 60-65 years, and recent studies suggest they may affect women more frequently than men The final diagnosis of this kind of tumors is made by histopathological and immunohistochemical analysis (presence of S-100 protein and vimentin), and often requires surgical resection, as submucosal biopsy is commonly insufficient A 56-year-old female patient with no relevant past medical history, except for hyperthyroidism and a cesarean section, was referred to our Gynecology Unit because of postmenopausal uterine bleeding. A pelvic examination and an endometrial biopsy were carried out with no abnormal findings. Subsequently, a transvaginal ultrasound was performed, visualizing a thin endometrial line without other uterine or adnexal findings. The ultrasound equipment employed was a GE Voluson 730 PRO device . Cervical pathology screening was performed by colposcopy and cytology, both within normality. Afterwards, a hysteroscopy was undertaken, which showed an atrophic endometrium, with no findings of interest.Despite the absence of other episodes of metrorrhagia, a new follow-up transvaginal ultrasound was performed one year later. Once again, the endometrial midline appeared linear, both ovaries were atrophic, and no genital abnormalities were evident. Incidentally, a hypoechogenic nodular image was visualized in the colonic lumen, sized 26 × 23 mm and surrounded by an hyperechogenic content congruent with intestinal gas. It presented strong vascularization (vascular score 4/4) and was located more than 18 cm distal to the anal verge, in a retrovesical location  gave us the diagnostic key, suggesting that the origin of the mass was intestinal. Further studies allowed us to classify it as an intestinal schwannoma that otherwise would have not been diagnosed. To the best of our knowledge, this is the first case of an intestinal schwannoma initially suspected by transvaginal ultrasound.Although not yet systematized, transvaginal ultrasound is a useful technique to diagnose non-gynecological alterations located in the pelvis. Therefore, from our point of view, gynecologists should be encouraged to carry out a complete pelvic examination during transvaginal ultrasound, instead of focusing exclusively on the genital tract. They should be aware of the possible extra-gynecological findings that might come up during this procedure, so that an adequate assessment of the patient can be completed.Informed consent for publication was obtained from the subject of this case report, according to the World Medical Association Declaration of Helsinki, revised in 2000, Edinburgh.


Labyrinthitis occurs because of the inflammation of the inner ear. We present a rare case of labyrinthitis ossificans following an acute otitis media. The T2‐weighted magnetic resonance imaging showed decreased signal intensity in the right inner ear due to labyrinthitis ossificans, consistent with the clinical presentation. Labyrinthitis is the inflammation of the inner ear and can result in labyrinthitis ossificans. The T2‐weighted magnetic resonance imaging can play a crucial role in the diagnosis of labyrinthitis ossificans. Streptococcus pyogenes. Given her recovery from AOM, we administered corticosteroid. On the 30th day of the first visit, T2‐weighted magnetic resonance imaging (MRI) showed decreased signal intensity in the right inner ear  with the perforation of the tympanic membrane Figure . Pure toLabyrinthitis can cause fibrosis in the membranous labyrinth filled with ossified material, resulting in labyrinthitis ossificans. In such cases, patients often present with irreversible SNHL and vertigo due to labyrinthitis ossification.KU cared for the patient, and contributed to the editing of the manuscript and preparation of the figure. SK and MA contributed to the design of the case report presentation, and performed the final revision of the manuscript.The authors declare that they have no conflict of interest.Institutional review board approval was deemed unnecessary.Written informed consent was obtained from the patient and patient's family for publication of this case report and accompanying images.


Teaching Point: A supernumerary heterotopic hemicerebellum is a rare congenital posterior fossa abnormality that should not be confused with tumor. A two-day-old boy was sent for an MRI of the brain in the neonatal work-up of a ‘cerebellar mass’ that was incidentally detected on prenatal ultrasound screening. To anticipate early intervention, he was born by elective caesarian section at 38 weeks. The brain MRI showed a probably benign exophytic seminodular hindbrain mass and along with the absence of postnatal complications, the intervention was called off. As expected, the mass showed no evolution on follow-up MRI performed six months later. Further clinical examination after birth remained normal.The exophytic seminodular hindbrain mass originated dorsally from the medulla oblongata on the left side. Superior, inferior, and lateral dysplastic soft tissue bridges were present between the mass and the dorsal medulla oblongata (On both T1- and T2-weighted images, the signal intensity of the lesion was identical to that of the adjacent cerebellum, with white matter signal intensity in the center and cortical signal intensity in the periphery of the lesion. Mainly on the T1-weighted imaging, discrete foliation was noted. The lesion showed no diffusion restriction or enhancement after IV gadolinium administration (Congenital midbrain-hindbrain malformations can roughly be separated into four major groups, according to Barkovich et al. in 2009, namely malformations caused by disturbances in the anteroposterior or dorsoventral ‘patterning’ of midbrain-hindbrain development, malformations associated with generalized neurodevelopmental disorders, localized brain malformations affecting the midbrain and hindbrain and combined hypoplasia and atrophy caused by putative prenatal neurodegenerative disorders.A supernumerary heterotopic hemicerebellum is a very rare malformation. It is probably caused by patterning disturbances and cell fate transformations at the pontine-medullar boundary of the early hindbrain where a primitive supernumerary heterotopic hemicerebellum is induced on the alar plate of the medulla oblongata. This malformation can be included in group 1 of the midbrain-hindbrain malformations classification according to Barkovich.A supernumerary heterotopic hemicerebellum as such has only been described earlier by Hattapoglu et al. in 2014. Other presentations of patterning disturbances in the posterior fossa have also been reported [


BRAF mutations in MST in pediatric patients which may serve as powerful diagnostic tools for distinguishing MST from other renal stromal tumors. We present a BRAF-mutated MST in an adult patient with a brief review of the pertinent literature. To our knowledge, our case represents to date the sixth report of adult MST and the first adult MST proven to harbor BRAF mutation. This is a 41-year-old man who was incidentally identified to have a left renal mass by ultrasonography. He had a 5-year history of hypertension which could be controlled with oral antihypertensive drug. Partial nephrectomy was performed which demonstrated a 2.6-cm, oval, circumscribed mass with a fibrotic and firm texture. Microscopic examination showed a hypocellular, spindle cell neoplasm with entrapped nephrons, within a predominantly fibrous and focally myxoid stroma. Foci of hyalinized stroma surrounding entrapped native renal tubules or blood vessels to form concentric collarettes-like structures, and small-sized arterioles showing angiodysplasia, were observed. Immunostains showed the tumor cells to be diffusely positive for CD34. Fluorescence in-situ hybridization analysis was negative for rearrangements involving both the EWSR1 and FUS loci. Targeted next-generation sequencing disclosed a pathogenic mutation of BRAF exon15: c.1799T>A (p.V600E). The patient’s hypertension normalized without oral antihypertensive drugs 2 months postoperatively and he was in good status 12 months after the surgery. Our case highlights the diagnostic dilemma of MST occurring in adults and points to the usefulness of molecular detection of BRAF mutation for arriving at accurate diagnosis.Metanephric stromal tumor (MST) is a rare, benign pediatric renal neoplasm of uncertain histogenesis that belongs to the metanephric family of tumors. MST involving adult patients is very uncommon, which could cause significant diagnostic confusions. Recent molecular studies have revealed recurrent  BRAF V600E mutation  is a rare, benign stromal neoplasm unique to the kidney that is thought to be part of a spectrum of metanephric family of tumors which also includes the epithelial lesion metanephric adenoma (MA) and the mixed stromal-epithelial lesion metanephric adenofibroma (MAF) . The vasmutation , 8. BecaA 41-year-old man was incidentally identified to have a left renal mass by ultrasonography for physical examination. His medical history was unremarkable except for a 5-year history of hypertension, which could be controlled with the oral antihypertensive drug hydrochlorothiazide. Workup for 24-hour urine metanephrines and norepinephrine was negative. Computed tomography scan showed a focally low-enhancing, circumscribed, oval mass in the upper pole of the left kidney  in the tumor  with only a few cases documented after 3 years  years wi. There iBRAF gene  in 6/7 (86%) and 11/17 (65%) of cases of MST, respectively  (cm 3–6)..6). Morp) in 6/7 6% and 11utations , 10. ForETV6-NTRK3  and clear cell sarcoma of the kidney (CCSK) . Both enV6-NTRK3 . CCSK isV6-NTRK3 . MoleculOR-CCNB3 , 14. TheOR-CCNB3 , 16. SEFonly FUS , which aof STAT6 . Importalt cases , just asBRAF mutation for arriving at accurate diagnosis.Adult MST is very rare and accurate diagnosis has important clinical significance. All the reported adult MSTs have had a benign course without recurrence or metastasis –6. ExcisThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Institutional Review Board Committee of Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College. Written informed consent for participation was not required for this study in accordance with the institutional requirements.YF, JY, and MZ were involved in conception and design of the work, acquisition, analysis and interpretation of data, drafting the manuscript and revising it critically for important intellectual content and scientific integrity. All authors have read and approved the final manuscript.This work was supported by Zhejiang Provincial Natural Science Foundation (LY21H160052) and Zhejiang Provincial Medicine and Health Research Foundation (2023KY040). The funder did not have any role in the design and conduct of the study, the analysis and interpretation of the data, and preparation of the manuscript.The authors are grateful to Anbiping Laboratory, Guangzhou, China, for FISH analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In this study, a review of available data and literature on the epidemiology and anamnesis of inguinal hernias in nonhuman primates, as well as on their clinical evaluation and surgical management, was conducted. Inguinal hernias are assumed to be relatively common in male nonhuman primates. Clinical signs are usually limited to a visible or palpable mass in the groin region without pain or systemic illness. Most hernias contain omentum. Careful monitoring is an acceptable treatment option for those animals. Size, the danger of incarceration, and the presence of strangulation are important factors when considering surgical repair. A strangulated inguinal hernia is an emergency, requiring prompt surgery to avoid tissue necrosis and death. Imaging techniques, as well as computed tomography (CT), ultrasonography, and magnetic resonance imaging (MRI), provide information about the anatomical characteristics of the suspected region, allowing for a diagnosis and treatment. An inguinal hernia repair can be performed with either open surgery or laparoscopic surgery. The hernia repair can be achieved by mesh or suture. Decisions regarding which repair technique to use depend on the surgeon′s skill level and preference. Complication and recurrence rates are generally low. The most common postsurgical complication is a recurrence of the hernia. Contraceptive measures are not indicated in breeders, as there is no known hereditary component, and the presence of hernia does not appear to affect fertility, nor does it predispose to occurrence, recurrence, or incarceration. A herniation is a condition in which there is a protrusion of an organ, fascia, fat, or omentum through the wall of the cavity in which it is contained . A herniCline et al.  reportedThis review describes the epidemiology, anamnesis, treatment, and postsurgical complications of inguinal hernias in NHPs. This is the only comprehensive published documentation of inguinal hernias in NHPs and will be an extremely helpful resource for veterinarians, caretakers, and scientists working with NHPs.The lifetime risk of developing an inguinal hernia is around 27% for males and 3% for females ,20,21. CMacaca silenus) are predisposed to the development of inguinal hernias. As part of this review, a study was conducted to calculate hernia incidence at the Biomedical Primate Research Centre . Data were obtained in retrospect from the electronic health record database of the BPRC. The dataset used for the analysis covered the period from January 2021 to December 2021. Marmosets  < 5 months of age or weighing < 200 gr, rhesus monkeys (Macaca mulatta) < 6 months of age, and cynomolgus monkeys (Macaca fascicularis) < 8 months of age were not sedated for their physical examination and were therefore excluded from this analysis. Data from the physical examination were analyzed on the presence of inguinal hernia at the moment of examination, in combination with age, sex, and body condition score (BCS). Physical examinations are routinely performed yearly, including a thorough physical examination, a tuberculosis screening test, complete blood count (CBC), and serum biochemistry. No animals were sedated solely for the purpose of this study. Ethical approval was not required for this study. All animals were housed in accordance with Dutch law and international ethical and scientific standards and guidelines (EU Directive 63/2010). All husbandry procedures were compliant with the above standards and legislation. The animal care at BPRC is in accordance with programs accredited by AAALAC International. Data included 897 NHPs: 88 common marmosets, 225 cynomolgus monkeys, and 582 rhesus monkeys. No inguinal hernias were observed in the marmosets . In the 225 examined cynomolgus monkeys , 6 adult males were observed with an inguinal hernia. Those males had a BCS of 3–3.5, age range between 2 and 12 years. In the 582 examined rhesus monkeys , 2 adult males and 1 adult female were observed with an inguinal hernia  was 0.37% . More rel hernia A,B. One Trauma . AlthougCongenital weakness of muscles of the groin region or other congenital anomalies from the time of birth ;In utero lead exposure .It is suggested that inguinal hernias in NHPs occur secondary to the following factors:Berg et al.  exploredIn most cases, this is an incidental finding discovered in healthy animals during routine physical examinations, manifesting as a bulge in the groin  area. The clinical appearance varies widely—from uni- to bilateral, reducible to nonreducible, immobile to mobile, and firm to soft. Hernias in the inguinal region may present as a mass in the femoral area near the vessels or as a scrotal mass. When intestines appear within the hernia defect, peristalsis of fluid in the hernia sac is palpable . AbdominInguinal hernia is often diagnosed based on the presence of a bulge in the inguinal region during physical examination A,B. HowePlain or contrast X-rays, ultrasonography (US), magnetic resonance imaging (MRI), and computed tomography (CT) provide information about the anatomical characteristics of the suspected region, i.e., the content of the hernial sac and the integrity of the anatomical structures, allowing for a diagnosis and treatment ,31,32,33In the event of strangulation, acute bowel ischemia may occur. Angiography and CT directly assess mesenteric vascularity, with CT having a high expectation of revealing early findings of bowel ischemia. CT provides a roadmap to assist veterinarians with the restoration of intestinal blood flow as early and fast as possible .A combination of the clinical signs and imaging results will assist veterinarians in the diagnosis of the mass in the groin region. These groin masses can be defined as being inguinal hernias, neoplasms, infectious or inflammatory processes, vascular conditions, as well as congenital abnormalities. Therefore, the differential diagnosis should include appendicitis, adhesions, abscesses, inflammatory bowel diseases, urinary tract infection, hip pathologies, pelvic pathologies, undescended testicles, hematoma, lymphadenopathy, lipoma, metastatic neoplasia, hydrocele, and vascular aneurysm ,31,36,37In humans, inguinal hernias are common and were in the past believed to all require surgical repair (herniorrhaphy) regardless of the presence or severity of symptoms, in order to avoid complications ,38,39,40In NHPs, inguinal herniation is usually of no significant consequence. Therefore, close monitoring is an acceptable course of action for NHPs in asymptomatic or minimally symptomatic patients. Surgery is necessary for acutely incarcerated hernias or those that cause significant discomfort, i.e., pain or physical limitations. Precise determination of the actual risk of serious consequences of an inguinal hernia in NHPs does not exist due to a lack of published data. In humans, the change rate in the cumulative probability of strangulation increases quickly over the first 3 months of the existence of a hernia . IncarceMany different techniques for surgical repair of inguinal hernias have been described in human medicine, mainly characterized as mesh reinforcement or suturing of defects, performed as an open or laparoscopic approach ,39,40,46In humans, mesh repairs demonstrated lower recurrence rates, compared with sutured repairs, presumably due to tension-free repair ,48. TherLaparoscopy is an alternative method to an open surgical approach ,46,51,52When performing surgery in NHPs, the surgical site should be clipped and shaved and asepsis achieved by prepping with disinfectants such as 70% alcohol and povidone-iodine ,55. The In case of strangulation, adequate exposure to the hernial content is crucial to visually determine its integrity and viability before closing the defect . A wide Surgical guidelines recommend antibiotic prophylaxis in open surgical procedures. The ideal timing for optimal serum drug levels is 30–60 min before surgical incision. However, postoperative administration of antibiotics is currently considered to be of no benefit in routine practice. In selecting an antibiotic to treat with, veterinarians estimate the organisms most commonly causing infection in the specific procedure and by the relative costs of available agents . HoweverIn the literature on human-related cases, inguinal hernias have a good prognosis. It was accepted that all inguinal hernias should be surgically repaired. However, this has recently come into question: Watchful waiting is judged nowadays as an acceptable option for patients in asymptomatic or minimally symptomatic cases, i.e., where the risk of incarceration and strangulation is judged minimal. Incarceration, strangulation, and recurrence worsen the prognosis. We can adapt a similar approach in cases of inguinal hernia in NHPs.Human reports of postoperative complications are approximately 10% overall. The complications are comparable to those seen in other surgeries and include surgical site infection, hematoma, wound dehiscence, chronic pain, anastomotic leak (when bowel resected), bowel necrosis, nerve injury, and vascular injury ,10,46. TIn humans, mortality and bowel resection are obviously linked to the duration of symptoms prior to treatment . StranguAt the BPRC, several complications were observed over the years, which are discussed in detail below A–C. The Pregnancy may render a pre-existing inguinal hernia apparent, because of progressively increasing intra-abdominal pressure ,72,73. BRound ligament varicosities (RLVs) appear almost exclusively in pregnant women and can simply be misjudged for an inguinal hernia, as both have an identical clinical appearance ,75,76,77Ablation of the testis during surgical hernia repair is not recommended, as heritable predisposition is unknown in NHPs. Contradictorily, although uncommon, postcastration evisceration of the bowel through the vaginal rings/internal inguinal ring  could occur, as reported after castrations in horses ,81.Castration is a routinely performed surgery in dogs and cats, primarily to avoid unwanted offspring or to reduce sexually motivated, unwanted behaviors. Removal of the testicles will result in the removal of testosterone and its active metabolite DHTs from the general circulation. Subsequently, a decrease in the size of the prostatic gland and a decrease in sexually motivated behaviors and infertility will occur ,83. AlthInguinal hernias are reported to occur relatively frequently in male NHPs. Most inguinal hernias do not present with symptoms nor with complications. However, strangulation of trapped tissue can occur. If permitted to continue, infarction of bowel or omentum, intestinal necrosis, diffuse peritonitis, or sepsis can follow and result in significant morbidity and even mortality. Emergency surgery is necessary in case of strangulation. Surgical hernia repair is the only treatment for inguinal hernias . A comprehensive health assessment (including imaging) will help in the diagnosis and subsequent treatment of inguinal hernias.


Infective Endocarditis (IE) refers to an infection of the endocardial surface of the heart which leads to a wide array of complications, including heart failure, perivalvular abscess, metastatic infection, septic embolization, mycotic aneurysms, neurological and renal complications. Mitral leaflet flail (MLF), defined as a failure of leaflet coaptation with the rapid systolic movement of the involved leaflet into the left atrium, is a rare complication of IE which can lead to severe mitral regurgitation. Echocardiography plays a key role in making its diagnosis with transesophageal echocardiograms (TEE), providing greater sensitivity and specificity compared to transthoracic echocardiograms (TTE). MLF is often misdiagnosed, or diagnosis is delayed due to its presentation with non-specific cardiac symptoms. However, early diagnosis with echocardiography and prompt surgical correction leads to improved long-term survival. Here we have presented a case of a 71-year-old female with a past medical history of IE nine years ago who was referred to the cardiology clinic for one month of exertional dyspnea. TTE showed severe mitral regurgitation, and subsequent TEE confirmed flail mitral leaflet. Mitral Leaflet Flail (MLF) is defined as failure of leaflet coaptation with the rapid systolic movement of the involved leaflet into the left atrium due to either ruptured chordae tendineae or papillary muscle. This may lead to acute, subacute, or chronic mitral regurgitation (MR) . MLF mayA 71-year-old female with a past medical history of hypertension, hyperlipidemia, syphilis, glaucoma, and IE nine years before the presentation was referred to the cardiology clinic for one month of dyspnea on exertion. On further chart review, it was confirmed that she had echocardiographic evidence of mitral valve vegetation on the posterior leaflet nine years ago. A physical exam revealed a Grade II-III holosystolic murmur. A transthoracic echocardiogram (TTE) was done, which demonstrated the presence of preserved left ventricular ejection fraction (55-60%), moderately dilated left atrium 4.2cm), and severe mitral regurgitation. There was no evidence of myxomatous degeneration of the mitral valve. Subsequently, she underwent a transesophageal echocardiogram (TEE) which showed a flail portion of the posterior leaflet involving the medial scallop (P3) and middle scallop (P2) (Figure cm, and sIE refers to an infection of the endocardial surface of the heart, usually involving one or more valves or an intracardiac device . It is aHere we have presented a rare case of a patient who presented with symptomatic mitral regurgitation because of MLF nine years after diagnosis of IE. To our knowledge, there are no reported cases of MLF that presented almost a decade after an incident of IE. Due to the wide array of symptoms caused by MLF, it is often misdiagnosed, or diagnosis is delayed leading to morbid outcomes. In this case, we highlight the severity of this valvular dysfunction, and we highlight the importance of echocardiography in its diagnosis when clinical suspicion is high. MLF is a rare complication of IE which can cause acute, subacute, or chronic mitral regurgitation. MLF is often misdiagnosed, or diagnosis is delayed as symptoms can mimic a wide array of cardio-pulmonary diseases. Prompt diagnosis with echocardiography and surgical correction is key for long-term survival benefits.