A 70-year-old white male, with past medical history of coronary artery disease, peripheral arterial disease status-post bilateral femoral artery stents, insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, arthritis, tobacco use, and alcohol use, presented with shortness of breath and an abnormal finding on a recent transesophageal echo. This had revealed a large, fixed mass in the right atrium. Our differential diagnosis had included thrombus, endocarditis, myxoma, papillary fibroelastoma, sarcoma, and metastatic tumor. The cardiothoracic surgeon excised this mass, which upon culturing, revealed what we found to be the only reported case of an atrial myxoma infected with Escherichia coli. In addition to surgical excision, the patient was treated with six weeks of intravenous cefepime. Atrial myxomas are the most common primary cardiac neoplasms and compose more than 50% of benign cardiac tumors . Around A 70-year-old white male presented to the hospital with shortness of breath and a recent abnormal finding on transesophageal echocardiogram. The patient had experienced shortness of breath for four weeks prior to admission. He underwent labs, an electrocardiogram, and a chest x-ray in the outpatient setting; these were all unremarkable. However, a transthoracic echocardiogram revealed concern for a mass in the right atrium. This prompted a transesophageal echocardiogram to be ordered. The patient had this transesophageal echocardiogram done one week prior to admission which revealed a large, fixed mass with dimensions of 26 x 28 centimeters; ejection fraction was 50-55% Figure .The patient was admitted to the hospital for possible excision of this right atrial mass. Initial vitals, physical exam, laboratory findings, and blood cultures were unremarkable. Electrocardiogram revealed normal sinus rhythm. Left heart catheterization and ventriculography were done for pre-op evaluation for excision of right atrial mass. This revealed the proximal first obtuse marginal artery to have a long 80% stenosis; ejection fraction was 65%. Therefore, the patient was accepted for surgery and was also planned for a single bypass graft to the first obtuse marginal artery. Cardiothoracic surgery was consulted. Although the Society of Thoracic Surgeons' risk score for coronary artery bypass graft surgery revealed 1.138% mortality and 11.269% morbidity and/or mortality, the patient was amenable and subsequently underwent coronary artery bypass graft surgery with the reversed segment of the right greater saphenous vein to the first obtuse marginal artery. Perioperative transesophageal echocardiogram revealed the mass again with dimensions of 3.3 x 2.8 centimeter on this occasion; the patient subsequently underwent excision of this right atrial mass along with atrial septal defect repair with autologous pericardium (Figure The mass was a firm, polypoid, yellow tumor greater than 3 centimeters arising from the atrial septum. This mass was sent to pathology as well as microbiology. Per pathology, the mass was found to have multiple hemorrhagic areas upon sectioning. On microscopic examination, the mass was composed of polygonal and stellate cells with irregular nuclei within myxoid stroma. Immunohistochemical stains as well as histochemical stains revealed the mass was CD34, calretinin, aclian blue, and mucicarmine positive. Immunophenotypic findings were consistent with atrial myxoma. Notably, per microbiology, E. coli was cultured from the mass. An infectious disease specialist was consulted. Of note, patient was determined to have poor dentition for the last two years and the patient was even supposed to have a procedure done for a dental abscess one year ago. The infectious disease specialist recommended six weeks of intravenous cefepime for treatment. Otherwise, the patient also experienced post-op atrial fibrillation with tachycardia-bradycardia syndrome. Since the onset was within the last 48 hours, transesophageal echocardiogram to assess the left atrial appendage was not deemed necessary. Therefore, direct current cardioversion was performed. Also, a permanent pacemaker was inserted instead of a temporary device because the pathologist had deemed the infected mass to have been completed excised, post-operative blood cultures were negative for more than 72 hours, and the infectious disease specialist was agreeable with the procedure. The rest of the patient’s hospitalization was unremarkable and he was discharged soon after. Upon follow-up, the patient had completed the course of antibiotics. He denied chest pain, paroxysmal nocturnal dyspnea, and orthopnea. No further complications were noted.Infected myxomas are very rare with only 39 reported cases as recently as 2015 -6. EmbolIn 1998, the most commonly isolated pathogens involved in myxomal infections were found to be streptococci, staphylococci, enterococci, Klebsiella, Neisseria, and Actinobacillus ,8. SubseWith regards to management, surgical excision of the infected myxoma and intravenous antibiotics appear to be therapeutic . Some reWe conclude that there are only a few documented cases of infected atrial myxoma in the literature. There are even fewer cases where myxomas are infected with gram-negative organisms and none to our knowledge where they are infected with Escherichia.Transesophageal echocardiogram, pathology, and microbiology are all useful tools in diagnosis. Urgent surgical excision and intravenous antibiotics are the preferred treatment for infected myxoma. However, further research could attempt to compare outcomes in cases in which pretreatment with antibiotics was followed by surgical excision versus cases in which surgical excision was followed by subsequent intravenous antibiotics.


The diagnosis of simple schizophrenia remains an unusual and controversial diagnosis today. The presentation of nonspecific symptoms shared by other nosological entities make differential diagnosis a challenge.The main objective of this case report is to review the diagnosis of simple schizophrenia and its differential diagnosis.Case report and literature review. We present the case of a 52-year-old man who was admitted to a medium stay unit for psychosocial rehabilitation with the diagnosis of simple schizophrenia after his debut at 49 years of age with clinical manifestations of progressive self-care abandonment and personality change.Given the psychosocial deterioration observed and lack of response to pharmacological and psychotherapeutic treatments, the possible diagnoses of dementia praecox and simple schizophrenia were considered. Several individual and family interviews, neuropsychological and projective tests  were performed in order to define the diagnosis. The results revealed age-appropriate cognitive functioning and the absence of data suggestive of an underlying psychotic disorder. On the other hand, it was observed that the patient was able to establish some social relationships and participate in group activities in the medium stay unit. These findings suggest the influence of factors related to the socio-familial environment and cast doubt on the initial diagnostic hypothesis.The diagnosis of simple schizophrenia continues to present itself as a complex diagnosis that requires a careful review of the differential diagnosis.No significant relationships.


We describe the surgical aspects of the resection of a large 2cm intramedullary ependymoma at the C6-7 level associated with an extensive syrinx using a unilateral minimally invasive approach through a fixed tubular retractor. A gross total resection was achieved. Total operative time was 5 hours. Estimated blood loss was less than 100 cc. Postoperative evolution was favorable, with the improvement of the patient’s neurological status. There was no cerebrospinal fluid (CSF) fistula. Hospital stay was four days. All narcotics were stopped on day 1 after surgery. Post-operative MRI showed no residual tumor. At the six-month follow-up, there was continued improvement in his neurological status. Scoliosis films did not reveal any cervicothoracic kyphosis. Intramedullary spinal cord (IMSC) tumors account for less than 5% of all spinal tumors. Of these, ependymomas and astrocytomas are the two most common types found in adults . SurgicaBecause of the high incidence of spinal deformities following laminectomies for resection of intramedullary tumors , many auThe use of minimally invasive surgery (MIS) approaches allows for a similar exposure while preserving the paraspinal muscle attachments and the posterior midline ligaments. MIS techniques for spinal intradural extramedullary tumors have been reported in many case series with satisfactory results -10. TheyHere we report a clinical case of complete resection of a large cervical intramedullary tumor associated with an extensive syrinx using a minimally invasive surgical approach via a dorsal root entry zone (DREZ), with a fixed tubular retractor. We present technical nuances for such minimally invasive approach, and a short-term neurological and radiographic finding.We report the case of a 42-year-old patient presenting to the outpatient neurosurgical clinic with worsening gait imbalance, prehension difficulties and bilateral distal hand weakness over the past six months. There was weakness noted in his intrinsics and flexor digitorum profundus bilaterally, which was graded at 2/5. There was mild spasticity noted as well in his lower extremities. His modified McCormick grade was IV.3  with gadolinium revealed a 2.0 cm contrast enhancing intramedullary lesion at the C6-7 level, associated with a syrinx extending from C2 to T12. Its exact dimensions were 10mm height x 20mm length x 20mm width, for a total tumor size of 2,000mmFurther cerebral imaging did not reveal any intracranial lesion. We opted for surgical treatment to obtain a histologic diagnosis and to prevent clinical worsening due to the presence of the extensive syrinx.Surgical techniqueUnder general anesthesia, the patient was placed prone on a standard surgical bed, on soft cushions. Intraoperative neuromonitoring was performed, with leads for motor and somatosensory evoked potentials placed accordingly. The head was secured in a 3-points rigid cranial fixation head clamp. The surgical tape was used to retract the shoulders. Using standard 2D fluoroscopy, an 18mm incision was marked 1.5cm paramedian on the right at the C6-C7 level. Using sequential dilators, a unilateral, standard blunt paraspinal muscles splitting approach was performed, and a final 18mm by 5cm deep fixed tubular retractor  was placed. Its final position was confirmed by fluoroscopy  is the preferred approach. The main advantage of the DREZ approach is to preserve sensory functions on the contralateral side by avoiding manipulation of the contralateral dorsal column.The most frequently encountered long-term complication after surgery for spinal tumors is spinal kyphotic deformity . In adulIn this setting, a unilateral MIS approach can present an alternative to open laminectomy and instrumentation, open laminoplasty and mini-open unilateral hemilaminectomies. When compared to open surgery for treatment of intradural-extramedullary tumors, MIS approaches are associated with shorter length of hospital stay, lower rates of narcotics use and pain postoperatively, lower blood loss and decreased rates of symptomatic CSF leak, all while achieving similar GTR rates ,14,15.There are few reports of MIS resection of intramedullary tumors. Yüce et al.  describe3. In our case, it was 2,000mm3.Kruger et al.  reportedOgden and Fessler  also repIn our case, we found comparable results with complete resolution of his neck pain on postoperative day 1, a 4-day hospital stay, no CSF leak or pseudomeningocele. More importantly, we were able to achieve a GTR based on postoperative imaging. Furthermore, scoliosis films at six months postoperatively did not show any kyphosis at the operated level.3, a single-level hemilaminectomy was done to completely remove the tumor, limiting the extent of ligamentous damage and bony resection. Although we recognize that tumor size may cause one to shy away from this MIS approach, we demonstrate here that such approach should not be limited to only infracentimetric intramedullary tumors. To our knowledge, we present the resection of the largest tumor size at the cervical level using a minimally invasive approach.Despite the relatively large tumor size of 2 cm or 2,000mmWe recognize that the presence of the cyst in the case reported by Ogden and Fessler  helped iIndication considerationsMIS approach to IMSC tumors is feasible, but cases must be carefully selected. More ventral or lateral lesions are better approached through the DREZ. The presence of cyst or syrinx can greatly help tumor dissection and resection. Vascular anatomy must be meticulously assessed to identify the midline, and to rule out the presence of anterior feeders that must be addressed before complete resection of the tumor and can be a relative contraindication to an attempt of en-bloc resection of the tumor. Tumor size remains the main limitation of the use of an MIS approach, especially in the absence of a large syrinx or cyst.Tumors that are large, firm, without adjacent cyst or syrinx or presenting a rich vascular supply especially anteriorly that is difficult to control may warrant a wider exposition not possible with MIS approaches. The main goal of surgery remains to achieve total gross resection while preserving neurological function, and not the size of the approach.We present a clinical case of complete resection of a large cervical intramedullary ependymoma via a dorsal root entry zone, using a minimally invasive approach with a fixed tubular retractor. At six months follow-up, there was an improvement in his neurological status. There was no surgical complication, nor any post-operative kyphosis reported. The post-operative pain resolved.Although resection of the intramedullary tumor remains challenging, we demonstrate that with careful patient selection and surgical planning, a complete surgical resection of large cervical IMSC via a dorsal root entry zone approach is a safe and feasible option even using minimally invasive techniques.


JAK2V617F mutation 11 years ago presented with two protruding, reddish, easily bleeding mass lesions over her left abdominal surface for 2 months  with Tumor excision biopsy revealed dense inflammation with cystic structure and a sinus tract‐like opening toward epidermis in low power view Figure , left. IRuxolitinib, a janus kinases (JAK) pathway inhibitor, is currently the standard of treatment in higher risk myelofibrosis patients with significant benefits. However, correlation with slightly increased risk of atypical or opportunistic infection has also been reported. To our knowledge, this is the first case reporting cutaneous cryptococcosis in patient receiving JAK‐inhibitor.


Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies.We used the MESH terms “appendicitis” AND “situs inversus” AND/OR “gut malrotation” to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data.We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener’s syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition.Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case. Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. There are many scoring systems that can help to increase the clinical diagnostic accuracy of acute appendicitis –3. ScoreThis systematic review was reported in adherence with the PRISMA statement Fig.  and the The search was carried out, independently by two authors, on PubMed, Scopus, ISI Web of Knowledge, Science Direct and Directory of Open Access Journal (DOAJ) databases on April 2021. We considered studies published in English, French and Spanish languages and with available full text. Any discordance was resolved by consensus. We used the MESH terms “appendicitis” AND “situs inversus” AND/OR “gut malrotation” to search for titles and abstracts. Duplicated publications were excluded from the search. At first, titles and abstracts were screened, then the relevant full text articles were retrieved and screened. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patients clinical and demographic data.All data were extracted independently from the full text of articles. We considered the following variables: lead author, year of publication, country, study design, age and sex of the patient, pain location, WBC count, diagnostic radiological tools such as X-ray, abdominal ultrasound or CT scan, time for diagnosis, type of anatomical anomaly, surgical approach. The methodology and context of the included studies were extremely variable, and therefore meta-analysis was not indicated. The analysis of collected data was performed using SPSS software version 13.0.Among 226 records, we excluded 89 of them since they were not coherent with our systematic review. Among the remaining 137 articles, we took into consideration those whose full text was available and language was English or French or Spanish, excluding therefore 67 more papers (Fig. Among patients referring to emergency room with abdominal pain, acute appendicitis is still one of the most common conditions requiring emergency surgery with an incidence between 4 and 8% . DiagnosAcute appendicitis can occur in association with rare anatomical anomalies and in these cases diagnosis can be challenging. SIT and MM should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic process with radiological examination. The diffusion of abdominal US and CT scan significantly increased preoperative diagnosis of acute appendicitis in patients with SIT and MM. Even though abdominal ultrasound is a useful exam when acute appendicitis is suspected, sometimes it is not effective or inconclusive. CT abdominal scan may be a reasonable step to make in order to achieve the correct diagnosis when doubtful clinical and ultrasound findings are present. The role of preoperative imaging is even more important considering that in less than 70% of cases pain is localized to the left lower quadrant of the abdomen. Finally, laparoscopic approach is helpful to identify and treat acute surgical emergency and can be tailored in order to offer the best exposition of the operatory field for each single case. Although laparoscopic treatment of acute appendicitis has been practiced since the 1980s and several studies have clarified the advantages of the laparoscopic approach for this pathology from this literature review, it was found that most of these patients with anatomical abnormalities are still treated with open approach.


A 66-year-old man presented to the outpatient clinic with back pain and progressive bilateral lower limb weakness over a period of 6 months. Magnetic resonance imaging showed a large extraosseous epidural lesion at T6-T7 arising from the left T6 spinal nerve root complicated with cord compression leading to cord oedema. The lesion was excised en bloc and histopathological examination revealed benign venous haemangioma. We report this rare case of venous epidural haemangioma to be considered as a differential diagnosis in a patient with a background of previous lumbar discectomy surgery and who was a nasopharyngeal carcinoma survivor. Haemangiomas are mostly benign blood vessel tumours that can form on the skin, tissues below the skin or in an organ. Vertebral haemangiomas involve the proliferation of normal capillary and venous structures in the marrow of the vertebral body. Such lesions are commonly an incidental finding upon radiological workup. Patients are usually asymptomatic or they may have a varying degree of back pain. Intraosseous vertebral haemangiomas represent the commonest benign tumour of the spine which are usually described as neoplasm of endothelial cells that grow inside the marrow of the vertebral body as they are vascular in origin. Extraosseous spinal haemangiomas are extremely rare and an aggressive growth within the epidural space can cause compression of neural elements and result in neurological deficit. Unlike intraosseous haemangiomas, which can be detected by plain radiographs or CT scans, extraosseous haemangiomas are more elusive and are usually only evident on MRI scans. It is vital for the treating physician to consider the differential diagnosis of extraosseous epidural haemangioma (EEH) when encountering patients with apparently normal radiographs or CT scans, especially in patients with multiple distracting red herrings.We report a case of a premorbidly active 66-year-old male who complained of progressive lower limb weakness associated with numbness below the umbilicus for six months. The bilateral lower limb numbness was accompanied by mid-thoracic back pain which was preceded by a trivial fall from the ladder 3 months prior. His symptoms progressed with difficulty in micturition requiring straining. He was also diagnosed with nasopharyngeal carcinoma 10 years ago and was a survivor having completed treatment with no relapse thus far. He had an open lumbar discectomy done five years prior to presentation in another centre for radiculopathy. He denied significant loss of weight and has a normal appetite. There was no prolonged fever. He was able to stand and ambulate short distance with a walking frame at the time of consult with Medical Research Council (MRC) grade 3/5 for right lower limb and grade 4/5 for left lower limb. Bilateral knee and ankle reflexes were hyper-reflexic but there was no sustained ankle clonus. His abdominal reflex was absent. He had sensory impairment below T9 level. His tumour and infective markers were not remarkable. His other blood panels were within normal range.An MR scan Figure  was ordeThe patient underwent decompressive laminectomy and resection of the tumour and instrumented spinal stabilisation. Intraoperatively, a soft tissue mass of 30 mm × 22 mm × 15 mm was seen compressing on the dura and encroaching into the left T6 neuroforamen following laminectomy Figure . The sofA check radiograph at 1-month postoperative revealed stable instrumentations Figures -4B. Our Vertebral osseous haemangiomas with extraosseous extension are rare entities but they are widely reported in comparison to solitary EEHs -3. EEHs Extraosseous epidural venous haemangiomas are often described by their radiological findings as a cyst-like mass in comparison to cavernous or capillary haemangiomas as a solid hypervascular mass . This isThis type of haemangioma due to its progressive presentation of symptoms will require some form of management, may it be via surgery, interventional radiology for embolisation, oncological treatment or a combination of treatment as there is no consensus at the current time for its management. However, due to its nature of being extraosseous and highly vascular, a biopsy can prove tricky and difficult. Any attempt to attain a soft tissue biopsy may risk an accumulation of haematoma which may worsen neurological status. Laminectomy and a complete haemangioma excision followed by spinal instrumentation for stabilisation have proven to be successful in our case. Given their inherent nature, haemangiomas pose a high intraoperative risk of uncontrolled bleeding due to their dense vascular structures and thus surgeons should pre-empt this by making sure an armamentarium of haemostatic products and techniques are available at hand. The risk of dural involvement such as adhesion and tear should also be considered, and appropriate intraoperative monitoring should always be on board. Controversies surrounding preoperative embolisation is due to the involvement of the watershed area in the thoracic spine which may potentially be one of the main blood supply vessels to the spinal cord. In some cases, due to its highly radiosensitive nature, treatment of the pain using radiotherapy has proven useful and, in some cases, has shown good outcomes in resolving the paralysis which it causes in patients. Some literature showed that it is used as first-line treatment in aggressive and recurrent haemangiomas . PostopeAlthough intraosseous vertebral haemangiomas are the commonest benign tumours of the spine, in rare cases, an extraosseous extension of these aggressive haemangiomas into the epidural space can cause neurological events. In contrast, EEHs can mimic malignant metastasis in the spine without any bony involvement. A neurological deficit can be marked permanent if operative removal is delayed. Tissue biopsy of these rare haemangiomas can prove difficult, and often, surgical intervention is usually needed. A differential diagnosis of EEH can help surgeons better prepare the patient for surgical intervention.


Sinonasal lymphoepithelial carcinoma (LEC) is an extremely rare malignancy that shares some characteristics with nasopharyngeal carcinoma. In Asian populations, Epstein-Barr virus has been reported to be associated with LEC located outside of the nasopharynx. We report a rare case of sinonasal LEC with locoregional extension (brain and orbit). A 39-year-old Malay male initially presented with profound blurring of vision on the left eye (LE) and proptosis, followed by nasal symptoms of anosmia. Clinical examination revealed that the LE visual acuity was 6/36, with reduced optic nerve function with normal funduscopic findings, non-axial proptosis, and minimal limitation of extraocular movement. Subsequently, his vision worsened with perception of light in three days. Radioimaging studies showed soft tissue lesion at the ethmoid sinus with extensive local and intracranial extension. Microscopic analysis and immunohistochemistry confirmed the diagnosis of LEC. The patient was given induction chemotherapy followed by concurrent chemoradiotherapy with weekly intravenous cisplatin. Upon completing the fourth cycle of chemotherapy, the patient’s ocular symptoms and general conditions worsened. Repeated imaging showed worsening intracranial extension with cerebral and cerebellar edema, and the patient succumbed to death. Sinonasal LEC is a rare malignant tumor with little mention in the literature. This case was reported to highlight the importance of a high index of suspicion for acute ocular symptoms with mass. The occurrence of malignant tumors of the paranasal sinus is uncommon . LymphoeA 39-year-old Malay male with underlying allergic rhinitis presented to the ophthalmology clinic with unilateral, painless progressive loss of vision for one week and proptosis for two months. The patient also had a history of recurrent headaches averaging one to two times per week for the past three months. He was a heavy smoker but then switched to e-cigarette (“vaping”) two years ago. There was no history of appetite loss or weight loss. Visual acuity on presentation was 6/36 in the left eye (LE) and 6/6 in the right eye (RE). There was a presence of relative afferent pupillary defect (RAPD) grade 2 in the LE with reduced red desaturation and light brightness. Both anterior segments were unremarkable. Fundoscopy showed normal optic disc and macula. The extraocular movement shows a limitation in LE lateral gaze and levoelevation with non-axial proptosis  . There was fullness of the left upper and lower lid extending towards the nasal bridge  scan of the orbit, brain, and paranasal sinus Figure  revealed2 followed by concurrent chemoradiotherapy (CCRT) with a dose of 70 Gy for 35 cycles for seven weeks and weekly intravenous cisplatin 40 mg/m2. However, after completing the fourth cycle of chemotherapy, the patient developed headaches, seizures, and altered consciousness. Repeated CECT shows worsening intracranial extension with the involvement of the optic nerve. There was also the presence of diffuse cerebral and cerebellar edema. Subsequently, the patient succumbed to death after a few days.Biopsy of the mass revealed LEC. Immunohistochemistry showed tumor cells that were positive for pancytokeratin (pan-CK), cytokeratin CK5/6, and p63 gene with approximately 50% Ki-67 proliferation index, and negative for Epstein Barr encoding region in situ hybridization (EBER ISH). A diagnosis of sinonasal LEC with locoregional extension (brain and orbit) was made. The LE visual acuity of the patient vision deteriorated further to perception of light within a few days of admission. The LE proptosis became more prominent with the limitation of eye movement. The patient also had a nasal obstruction and anosmia Figure , but theSinonasal malignant neoplasm accounts for 0.1% of all neoplasms and 60% involving the maxillary sinus. It has a strong predilection for males, with a ratio of approximately 3:1 in the fifth to seventh decade of life . SinonasThe signs and symptoms differ depending on the type, location, and stage of the malignancy . The occOn standard radiography, sinonasal LEC shows a diffuse opacity of soft tissue density. CT scan of paranasal sinus shows a homogenous mass occupying the sinus cavity, which does not enhance even with contrast. The LEC cannot be distinguished from other sinonasal malignancies, particularly squamous cell carcinomas or lymphomas, and all these tumors are locally invasive with characteristics to metastases to retropharyngeal and cervical node . In termThere is no standard treatment guideline for sinonasal LEC due to the rarity of this tumor and its anatomical complexity with close proximity to vital structures . InitialIn summary, we reported a case of an aggressive tumor of EBV-negative sinonasal LEC with locoregional extension (brain and orbit) that initially presented to us with ocular signs and symptoms. Due to LEC's rarity, diagnosis is based on histopathological examination with immunohistochemical studies, but definitive therapy is still not established. Our case report reminds us of the need to bear in mind that a harmless appearing swelling combined with ocular complaints could be a rare malignancy. This rare and challenging tumor needs a systematic clinical approach with vigilance, proper diagnostic tests, and appropriate treatment. A high index of suspicion among clinicians for early recognition and timely referral with further studies to guide appropriate management is required for the betterment of patients.


A 57-year-old female presented with headache and dizziness for 3 months. Preoperative MRI revealed a lesion located at the pineal region and back side of the third ventricle, accompanied by hydrocephalus. The infratentorial supracerebellar approach may cause visuomotor, acousticomotor, and hearing disturbances. With the patient in a supine position, the authors used a frontal linear incision that was 3 cm anterior to the coronal suture and 2 cm away from the midline and an anterior endoscopic transcortical approach, which could achieve endoscopic third ventriculostomy, alleviating and preventing hydrocephalus due to postoperative adhesion and resection of the lesion at the same time. The pathological diagnosis was cavernous hemangioma.https://stream.cadmore.media/r10.3171/2021.4.FOCVID215.The video can be found here:  Anterior endoscopic transcortical approach to a pineal region cavernous hemangioma. This patient was a 57-year-old female. Her chief complaint was headache and dizziness for 3 months. MMSE [Mini-Mental State Evaluation] was 18 scores. Other laboratory findings are unremarkable.MRI showed the lesion located at the pineal region and back of third ventricle, which leads to obstructive hydrocephalus. The diagnosis was pineal region lesion (cavernous hemangioma most likely), accompanied by obstructive hydrocephalus. For the lesion located at the anterior side of pineal region, there are four approaches to access the lesion backward. Whether it is possible to access the lesion from anterior direction by endoscope? The answer is yes.1 In order to avoid these defects, tonsillouveal transaqueductal approach may be used; however, it may lead to postoperative obstructive hydrocephalus.2 So, we decided to use anterior endoscopic transcortical approach to achieve endoscopic third ventriculostomy (ETV) and resection of the aqueduct lesion.The most commonly used approach is infratentorial supracerebellar approach; however, it might result in visuomotor, acousticomotor, and hearing disturbances due to destructing the pineal, superior, and inferior colliculus in this case.With a supine position, we use a left frontal linear incision, and the center of the burr hole is 2 cm ahead of Kocher’s point, which is 3 cm anterior to the coronal suture and 2 cm away from the midline. This approach enables us to achieve an ETV and also access the posterior third ventricle at the same time.This is the procedure of craniotomy. After entering the lateral ventricle, we use coagulator and scissors to enlarge interventricular foramen. We find the floor of third ventricle sinks and is adherent closely to the basilar artery. Then we coagulate and bluntly separate it.Subsequently, we use coagulator and scissors to make ETV and further enlarge the fistula. Special attention should be paid to protect the basilar artery and surrounding vessels. Then we fill the fistula with Gelfoam. After that, we seek the lesion backward. The lesion locates at the backside of the third ventricle. It is grapelike looking and obstructs the midbrain aqueduct.Firstly, we coagulate along the surface of the lesion in a circle. We recognize the boundary between the lesion and normal structures carefully. Then we coagulate to shrink the lesion and expand the operating space. We separate along the boundary of the lesion very carefully to protect brain tissue. The direction of separation should always be toward the lesion. The inlet of aqueduct is revealed after displacement of the lesion. Gelfoam is used to protect surrounding brain tissue. The lesion is hard and calcified. We cut and remove the lesion piece by piece. After the operation, the surgical field is clean and without hemorrhage. Finally, we removed all the Gelfoams in the ventricle before the end of the surgery and check the fistula, which is fluent.At last, we made closure layer by layer, including suturing the periosteum. Postoperative CT showed hydrocephalus alleviated. Postoperative MRI revealed gross-total resection of the lesion and also demonstrated our operative pathway. Fluent flowing of cerebrospinal fluid was confirmed in CSF film 3 months postoperatively. Pathological findings show vascular tissue of different sizes and calcification, which confirms the diagnosis of a cavernous hemangioma.The patient had slightly worsened orientation and concentration 2 days after operation and no other early complication occurred. And MMSE score improved 3 months postoperatively. Neurological specialist physical examination showed good recovery of the patient.Finally, here is the summary of the operation. First, surgical approach of neuroendoscopy making needs tailoring to the individual lesion characteristics. Second, the correct procedure for the operation is first making a third ventriculostomy and then removing the lesion. Finally, the key point of the surgery is precise and careful anatomical separation and strict protection of surrounding tissues.Cranial Anatomy and Surgical Approaches. Lippincott Williams & Wilkins; 2003).The current study was financially supported by the Sichuan Science and Technology Support Program (no. 2017SZ0195) and Program of Health Commission of Sichuan Province (no. 20PJ051). Three of the pictures shown in the video are from Rhoton’s Collection (Rhoton AL: Primary surgeon: Zhou. Assistant surgeon: He. Editing and drafting the video and abstract: all authors. Critically revising the work: all authors. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Zhou. Supervision: Zhou, Li, Liu.


Cecal appendix tumors are unusual and have a low frequency of presentation, which is reported between 0.2 and 0.5% of all digestive tract tumors. From the mentioned tumors, the carcinoid ones are the most common neoplasms of the cecal appendix and are characterized in most cases by slow growth and an asymptomatic clinical course. However, in some cases, they can present as a metastatic disease with fatal outcomes. We report the case of a 24-year-old female patient with a typical case of acute appendicitis, in whom an additional diagnosis of a carcinoid tumor is obtained upon receipt of the pathology report. The prognosis of appendicular carcinoid tumors is good, with a five-year survival rate of 95%-100% and a recurrence rate of less than 1%. Acute appendicitis is the most common surgical emergency performed by a general surgeon . It is pCecal appendix tumors are unusual  and have a low frequency of presentation, which is reported between 0.2 and 0.5% of all digestive tract tumors . RegardiEven though primary appendiceal cancers are rare, there is diverse histology. Carcinoids are by far the most common, accounting for approximately 66%, with cyst-adenocarcinoma accounting for 20% and adenocarcinoma accounting for 10%.Carcinoid tumors originate from the cells of the GI diffuse endocrine system located along the lining of the crypts and in an isolated manner in the lamina propria of the digestive tract . These nDespite its low incidence, its importance lies in the fact that appendiceal tumors are exceptionally diagnosed before or during surgery, the majority being diagnosed through the pathology report of the removed appendix .A 24-year-old Peruvian woman, previously healthy, presented to the ER with a history of three days of abdominal pain beginning in the mesogastrium that, after 12 hours, migrated to the right iliac fossa. The pain was associated with nausea, vomiting, and hyporexia. She was assessed by the emergency medicine's attending physician, who requested laboratory exams and consults from gynecology and general surgery.Relevant laboratory results revealed normal hematocrit (37.8%) and leukocytosis .Gynecology ruled out adnexal pathology. When assessed by general surgery, a diagnosis of acute appendicitis was made, and an appendectomy was scheduled.A conventional appendectomy was performed without complications: A Rockey-Davis incision was made in the right lower quadrant of the abdomen, and the abdominal wall was dissected through the incision into the peritoneal cavity. After the appendix (with signs of gangrene) was found, the mesoappendix was divided between hemostats and tied with 3-0 silks. The base of the appendix was tied with 2-0 silk, and the appendix was resected using a scalpel. Aponeurosis was closed with running nylon 2-0, and the skin was closed with simple interrupted nylon 4-0. The surgery procedure report stated acute gangrenous appendicitis as the operative diagnosis. The patient progressed favorably and was discharged on postoperative day 1.The pathology report revealed a well-differentiated carcinoid tumor that infiltrated the serosa, no vascular or lymphatic invasion was observed, and the appendiceal wall presented areas of gangrenous necrosis Figure . On grosCarcinoid tumors are well-differentiated neuroendocrine neoplasms that can be found in the GI tract (55%), respiratory tract (30%), and other organs (15%), such as the kidneys or ovaries. In the GI tract, the location in the small intestine corresponds to approximately 45%, in the rectum to 20%, in the cecal suspect to 16%, in the colon to 11%, and in the stomach to 7% ,9.The description made by Lubarsh in 1888 is considered the first to report the characteristics of the carcinoid tumor. Soon after, in 1890, Obendorfert introduced the term carcinoid in an attempt to emphasize its benign nature; therefore, their malignant nature was not given importance until the end of the 1940s, and the possibility of producing metastases from them had been known since 1890 .Carcinoid tumors at the cecal appendix location occur more often between the third and fourth decades of life, affecting women more frequently than men (which corresponds to the case presented) . Its locIn tumors smaller than 1 cm in diameter, the treatment of choice is a simple appendectomy. In comparison, in tumors with a diameter larger than 2 cm, right hemicolectomy with lymph node dissection is recommended . There iRegarding a differential diagnosis, other types of appendiceal malignancies include cystadenoma, cystadenocarcinoma, goblet cell carcinoid, and colonic-type adenocarcinoma. Mucinous cystadenoma and cystadenocarcinoma are indistinguishable prior to resection when confined to the appendix. They should be resected without rupturing the appendix to reduce the risk of peritoneal seeding and the development of pseudomyxoma peritonei. When suspected preoperatively or encountered intraoperatively, a right hemicolectomy is advised if it is suspected preoperatively or identified intraoperatively. Goblet cell carcinoid and colonic-type adenocarcinoma are more aggressive tumor types. They should be treated similarly to colon cancer, including the right colon resection and adjuvant chemotherapy .Despite all the presented information, its results are contradictory as in some developing countries, the practice of sending all appendices specimens for routine histopathology examination depends on the concerned clinician and is variable. Some authors are against the policy of routine histopathological examination of every appendectomy specimen. They suggest that appendices should be sent for examination only if there is an obvious macroscopic abnormality at surgery , 20.The finding of an appendiceal carcinoid tumor, and appendiceal tumors in general, is incidental in the vast majority of cases. However, it is a diagnosis that should be considered when facing acute appendicitis, given that the overall survival rate is very high with appropriate and especially timely treatment.Routine pathology study of resected appendices is vital for adequate diagnosis and management. Therefore, we emphasize the importance of obtaining histopathological studies of every removed appendix, given the fact that visual examination does not always correlate with later pathological examination.


Cases of lateral ventricular ectopic schwannomas (LVES) are extremely rare, with only 23 cases reported thus far. This study aimed to obtain a better understanding of the disease.We reported a rare case of LVES, in which the patient was admitted to our hospital, and reviewed the relevant literature on LVES to summarize and analyze the clinical manifestations, pathologies, imaging features and progress.Of the 23 patients, LVES was more common in men  than in women and was mostly located on the right side . The average age at clinical presentation was 28 years, with an age range between 8 and 68 years. Moreover, most cases were histologically benign, except in one case of malignancy. In all the benign cases, there were 2 cases of subtotal resection, but no recurrence was found during follow-up.The origin of LVES could be the tumor transformation of autonomic nerve tissue in the perivascular choroid plexus. For lateral ventricle tumors,which are rare benign lesions with good prognosis after surgical resection, LVES should be considered in the differential diagnosis. Moreover, whether LVES could be considered for gamma knife treatment, similar to a small acoustic neuromas,requires further investigation. Vestibular schwannoma is the most common, but schwannomas occurring in the brain ventricle or parenchyma are extremely uncommon , 2. EctoHerein, we report a case of right LVES, which was misdiagnosed as a meningioma before surgery. To obtain a better understanding of LVES, this study reviewed the relevant literature on LVES to summarize and analyze the clinical manifestations, pathologies, imaging features and progress.22.1A 22-year-old Han Chinese woman presented with paroxysmal dizziness, fatigue, nausea and vomiting for 6 years, and the symptoms had worsened over the prior few months. The patient had no previous medical history and no family genetic history of related diseases, and there were no obvious abnormalities on physical examination and laboratory tests, such as blood cell analysis, blood coagulation function, blood biochemistry test, plasmic electrolyte test, cranial nerves examination, motor function and sensory function. Magnetic resonance imaging (MRI) revealed a heterogeneously contrast-enhancing, irregular, lobulated lesion (3.0 cm × 2.5 cm × 2.5 cm in size) at the posterior horn of the right lateral ventricle, and the lesion was intimately related to the choroid plexus. The mass was hypointense on T1-weighted images and iso-hyperintense on T2-weighted images  tumor transformation of the autonomic nerve tissue in the perivascular choroid plexus; (2) the transformation of multipotent mesenchymal cells into Schwann cells after tissue injury; (3) the transformation of ectopic fragments of neural crest cells into tumors in the ventricular system during abnormal embryonic development; and (4) the possibility of transformation of mesoderm-derived mesenchymal leptomeningeal cells in the brain into Schwann cells –10. In oOf the 23 cases Table 1 Surgical resection is considered to be curative. Most patients have good results after surgical removal of the tumor Table 1.These tumors cause symptoms that depend on where they are located. The most common symptoms are headache and epilepsy. Of the 23 previously reported cases, except for 4 cases where the symptoms were not recorded, 12 of the patients presented primarily with symptoms such as headache, which may be caused by the mass effect of the tumor . In our Immunohistochemical staining is indispensable for the diagnosis of ES. Sometimes it is difficult to distinguish it from meningioma visually and microscopically. S-100 and vimentin are typically positively expressed, while GFAP and EMA are often negatively expressed , 25. ThrIn terms of imaging features, LVES has specific characteristics. MRI is the best diagnostic tool for these tumors because it can be used to determine the location of the ventricles and the relationship between the tumor and choroid plexus.Combined with this case and related literature, these characteristics are summarized as follows. Cystic changes: cystic and solid changes are characteristic of this disease. The cystic part is mostly manifested as low signal intensity on T1WI and high signal intensity on T2WI, while the solid part is often characterized by slightly low signal intensity on T1WI and high signal intensity on T2WI.Moreover, contrast-enhanced MRI showed significant enhancement in the solid but not cystic areas. Edema: peritumoral edema is considered characteristic of benign schwannomas. ES is characterized by peritumoral edema of different degrees . Calcifi4The origin of LVES could be the tumor transformation of autonomic nerve tissue in the perivascular choroid plexus. Lateral ventricle tumors are rare benign lesions with good prognosis after surgical resection, and LVES should be considered in the differential diagnosis. Moreover, whether ES could be considered for gamma knife treatment, such as a small acoustic neuroma, requires further investigation.All authors contributed to the diagnosis and treatment of the patient. YuL and YX drafted the work and wrote the manuscript. HZ and JZ edited the manuscript, substantively revised it, and approved the re-submitted version. HL and XH provide substantial help to the writing of the article. XH and YuL made substantial contributions to the treatment and diagnosis of the patient. All authors contributed to the article and approved the submitted version.


Painless solid testicular masses on ultrasonography are commonly malignant. However, if the lesion is well demarcated, rounded, and hypoechoic with alternating hyperechoic and hypoechoic layers, and no internal vascular flow, the possibility of an epidermoid cyst should be considered. Epidermoid cysts are uncommon benign testicular lesions and are extremely rare in the intrascrotal extratesticular region. Including these cysts in the differential diagnosis may allow the urologist to perform testis-sparing surgery.Teaching Point: The possibility of an epidermoid cyst should be considered when a scrotal mass shows an ‘onion ring’ appearance on sonography and no vascularity on Doppler. Epidermoid cysts (ECs) are uncommon benign tumors. On ultrasonography, especially in young men, finding a testicular mass should raise suspicion for malignancy. However, in view of certain sonographic characteristics, that is, an ‘onion ring’ appearance and lack of vascularity on color Doppler imaging, ECs should be included in the differential diagnosis.A 25-year-old male was referred for sonographic evaluation after noticing a painless swelling in the left testis. Ultrasonography showed a hypoechoic, well-circumscribed, rounded 17 mm mass in the left testicle. The mass showed alternating rings of hypo- and hyperechogenicity with an echogenic central core . Color DA 58-year-old male consulted for a right-sided painless scrotal nodule present for years. The test for the HCG marker was negative, but his AFP was elevated . Ultrasonography revealed a right well-circumscribed, rounded intrascrotal extratesticular mass measuring 17 mm, associated with a moderate hydrocele. The lesion demonstrated an ‘onion ring’ appearance with an echogenic central target appearance and was avascular on color Doppler sonography , Video 1ECs are keratin-filled cysts, accounting for between 1 and 2% of all testicular tumors 14.The sonographic findings include well-demarcated round-shaped lesions with an ‘onion ring’ pattern consisting of alternating hyperechoic and hypoechoic layers 67. Howev6While ECs are benign lesions, they can be mimicked by epidermoid cysts developing in association with invasive germ cell tumors, thus representing a specific differentiation in teratomas, analogous to the occurence of other intratumoral benign structures, such as hairs or teeth. Anheuser et al. reported two such cases with preoperative imaging detecting only ‘simple’ ECs that were later associated with embryonal carcinoma in one patient and a germ cell neoplasia in situ in the other patient .A suspicion of EC by the radiologist may allow the urologist to proceed with a frozen section examination, biopsies of the surrounding parenchyma, and possibly testis-sparing surgery instead of an intentionally planned orchiectomy 5.On ultrasonography, a solid and painless solid intratesticular mass should raise suspicion of malignancy, especially in a young man. However, if the tumor markers are negative and if the lesion has a typical ‘onion ring’ sonographic pattern, well circumscribed and without vascularity on Color Doppler, ECs should be included in the differential diagnosis. If the lesion is confirmed to be an EC, the urologist may be able to perform testis-sparing surgery with frozen-section analysis rather than orchiectomy. Very rarely, ECs can be extratesticular in the cavity of the tunica vaginalis.


Malakoplakia is a rare inflammatory condition, commonly affecting the genitourinary system of immunocompromised patients. Gastrointestinal malakoplakia has been reported in the literature, with previous endoscopic findings mimicking mass lesions.To describe a case of colonic malakoplakia after referral for endoscopic management of a large non-pedunculated colorectal polyp.Case report and review of the literature.Case ReportAn 80-year-old male with chronic kidney disease and remote renal transplant on immunosuppressive therapy  was referred for endoscopic resection for a large non-pedunculated colorectal polyp in the cecum. Original presenting symptoms included chronic diarrhea, iron deficiency anemia, and fecal immunochemical test (FIT) positivity. A repeat colonoscopy demonstrated a 40mm Paris 0-IIA plaque-like lesion in the cecum with optical features not in keeping with adenomatous or serrated histopathology. Biopsies were performed with histopathology demonstrating normal colonic mucosa with confluent sheets of histiocytes with concentrically layered cytoplasmic inclusions, in keeping with malakoplakia.Literature reviewE. coli being the most common; specifically in immunocompromised patients, whether from immunosuppressive medications, immunodeficiency syndromes, or clinical conditions precluding effective immune function. Malakoplakia commonly presents as a mass-like lesion and has been found in all organs, most commonly in the genitourinary system. Diagnosis is made by biopsy and allows for appropriate treatment, which is most commonly a reduction in immunosuppressive therapy and antibiotic therapy.Malakoplakia, Greek for “soft plaque”, is a rare inflammatory condition characterized by impaired dysfunction in macrophages leading to the accumulation of incompletely degraded bacteria in phagolysosomes. Histologically, this appears as concentrically layered cytoplasmic inclusions, comprising the pathognomonic Michaelis-Gutmann bodies. Many bacterial organisms have been implicated in the development of malakoplakia, with Malakoplakia is rare but should be considered when a lesion with atypical optical evaluation features is found in immunocompromised individuals or those with recurrent infections.NoneNone Declared


Jacob’s disease is a rare entity consisting of the formation of a pseudojoint between an abnormal coronoid process of the mandible and the inner surface of the zygomatic bone. First described by Jacob in 1899, its diagnosis and definition have never been entirely univocal. In this paper, we present three emblematic cases and an extensive review of the literature on Jacob’s disease. Given the variability observed in the presentation of the disease, we have developed a proposal for the classification, here reported. In 1899, Oscar Jacob first described the eponymous disease. He noticed, as a post-mortem relief, a restricted jaw range of motion in a patient caused by an impingement between the inner side of the zygoma and the coronoid process of the mandible (CPM) . SubsequAfter having established the definition of JD as a condition where a pseudojoint forms between an abnormal coronoid process and the inner aspect of the zygoma, with a broad spectrum of presentation and pathology, we conducted a comprehensive literature review to identify the cases that matched this definition or were already identified as JD by the authors. Articles were retrieved from PubMed, Cochrane and Semantic scholar databases using the following search terms: “Jacob’s disease”, “Coronoid Osteochondroma”, “Coronoid hyperplasia”, “Coronoid process pseudojoint” and “Coronoid process enlargement”. Articles were also retrieved indirectly by screening the references of papers identified through the aforementioned keywords. The results were filtered, limiting the selection to papers written in the English language. Cases in which a certain JD diagnosis could not be established through author declaration, imaging or inferences were excluded. Full texts of all articles meeting the inclusion criteria were thoroughly reviewed for data extraction. We extracted reports of age, gender, the side and type of the CPM anomaly, MMO before and after surgery, surgical treatment approach, follow-up period and reported recurrence. A total of 116 cases, including the 3 cases hereafter reported, were selected from a total of 107 articles, and the data collected are summarized in A 19-year-old woman was referred to us, presenting with a history of progressive limitation in mouth opening over the previous 18 months. She complained of a dull pain just in front of her right ear, exacerbated by palpation and mandibular movements. She had no medical history and did not report any previous local trauma. She was initially diagnosed with temporomandibular disease (TMD) dysfunction and treated conservatively with an occlusal bite with no symptomatologic relief. At physical examination, the maximum mouth opening (MMO) was reduced to 25 mm, but mandibular movements were preserved. No articular noises during temporomandibular joint (TMJ) bilateral palpation were perceived, but she complained of pain in the masticatory muscles bilaterally. No malocclusion, facial asymmetry or swelling were identified. The orthopantomogram (OPG)  and the TM  were prescribed. At 1 month follow-up, the patient had an MMO of 20 mm, 18 mm at 2 months and 10 mm at 3 months. The cause of this negative trend was initially identified as the fibrotic retraction of the intraoral scar of the surgical access. At 5 months follow-up, the MMO was 32 mm and increased to 38 mm 1 month later. At 12 months follow-up, the MMO was 44 mm. A control CT scan was conducted and showed no recurrence and no significant changes on the contralateral side.An 18-year-old male patient with a 24-month history of worsening reductions in mouth opening was referred to our attention for an evaluation of suspected TMD. No previous history of trauma was reported by the patient, and the medical history did not report any relevant elements. A physical examination showed an MMO of 20 mm with a deviation to the right during mouth opening . The patTM . At 1 month after the surgery, the MMO was 25 mm and increasable after forcing, 2 months later it was 30 mm and 35 mm at 3 months. At 14 months follow-up, the patient MMO was stable at 37 mm, and the radiographic evaluation was negative for recurrence.A 23-year-old male patient presented complaining of a progressive limitation in mouth opening. He did not report any pain. The reduction in the MMO had been worsening over the prior 5 years. There was no history of trauma. Clinical examination revealed an MMO of 20 mm with no deviation . There wJD is a rare condition in which an elongated CPM interferes with the inner surface of the zygomatic arch, establishing a pseudojoint. In our review, which represents, possibly, the widest review in the literature, we report a mean age of 28.7 years old 5–73), with a difference in the age of incidence of almost 10 years between the two genders . In 12 cases, it was not possible to trace back the age of diagnosis of JD. We collected the data of 71 males 61.2%) and 34 females (29.3%). Unfortunately, 11 patients’ genders were not reported. These data are in agreement with what was previously reported in the literature, as affecting mainly men between the second and fourth decade 1.2% and . The lef, with a The diagnosis of JD is also often delayed because an OPG does not always permit suspecting a CPM enlargement, and the reported symptoms push the clinician to request an MRI with TMJ scans, which do not permit a proper CPM visualization. CT is frequently the last radiological examination performed. Multiplanar CT and 3D CT reconstructions, as well as VSP , represent the most effective tool for the correct diagnosis and surgical planning of JD cases. The definitive treatment of JD is surgical. Those submitted to surgery are patients that obviously cannot open their mouths properly, and this also entails anesthesiological issues, such as often having to resort to awake intubation or the use of a fibroscope. We saw that, despite this, in 66 cases (56.9%), the coronoidectomy was performed by an intraoral approach, while an extraoral approach was used 32 times 27.6%), and a combined approach was used 12 times (10.3%). This analysis shows slight differences in the rates reported in the literature but a significant 10% increase in the percentage of intraoral coronoidectomies previously reported .6%, and . Other aJD is a complex condition where a pseudojoint is established between an abnormal CPM and the inner aspect of the zygomatic bone, determining a progressive and worsening reduction of MMO. The diagnosis is often delayed because of its similarities with TMD and other more frequent causes of MMO reduction. CT scan that has to be performed for its provisional diagnosis, is often requested as the last radiological diagnostic examination. The spectrum of disease presentation is extremely wide, and a classification of the disease is certainly something useful that should be established internationally. Our proposal has to be intended as suggestive. A widely accepted classification may help physicians who detect this condition make a more specific diagnosis and more standardized treatment planning. The intraoral coronoidectomy approach is the most widely used procedure and allows a comparable clinical result to the extraoral approach with a lower risk of complications. More information about the follow-up of these patients is needed. A very low recurrence rate is confirmed.


Teaching Point: This case highlights the importance of extending the medical analysis to other areas with lumbar computed tomography, especially to the kidneys and the retroperitoneum. A 47-year-old female was admitted to the emergency with exacerbating left lumbar pain, irradiating to the inguinal region. The patient had no known medical or surgical history, other than chronical lower back pain. Laboratory workup showed no sign of inflammation or urine abnormalities, except for a drop of haemoglobin.A double-phase  contrast-enhanced computed tomography (CT) was performed. The late arterial phase showed a 54 mm heterogeneous fat containing mass involving the lower pole of the left kidney and most likely the cause for intra- and retroperitoneal fluid collections . LeakageGiven the location and the presence of active bleeding, it was decided to treat the patient by selective renal artery embolization rather than nephrectomy .Renal angiomyolipoma (AML) is a rare benign tumour, composed of thick-walled vessels, smooth muscle elements and fatty tissue. The diagnosis of sporadic AML is incidental during cross-sectional imaging in the majority of cases because the lesion is often asymptomatic and small in size. Rarely, a bulky AML can present as a palpable mass. A tumour with a diameter larger than 4 cm is more likely to develop aneurysms more susceptible to bleeding . Acute ATreatment options have to be discussed on an individual base. Selective embolization of AML is a safe and minimally invasive procedure with very few complications. It allows to achieve fast curation of the bleeding in the majority of patients. In addition, the acquired reduction in tumour size is long-lasting and significant. Partial nephrectomy, or more rarely, nephrectomy has a lower incidence of recurrence but a higher complication rate as compared with embolization and should be performed in selected patients only.


Pigmented villonodular synovitis (PVNS) is a locally aggressive benign tumour of the synovial membrane and tendon sheath. The unique presentation of this tumour is hemosiderin deposition with synovial proliferation. Depending on the situation, surgical excision is always the first line of treatment with adjuvant radiotherapy. Arthroscopic excision is preferred in some intraarticular nodular PVNS cases. This is a rare pigmented villonodular synovitis involving flexor hallusis longus, flexor digitorum longus, and tibialis posterior (TP). The tumour was entirely extra-articular without any joint involvement. The tumour was the diffuse type of PVNS and was treated by excision followed by radiotherapy. There is no recurrence till nine months of follow-up. Pigmented villonodular synovitis (PVNS) is a rare benign condition arising from the synovial membrane of joints and tendons . The firThis is a rare pigmented villonodular synovitis arising from the synovial sheath of the flexor hallucis longus (FHL), flexor digitorum longus (FDL), and tibialis posterior (TP) tendons.A 17-year-old male patient presented to the hospital with a chief complaint of swelling around the right ankle for one year. The swelling was gradually increasing on the medial aspect of the ankle. The patient had a flexible flat foot bilaterally. The right foot had more exaggeration than the other foot because of the tumour affecting medial structures. The swelling was diffuse nodular, roughly around 7 cm × 14 cm extending from the navicular bone to the medial malleolus on the posteromedial aspect of the ankle. The overlying skin was normal, and there was no sinus, venous engorgement, or inflammation. On clinical examination, the ankle, joint, and subtalar joint were not involved. No other joints were found to be involved in the body. A plain radiograph of the ankle and subtalar joint showed no abnormality  sequences of MRI, suggesting paramagnetic depositions, probably hemosiderin Figure .Some of the T2 weighted images were heterogeneous. Synovial thickening had extended up to midfoot. The tendons were normal in thickness and signal intensity. There was no involvement of the ankle joint. The lobulated thickening MRI features were consistent with pigmented villonodular synovitis Figure .After proper evaluation and preoperative workout, we planned for the excision of the lesion. The lesions were approached through a posteromedial approach to the ankle and the three tendons. The tumour tissues were surrounding the tendons of FHL, FDL, and TP. There was no involvement of the neurovascular bundle. All the tumour tissues were excised from the midfoot area to 5 cm above the medial malleolus. The diseased tissue was nodular and brownish, surrounding the tendons Figure .The tendons were found to be normal without damage from tumour tissues. The tendons were stretched due to tumour tissues but were not severe. The excised synovial tissue was sent for a histopathology examination Figure .Histopathological examination showed villous structures with focal hyperplasia. A synovial lining with underlying stroma had haemosiderin-laden macrophages, granulation tissue, and mononuclear cell infiltration. The stroma showed scattered giant cells. All the features were consistent with pigmented villonodular synovitis Figures -7.Post-operatively, the patient was given an ankle brace with medial arch support for the foot. Passive stretching exercises were started. Weight-bearing started after three days. Full range of motion of the ankle and subtalar joints was achieved soon without any instability. Postoperative radiotherapy was given because of the diffuse verity of the pigmented villonodular synovitis. The patient was followed up for six months without any recurrence.Pigmented villonodular synovitis of the foot and ankle region grows into different joint spaces and extraarticular regions diffusely because there is no compact superficial muscle layer like in other joints . CompletGuo et al. showed that pigmented villonodular synovitis of the ankle with extraarticular extension has a higher recurrence rate ,11. TheyArthroscopic excision is an effective treatment modality because of its less morbidity and smaller incision. If the PVNS is diffuse and spread along the tendon sheath, open excision is better with less recurrence . In our In feet and ankles, fusion of the affected joints reduces the chance of recurrence . It is mPigmented villonodular synovitis is a rare tumour arising from the joints and tendon sheath. Excision is still the primary modality of treatment. Postoperative radiotherapy is considered a diffused verity of PVNS. The risk of recurrence is more for the diffuse verity of PVNS. Chemotherapies like imatinib and tyrosine kinase inhibitors are still under investigation.


Primary pleural squamous cell carcinoma (PPSCC) is a sporadic disease that is rarely reported in the literature. Due to its low incidence, the pathogenesis of PPSCC is unknown.We report a case of a 68-year-old male with PPSCC and sizable pulmonary bullae. Two months after complete resection of both lesions, a total dose of 50 Gy radiotherapy was administered over the operative field. After more than a year of follow-up, the patient is in steady condition without any sign of recurrence.Since PPSCC is rarely reported, our case proposed that complete surgical resection combined with radiotherapy may be a promising therapeutic approach. Among epithelial tumors derived from the pleura, the most common are mesothelial tumors such as malignant mesothelioma . HoweverA 68-year-old male complained of right-sided chest pain for 4 months with no other symptoms. He did not have history of echinococcosis, tumor, or tuberculosis. However, he had been smoking 20 cigaretes and drinking 100 g of alcohol daily for 40 years. Physical examination revealed no relevant findings. Routine blood and urine tests showed no anemia or proteinuria, respectively. Computed tomography (CT) revealed thickened pleura on the right anterolateral aspect of the chest wall, a soft tissue mass adjacent to the chest wall surrounding part of the 3rd and 4th ribs, a big pulmonary bulla with a size of 4.4 cm × 5.1 cm, and normal mediastinal lymph nodes . We recoSMARCB1/INI1 gene, which was a tumor suppressor gene. The loss of SMARCB1 was associated with malignant tumors of the kidney, gastrointestinal tract, pancreas, and uterus (PPSCC is an extremely rare disease, with sporadic cases reported in the literature. Due to its low incidence, the pathogenesis of PPSCC remains largely unknown . Emergind uterus . As for d uterus . In thisd uterus , 5, 11. Resection is a recommended approach for local tumors . RüttnerWe reported a rare case of PPSCC combined with pulmonary bulla in an elderly patient. Complete surgical resection combined with radiotherapy achieved more than 1 year of disease-free survival, which may provide a reference for the treatment of PPSCC.


A 69‐year‐old male patient presented with bloody pleural fluid effusion and elevated beta‐human chorionic gonadotropin (β‐hCG) levels obtained by thoracentesis. The patient's condition rapidly deteriorated, and he died. The autopsy revealed primary pulmonary choriocarcinoma. Early diagnosis of choriocarcinoma based on β‐hCG levels in the pleural fluid may be possible. We report the case of a male patient with primary pulmonary choriocarcinoma who died within a short period. Bloody pleural fluid effusion with high human chorionic gonadotropin levels may be used as a marker for early diagnosis of choriocarcinoma. Primary pulmonary choriocarcinomas (PPC) are rare, with only 65 cases reported to date.Here, we describe the rapidly progressing clinical course of a male patient with primary pulmonary choriocarcinoma and suggest that β‐human chorionic gonadotropin (β‐HCG) measurement in pleural fluid effusion may contribute to early diagnosis.2A 69‐year‐old man with bronchiectasis, hypertension, hyperlipidemia, and a history of smoking 13 packs per year visited another hospital 3 months earlier for left shoulder pain and was found to have a 20 mm large left upper lung lobe nodule Figure . In addi3Choriocarcinoma is a disease characterized histologically by sheets of cellular trophoblastic and syncytial trophoblastic cellsThe prognosis of this tumor is extremely poor despite surgical treatment and chemotherapy.However, since there are many reports that surgery and postoperative chemotherapy are effective,This case illustrates two important clinical points.First, choriocarcinoma is considered a tumor tissue with high blood flowSecond, in choriocarcinoma, tumor samples are small and cytology is difficult because of hemorrhage and necrosis.It should be noted that large cell carcinoma,Therefore, in cases where a bloody pleural effusion is obtained, the measurement of β‐hCG is recommended, suggesting that it may aid in early diagnosis and treatment.KI wrote the initial draft of the manuscript and was responsible for drafting and image modification. KI, KW, HK, and SY were directly involved in treatment, critically revised the manuscript, and approved the final version.This research was not supported by any specific grant from any funding agency in the public, commercial, or nonprofit sectors. Therefore, no funding body was involved in the study design, collection, analysis, and interpretation of the data, writing of the manuscript, or decision to submit the manuscript for publication.None.Consent for publication was obtained from living patient prior to submission.


A 68-year-old man, without a family history of cancer, was treated for primary cutaneous melanoma of the scalp. Two years later, a right lateral cervical lymph recurrence was observed and he was treated with lymphadenectomy and adjuvant nivolumab for 1 year. Four years from the initial melanoma diagnosis, a computer tomography scan showed a solid nodular lesion of 26 × 40 × 75 mm inside the previously known inguinoscrotal hernia. A new recurrence of melanoma was the most probable diagnosis and a right inguinal hernioplasty was performed. Notably, the histopathological examination revealed a mesenteric fibromatosis with the typical immunohistochemical pattern (strong nuclear staining of β-catenin). Interestingly, this represents the first case of a patient with a mesenteric desmoid tumour presenting as an inguinal hernia masking a cutaneous melanoma recurrence. Aggressive fibromatosis, also known as desmoid tumour (DT), is a benign, locally invasive, non-metastasising neoplasm with a very high rate of recurrence. This entity represents 0.03% of all neoplasms and less than 3% of all soft tissue tumours , 2.DTs can arise in virtually any part of the body, and according to their main localisations, they are classified as extra-abdominal (60%), abdominal wall (25%) and intra-abdominal (8%–15%) , 4.Mesenteric fibromatosis represent 0.73% of all abdominal tumours and accounts for up to 8% of all desmoid neoplasms . InteresHere, we report the first case of a patient, with prior diagnosis of melanoma, with a mesenteric DT presenting as an inguinal hernia. In this case report, Case Reports (CARE) guidelines were followed and the patient’s authorisation was obtained before manuscript submission.A 68-year-old man, without a family history of cancer, was diagnosed with a pT2N0M0 BRAF  wild type primary cutaneous melanoma of the scalp in April 2017. The treatment approach included a wide tumour resection and a sentinel lymph node biopsy. After that, the proposed follow-up scheme was physical examination and computer tomography (CT) scans every 6 months. Of note, in the baseline CT scan, a small right inguinal hernia with adipose content was evidenced.Two years after the initial diagnosis, an enlargement of a right lateral cervical lymph node was detected. A core needle biopsy confirmed the presence of melanoma recurrence. At this time, the patient underwent a right cervical lymph node dissection, obtaining 2 out of 23 lymph nodes with melanoma metastases. Adjuvant treatment with nivolumab was completed for 1 year with excellent tolerance.In September 2021, 4 years after the initial melanoma diagnosis, a follow-up CT scan showed a solid nodular lesion of 26 × 40 × 75 mm inside the already-known inguinoscrotal hernia . In thisDuring the last follow-up exam (December 2021), the patient remained with no evidence of the disease.DTs appear to be of aponeurotic origin, have a benign histological appearance and result from an aggressive fibroblast–myofibroblast proliferation . John MaHowever, the real aetiology of mesenteric fibromatosis remains unknown. Most cases have been reported in association with Gardner’s syndrome, previous trauma and prolonged oestrogen exposure, but mesenteric fibromatosis can occur as a primary condition in the absence of any predisposing factors .Atypical localisation of DT represents a diagnostic challenge. Watchful waiting is usually the first recommended approach.et al  OR  OR “abdominal fibromatosis”[All Fields] OR (“mesenteric”[All Fields] AND “fibromatosis”[All Fields]) OR “mesenteric fibromatosis”[All Fields] OR  OR “aggressive fibromatosis”[All Fields] OR (“desmoid”[All Fields] AND “tumor”[All Fields]) OR “desmoid tumor”[All Fields]) OR  OR “aggressive fibromatosis”[All Fields] OR (“aggressive”[All Fields] AND “fibromatosis”[All Fields])) AND  OR “inguinal hernia”[All Fields] OR )).


Jejunal diverticulitis is an uncommon pathology wherein a delay in diagnosis can lead to significant morbidity and mortality. We report a case of such diverticula requiring operative management, after patient failed non‐operative management, likely due to advanced jejunal inflammation from a delay in diagnosis and subsequent management. With a low reported incidence rate, jejunal diverticulitis can be easily overlooked in elderly patients presenting with nausea and abdominal pain. A delay in diagnosis and treatment has potential for intestinal obstruction, bleeding, and perforation. Mortality rates of 40% have been reported in cases of perforation secondary to jejunal diverticulitis. The data from the published articles regarding patient demographics, presentation, length of stay (LOS), and management were compiled and described.3An 85‐year‐old man presented as a hospital transfer with leukocytosis, nausea, and worsening intermittent, sharp, periumbilical abdominal pain previously requiring multiple visits to an outside emergency room. The patient had been treated with oral antibiotics as an outpatient for suspected sigmoid diverticulitis but had failed outpatient management. During his third visit to the outside emergency department, a CT scan was obtained which demonstrated proximal small bowel diverticulosis and severe sigmoid diverticulosis, with no diverticulitis noted. He also reported a bright red bowel movement prior to transfer. With the combination of periumbilical abdominal pain, bright red bowel movement, leukocytosis, and severe sigmoid diverticulosis demonstrated on CT scan, colonic diverticulitis was suspected. The patient was transferred to our facility and admitted to the emergency general surgery service, where he was initially treated conservatively with intravenous antibiotics and bowel rest. By hospital Day 4, he remained afebrile and hemodynamically stable but continued to endorse focal tenderness to palpation in the periumbilical region, and a second CT scan was obtained which demonstrated a prominent small bowel diverticulum with internal fecalization and newly seen wall thickening with adjacent fat stranding Figure . Redemon4Jejunal diverticulitis is a rare disorder associated with a high morbidity and mortality, primarily due to the elderly age group of the patients most commonly affected. The aforementioned case demonstrates the symptomatic potential of the disease. Although the reported incidence rate of jejunal diverticulosis is low, some studies have shown 10%–15% of diagnosed cases required surgical intervention for sequelae of jejunal diverticulitis including perforation, obstruction, peritonitis, or gastrointestinal bleeding.Due to its uncommon nature, diagnosis can often be delayed or missed. If jejunal diverticulitis is suspected, an abdominal acute series can be obtained with attention to any free air under the diaphragm indicating perforation, or signs of obstruction indicated by dilated loops of bowels with air‐fluid levels. CT scanning can provide additional detail and information regarding the segment of bowel affected, as well as additional lesions, and evidence of inflammation, such as thickening of the bowel wall and fat‐stranding.The treatment of choice for complicated jejunal diverticulitis is an exploratory laparoscopy or laparotomy with resection of the diverticulum or segmental resection of small bowel. Non‐surgical management, with intravenous fluids, antibiotics, and bowel rest, has shown to be useful in acute uncomplicated cases. Knowledge of the possibility of conservative management of these stable patients is of great importance, as not all patients with jejunal diverticulitis require a laparotomy.Table 5In summary, jejunal diverticulitis is an uncommon disease that can cause serious morbidity and mortality. A review of the literature demonstrates a mix of operative and non‐operative management for this disease. The reported case details the progression of symptoms leading to surgical intervention. Early initiation of treatment with intravenous antibiotics could potentially prevent a morbid surgical procedure in the elderly population, where jejunal diverticulitis is most often seen.D. Scheese conceived the idea for the document and contributed to writing and editing of the manuscript. Y. Alwatari contributed to writing and editing of the manuscript. J. Khan contributed to writing and editing of the manuscript. A. Slaughter reviewed and edited the manuscript. All authors read and approved the final manuscript.None.None.Ethical approval was not required and patient identifying knowledge was not presented in the report.Published with written consent from the patient.


Sinonasal inverted papilloma (SNIP) is a rare benign tumor of paranasal sinuses. SNIP is known to be locally aggressive, with high rates of recurrence and a high potential for malignant transformation. We present a patient who presented with right-sided cheek pain and swelling for two weeks. The initial biopsy revealed SNIP. However, postoperative histopathology examination results revealed synchronous squamous cell carcinoma (SCC) with sinonasal inverted papilloma. Although the initial biopsy result showed a benign lesion, the aggressive features such as bony destruction and orbital involvement in computed tomography scan should raise a suspicion of a malignant lesion. Imaging features of SNIP from synchronous SCC are discussed. Sinonasal inverted papilloma (SNIP) is a benign tumor of the paranasal sinuses. SNIP is a histological subtype of papilloma that originates from Schneiderian mucosa, an ectodermally derived respiratory epithelium. SNIP accounts for the majority of Schneiderian papilloma, and other subtypes include exophytic papilloma and oncocytic papilloma . DespiteSynchronous carcinomas are defined as carcinoma that occurs simultaneously or within a six-month period of the primary malignancy, while it's considered metachronous after this period . Five-yeWe present a patient who presented with right maxillary swelling reported to be SNIP; however, in imaging, it shows extensive bony destruction and therefore warranted an open surgery; histopathological examination (HPE) revealed synchronous SCC with SNIP. In this report, we discuss how to differentiate SNIP with synchronous SCC and its management based on literature.A 65-year-old man who was a chronic smoker but with no known comorbidities presented with right cheek pain and swelling for two months. The swelling was progressively increasing in size immediately after tooth extraction two weeks prior to the presentation. Nasoendoscopic examination revealed a right pinkish irregular nasal mass arising from the right middle meatus. A biopsy was taken, and a histopathological examination reported SNIP Figure . ContrasDue to the extensive nature of the swelling, he underwent right total maxillectomy and ethmoidectomy via classic Weber-Ferguson incision Figure . His orbMicroscopic description Figure  showed iSNIP is a rare tumor of paranasal sinuses and nasal cavity, which only accounts for 0.5-4% of all sinonasal neoplasms with an incidence of 0.2-1.5 cases per 100,000 patients per year . Our patAn average percentage of malignant transformation of SNIP reported in the literature is 10% ranging from five to 27% [6}. Mirza et al. reported a 7.1% incidence of synchronous and 3.6% metachronous SCC in SNIP . Our patIt is challenging to differentiate SNIP and malignant transformation preoperatively, as there are no distinct clinical signs in-between these two . Even hiSome radiological features help to differentiate SNIP from its malignant counterpart. Bony erosion and orbital wall involvement in CT imaging were suggestive of an aggressive tumor. However, orbital wall involvement was found in both recurrent tumors of SNIP and SNIP with SCC . Jeon etMagnetic resonance imaging (MRI) is superior to CT in distinguishing between SNIP and SNIP with SCC. SNIP demonstrated a unique pattern on MRI known as a convoluted cerebriform pattern (CCP), which is a mix of linear or curvilinear hyperintense and hypointense striations partially or diffusely seen in solid components of the tumor on T2-weighted or contrast-enhanced T1-weighted MRI . Sixty pGenetic factors such as muscle segment homeobox gene 2 (MSX2), programmed cell death 4 (PDCD4), Kirsten rat sarcoma virus gene (KRAS), and phosphatase and tensin homologue (PTEN) are postulated in malignant transformation. Proteins such as SCC antigen, fascin, survivin, cyclooxygenase-2 (COX-2), cell adhesion molecules, and Ki-67 are found at higher levels in SNIP with SCC than in SNIP. However, a recent systematic review by Long et al. demonstrated that none of the aforementioned biomarkers conclusively differentiate SCC from SNIP currently . Several other authors have also recommended a combination of CT, MRI, and PET/CT as a preoperative workup to differentiate SNIP from synchronous SNIP . HoweverAn aggressive surgical approach to remove the tumor completely with postoperative radiation therapy is the recommended treatment for SNIP with SCC. Completeness of removal appears to be the key aspect, not the approach .A rapid increase in the size of a nasal swelling should raise a suspicion of malignant disease or malignant transformation of SNIP. CECT and MRI preoperatively can aid in an accurate diagnosis of synchronous SNIP with SCC from SNIP alone. Aggressive treatment of surgery and adjuvant therapy such as radiotherapy is required to prevent recurrence and to improve the overall survival rate.


Omental infarction is a rare cause of acute abdominal pain, and its rarity is mainly due to its relatively rich blood supply by multiple collateral vessels. It usually presents with right lower quadrant pain, as left-sided torsion is infrequent and is usually diagnosed intraoperatively.Since omental infarction is frequently diagnosed by CT scan, conservative management should be considered in most patients to avoid subjecting the patients to unnecessary surgical intervention.We present a rare case of idiopathic omental infarction in which the patient was initially radiologically diagnosed with Meckel's diverticulitis but was later found to have omental infarction on diagnostic laparoscopy. Omental infarction due to torsion is a rare condition, and idiopathic infarction is furthermore rare; only 400 cases of omental infarction have been reported in the literature . TypicalA 17-year-old previously healthy male presented to the emergency room with a two-day history of abdominal pain. The pain started in the right lower quadrant, then became more generalized, with no history of fever, nausea, or vomiting, no changes in bowel habits, or a loss of appetite. On further assessment, the patient's vital signs were normal, his abdomen was lax with mild tenderness in the periumbilical area, and his labs were as shown in Table To complete his evaluation, a computed tomography scan , which was resected; and a small bowel was run without any gross pathology detected. Therefore, a diagnosis of omental infraction was made, and an omentectomy was done for the ischemic part, and the fluid was sent for culture. The patient postoperatively was doing well, started on diet gradually, and was discharged on day 2 postoperatively with a follow-up appointment in the clinic. Later, the fluid culture was negative, and histopathology proved omental hemorrhagic infarction. The patient was reassured and discharged from the general surgery clinic.The great omentum is a double fold of peritoneum that extends from the greater curvature of the stomach to the transverse colon. It is regarded as the policeman of the abdomen as it is rich in lymphatic tissue, and therefore its role is to defend against intra-abdominal infection .Omental infarction is a rare cause of abdominal pain; almost 400 cases have been reported in the literature . The usuTorsion of the omentum can be either primary, where no other intra-abdominal pathology could be identified, or secondary infarction, in which case a pathology could be identified that could act as a lead point for torsions like adhesions, tumors, or hernias. However, in rare cases, omental infarction could be idiopathic without torsion, in which case no clear mechanism can be identified. Some case reports have regarded abdominal trauma, mesenteric artery occlusion, obesity, or congestive heart failure as possible causes of idiopathic omental infarction . HoweverDiagnosis of omental infarction is quite challenging as it mimics features of acute abdomen, CT abdomen therefore would be the imaging of choice to exclude other causes of acute abdomen, including acute appendicitis, diverticulitis, epiploic appendagitis, and perforation .The expected CT features in omental infarction would include a focal area of fat stranding and swirling of omental vessels in omental torsion with a hyperdense peripheral halo . HoweverThere has been controversy in the management of omental infarction with no specific guidelines in the literature, and thus it should be decided individually based on the clinical findings and imaging .Conservative management includes oral analgesics, anti-inflammatory medications, and antibiotics. The advantage of early surgical intervention is the reduced incidence of necrosis, abscess formation, and adhesion formation. Laparoscopic surgery can also decrease the patient's time in the hospital . In our After ruling out other differentials, omental infarction should be considered as a differential in patients presenting with acute abdomen. Specific CT scan features can help in supporting the diagnosis, and management would be case-based. In our case, CT features were not supportive, and our previously healthy 17-year-old patient was successfully managed by a laparoscopic approach due to persistent pain.


Meckel’s diverticulum is generally asymptomatic, but it may become symptomatic due to various reasons and maybe the etiology of the acute abdominal syndrome. Bezoars are formed by the combination of non-digestible substances in the gastrointestinal tract, and which are among the rare causes of intestinal obstruction. The formation of bezoars in Meckel’s diverticulum and subsequent intestinal obstruction is a rare condition. In this article, two cases with intestinal obstruction due to bezoar in Meckel’s diverticulum and their surgical treatment had presented. Bezoars are made up of substances taken by mouth, and which cannot be digested and accumulate in the stomach and small intestine. They have been named by different names according to the type of material they contain  [obezoar) . Phytobeobezoar) . Meckel’obezoar) . While iobezoar) . Phytobeobezoar) .Case 1 – A 34-year-old female patient was admitted to the emergency department with complaints of severe abdominal pain and vomiting lasting for 1 day. There was no history of a co-morbid disease or previous abdominal surgery. Hemodynamic parameters were stable at presentation . Physical examination revealed abdominal distention and generalized tenderness, but no rebound was detected. Laboratory investigations were normal, except leukocytosis . Conventional abdominal X-ray showed air-fluid levels consistent with mechanical intestinal obstruction . Physical examination revealed abdominal distention and generalized tenderness, but no rebound was detected. Laboratory investigations were normal, except leukocytosis (10.500/mm3). Conventional abdominal X-ray showed air-fluid levels consistent with mechanical intestinal obstruction (truction . In abdotruction . In the truction . The patMeckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract and encountered in approximately 2% of the population . AlthougIt has been reported in the literature that a history of gastric surgery such as pyloroplasty or gastrojejunostomy, where the gastric outflow pathway is enlarged, the presence of medical conditions such as hypothyroidism with slowing gastrointestinal tract passage and diabetes mellitus, are factors that facilitate the intestinal phytobezoar formation . On the Abdominal CT is quite effective in the diagnosis of intestinal bezoar cases, and sensitivity and specificity rates were reported as 90% and 57% in the presence of obstruction .As a result; although bezoars are among the rare causes of intestinal obstruction, they should have considered as the first diagnostic option in the geographic regions in which high fibered food consumption is a tradition. Since the presence of Meckel’s diverticulum constitutes a potential site for bezoar accumulation in the intestinal tract, it should be kept in mind that these two rare conditions may coexist.