Splenosis, an autotransplantation of splenic tissues in another compartment of the body, is only symptomatic when hematologic diseases have recurred or compression of other adjacent structures have occurred. Therefore, we report a clinical case of a patient with bowel obstruction due to splenosis.A patient with a history of splenectomy, presented to the emergency room for abdominal pain and obstipation, suggesting intestinal obstruction which is also seen on CT scan. During laparotomy, multiple splenic nodules were seen on the mesentery of the small bowel and colon, with vascular bridges between them, resulting in bowel obstruction. Resection of splenic nodules was performed. The post-operative course was uneventful and the patient was discharged a week after.Although very rare, gastrointestinal symptoms may sometimes be described in patients with splenosis. Bleeding or obstruction can occur because of intramural grow or external compression, respectively. Treatment consists of resection of these nodules.Splenosis should always be thought in patients with previous splenic rupture and presenting with incidental nodules seen on imaging, with further investigations when symptoms are present. KnowlSplenosis should be differentiated from the congenital accessory spleen, which arises from the left side of the dorsal mesogastrium during the embryological period of development .We present in this report a case of splenosis post splenectomy, with vascular bridges between multiple splenic nodules causing simultaneous small bowel and colon obstruction.This report is reported in line with the SCARE criteria .2A 46 year old male patient presented to our emergency department with a 24 h history of diffuse abdominal pain and obstipation. It was not associated with vomiting or fever. The patient has a negative medical history, but a surgical history of splenectomy 12 years ago, post traumatic rupture of the spleen. On presentation, patient was afebrile, and vital signs were within normal limits. On physical exam, his abdomen was distended with diffuse tenderness. His blood tests showed a high White blood cell count of 23040/ mm³[4000–10500], with normal hepatic and pancreatic enzymes. CT scan of abdomen and pelvis showed multiple splenic nodules in the left upper quadrant, with small bowel distention and air-fluid levels mostly in the jejunum, suggesting an intestinal obstruction. A decision for exploratory laparotomy was made 3First described by Albrecht in 1896, the term splenosis was first used by Buchbinder and Lipkoff in 1939 . Its incDifferentiation between splenosis and accessory spleen is not so complicated, as accessory spleens are usually fewer in number, with a maximum of six, whereas more than 100 splenic nodules can be found in the other case . AccessoThis mechanism starts with splenic rupture, either from surgery or trauma. The splenic pulp is spilled in the surrounding structures and the seeding begins, giving birth to multiple splenic nodules over time ,7. AnothMost patients are asymptomatic, and splenosis is found during imaging or surgical procedures done for other conditions. When symptoms persist, it consists mainly of abdominal pain (maybe due to infarction), bowel obstruction, caused by external compression, and gastrointestinal bleeding due to intramural grow of splenic nodules in the bowels ,6,12,13.Although splenosis is a benign condition, it can mimic malignant lesions such as lymphoma, therefore diagnosis can be challenging. It is seen usually incidentally on ultrasound, CT scan or MRI, which can’t confirm the diagnosis; however, CT scan with IV contrast may lead to the correct diagnosis in a patient with previous splenectomy or splenic trauma ,16. MRI The diagnosis of splenosis being confirmed, no further evaluation or treatment is recommended when the patient is asymptomatic, as no death from splenosis was described in the literature. However, presence of symptoms prompts therapeutic intervention. Our case is the first case described in the literature where bridges between different splenules were causing the bowel obstruction, while in the other rare cases, it was caused by intra-mural splenic growth, adhesions or mechanical obstruction from scarring and shortening of the mesentery. The mechanism of this presentation is not totally understood, but the authors believe that it’s caused not by neovascularization, but by elongation of branches of splenic vessels after traumatic fragmentation, with splenules migrating downward to the mesentery of the bowels due to gravity.4Splenosis should be always kept in mind in patients with previous splenic rupture and/or splenectomy, showing incidental nodules on imaging done for other conditions, thus avoiding unnecessary invasive diagnostic procedures; while further evaluation is recommended when symptoms like bleeding and obstruction are present.We have no conflict of interest to declare.No funding source.The submitted article is a case report, ethical approval has been exempted by our institution.The patient was consented for operation and for publication of the case report and imaging.Alaa El-Kheir: paper concept, design, data collection, interpretation and writing the manuscript. Jihad Boutros and M. Abdelnour: reviewing and editing. Jihad Boutros was the operating surgeon and responsible for drafting and revising the article content and for the final approval of the manuscript prior to submission.Not applicable.Dr. Jihad G. Boutros.N/A.Not commissioned, externally peer-reviewed.


In recent years, the incidence of placenta accreta and associated complications has increased significantly. The authors report the case of a pregnant woman in the 5th month of pregnancy for premature rupture of the membranes. The placenta was inserted low. The evolution was marked spontaneous work followed by the expulsion of the fetus. The delivery of the placenta was haemorrhagic and incomplete. Ultrasonic testing showed a placental fragment integrated in the thickness of the myometrium. Conservative treatment with methotrexate was published a few days later and MRI showed that the anterior uterine sac was filled with blood clots associated with pelvic effusion. A laparotomy was then performed to resect the pouch and the one-piece fragment. The follow-up was uneventful. Placenta accreta or abnormally adherent placenta remains a source of concern to any obstetrician despite the progress made in terms of both diagnosis and management during delivery and the postpartum period. Because of the dramatic increase in its incidence in the last few decades, together with the rise in caesarean delivery rates and the still-high maternal morbid-mortality rates, much more vigilance is required. Furthermore, a rescue hysterectomy has a significant psychological impact, mainly because of early permanent loss of fertility. This is why there is a tendency to opt for a conservative treatment whenever possible.Many authors , 2 reporA 26-year-old woman, fourth parity second gesture two abortion (G4 P1 A2), was referred to our hospital for a 24-hour history of premature rupture of membranes. She was at 22 weeks of gestation with a normal pregnancy. She had a history of prior cesarean section due to severe preeclampsia at 34 weeks of amenorrhea (WA) three years earlier, a spontaneous miscarriage, and a medication-induced termination of pregnancy without complications. Apart from this, she had no other significant past medical history.3 and that was why the prescription of antibiotic therapy was justified.On admission, the clinical examination showed a clear amniotic fluid flow, a spaced out uterine contraction pattern, and a one-centimeter dilated and 50% effaced cervix. An ultrasonographic examination revealed an ongoing viable pregnancy, anamnios and a low-lying anterior placenta with multiple lacunae . The bioThe evolution was marked by the expulsion of the fetus after 4 hours and the complete retention of the placenta despite an oxytocin infusion already on for 6 hours without any bleeding. The fetal weight was 560 grams.The patient was then transferred to the operating room for uterine revision under general anesthesia. This was difficult and haemorrhagic due to an abnormally adherent placenta. The initial amount of blood lost was about 1200 ml. To control bleeding, a Sulprostone infusion was required in addition to 4 packed red blood cells and 4 fresh frozen plasma bags. An ultrasound performed immediately postabortion revealed only a 3 cm isthmic and echoic image suggestive of a retained placenta increta . TherefoGiven the patient's favorable initial evolution, she was discharged on the 5th day with an ultrasound control scheduled in about ten days. The ultrasound showed a swelling of the isthmic region in the form of a hernial sac containing a heterogeneous echoic image of 7 cm along its long axis. There was no associated abdominal effusion. A further exploration by pelvic MRI confirmed previous uterine herniation and revealed a content that was suggestive of an organized hematoma. It also led to a suspected uterine scar dehiscence with possible loss of substance at this level . After tA surgical exploration revealed an unruptured isthmic hernial pocket, covered by the peritoneum and traversed by multiple dilated veins . Conductβ-HCG level. The histopathological examination of the resection specimen confirmed the increta character of the placenta. A hysterosalpingogram performed 6 months later showed a normal uterine cavity without isthmocele.Subsequent follow-up was uneventful without any abnormal bleeding. A pelvic ultrasound was normal and there was an insignificant Our case illustrates well the progressive continuation of a fragment of placenta increta left in place after delivery in the second trimester of pregnancy on a cicatricial uterus despite the medical treatment with methotrexate. This fragment was at the origin of an anterior and isthmic uterine sacculoform neoformation.In recent decades there has been a rise in the incidence of placenta accreta and its variants (increta and percreta) coinciding with an increasing number of caesarean sections worldwide , 4: currSeveral risk factors are described in the literature, the most important of which are caesarean section scars and curettage . These tDespite its low incidence, placenta increta continues to be the most feared complication in obstetrics as it is one of the main causes of maternal and fetal/neonatal morbidity and mortality , 8.The ideal management of this complication remains uncertain although much progress has already been made . IdeallyConventionally, the recommended management consists in a caesarean hysterectomy or hysterectomy scheduled as soon as the diagnosis is retained after the delivery of the fetus, in the presence of a multidisciplinary and experienced team . HoweverSince the publication of the first case managed conservatively by Arulkumaran et al. in 1986  leaving Although medical imaging is useful for antenatal diagnosis, findings suggestive of placenta increta are not always obvious. In a recent and extensive review of 167 placenta accreta cases, only 44% of them were suspected on ultrasound . In anotUltrasound diagnosis of placenta accreta is suspected when there is at least one of the following signs: placental lacunae, obliteration of the retroplacental clear space, interruption of bladder boundaries, andmyometrial thickness less than 1 mm . In our The MRI is not a first intention in screening, but it is of great help in the presence of technical difficulties with ultrasound  or to make an extra uterine lesional assessment when placenta percreta is suspected . It is tUterine herniation is a rare and specific complication of pregnancy in which a weakened part of the uterus is transformed into a pouch or hernial sac whose wall contains all the usual uterine layers . Cases rElsewhere, the retention of a placenta increta fragment is manifested by the delayed onset, in relation to the abortion date, of a heterogeneous echogenic uterine mass. This interval varies from 2 weeks for Ju et al.  to 3 yeaThis abnormal placentation also predisposes, as described in our observation, to premature delivery and premature rupture of membranes , 22. In Several therapeutic options for conservative treatment are described in the literature , 7, 9. T2 body surface area dose of methotrexate to promote placental resorption or its secondary delivery. The median timerequired for complete spontaneous resorption of the placenta was 13.5 weeks (range: 4-60 weeks) in the Sentilhes et al. [The adjuvant therapy was based primarily on the administration of a 50 mg/ms et al.  review. s et al. .Overall, Sentilhes et al. found a conservative treatment failure rate of 22%. In these cases a hysterectomy was performed either immediately or secondarily given the extent or recurrence of bleeding or for severe sepsis .In our case, despite the prescription of methotrexate, the placental fragment left in place was a source of endometritis and a progressive increase in the volume of the hernial sac probably due to the pressure exerted by bleeding. An exploratory laparotomy was then carried out on the 18th day for fear of imminent uterine rupture and to control the infection. Indeed the excision of the increta fragment allowed us to repair the weakened uterine zone and to control the infection.Other authors reoperated on their patients to complete the resection of an evolutive placenta increta fragment by laparotomy , hysteroThe trophoblastic invasion of a pregnancy implanted on a cicatricial uterus is a situation that has been on the rise in recent years due to the increase in obstetric scars. This invasion may be the source of an abnormal placentation that causes weakening of the isthmic region, which becomes thin, and an abnormal adherence of the placenta. These abnormalities may in turn be responsible for obstetric morbidity caused by premature rupture of the membranes, late abortion, severe postabortion or postpartum hemorrhage, and placental retention. The retention of a fragment of placenta increta after abortion may remain poorly symptomatic initially and may cause, by an excess of pressure on an already thinned and weakened area, an anterior bulge like a hernia sac. Thus a mass made of placenta and embedded blood is made and can be complicated by infection, rupture, and hemorrhage. The diagnosis is guided by systematic ultrasound which should check, in addition to uterine emptiness, the condition of the lower segment to search in the thickness of the uterine wall of an evocative heterogeneous echogenic image. The MRI is a more precise imaging procedure for identifying herniation and its content. To treat this mass, two approaches can be adopted on a case-by-case basis according to the state of the patient and the radiological workup of the lesion. The first treatment modality is medical, based on methotrexate injections and regular monitoring until the involution of the mass. The second is surgical, aiming at either extracting the increta fragment by curettage or better by hysteroscopy or resecting the hernia and its contents followed by complete reconstruction of the lower segment. It seems that the latter solution is the safest and can be performed by laparotomy or laparoscopy. Arterial embolization may be associated with this treatment.Conservative management of uterine herniation due to placenta accreta should be considered as the first-line approach for women who desire future fertility. Otherwise, hysterectomy may be the ultimate life-saving solution in case of failure of conservative approaches or if required by the workup of the lesion.


Raoultella planticola osteomyelitis is rarely reported in the literature. The most likely source in our case is the oral microbiome secondary to the tooth extraction. Herein we present a case of Raoultella planticola osteomyelitis of the jaw that leads to the diagnosis of diffuse large B-cell lymphoma (DLBCL) of the jaw. A 75-year-old male with no significant medical history, presented to the emergency department with right upper jaw pain after he had a tooth extraction a week before his presentation. Computed tomography (CT) scan of the face showed concerns of right maxillary osteomyelitis with soft tissue swelling and prominent cervical lymph nodes. He underwent a bone biopsy of the maxilla and was started on intravenous ampicillin-sulbactam. His bone culture grew pan-sensitive Raoultella planticola. in addition to that, his bone biopsy revealed diffuse large B-cell lymphoma of the jaw. The patient underwent staging imaging, and he was found to have metastasis to the liver. He was started on chemotherapy and had a good response. In conclusion, Raoultella planticola osteomyelitis is extremely rare. The diagnosis of maxillary DLBCL can be a challenge. Fortunately, our patient had an infection at the same site that led to the diagnosis of DLBCL. Raoultella planticola is a gram-negative, aerobic bacillus which inhabits natural environments like water, soil, and plants and is not typically known to cause invasive infections in humans . It has A 75-year-old male with no significant medical history, presented to the emergency department with right upper jaw pain after he had a tooth extraction a week before his presentation. After the tooth extraction, the patient was complaining of worsening pain in the upper jaw, and he started experiencing fever and chills as well. On review of systems, the patient endorsed night sweats and weight loss for the last two months. On physical examination, he was febrile with a temperature of 103 F, the rest of his vital signs were stable. Computed tomography (CT) scan of the face showed concerns of right maxillary osteomyelitis with soft tissue swelling  of the face revealed a large infiltrative soft tissue lesion with extensive surrounding enhancement involving the right side of the face, especially the maxilla, and it was extending intracranially Figure . The patRaoultella species are aerobic, gram-negative bacilli that belong to the family of Enterobacteriaceae. R. planticola and R. ornithinolytica have been identified as causative pathogens in reported cases. R. planticola, previously described as Klebsiella planticola, was re-named in 2001 based on 16S ribosomal RNA and rpoB  gene sequencing .While it is known as a harmless aquatic, botanic, and soil organism, prior studies estimate up to nine to 18% of humans being colonized with R. planticola . Risk faFreny et al. reported the first case of human disease by R. planticola  in 1984: a 69-year-old female admitted for infective endocarditis requiring ICU stay and found to have R. planticola bacteremia nine days following mitral valve replacement . Only onMost R. planticola isolates in reported cases have been sensitive to third and fourth generation cephalosporins, beta-lactam, and beta-lactamase inhibitor combinations and carbapenems . RecentlNon-Hodgkin’s lymphoma comprises two percent of all primary bone tumors . DiffuseClinical staging, preferably by a PET/CT scan with or without a bone marrow biopsy, allows for differentiation between a primary osseous NHL versus the presence of disseminated disease with bone involvement. Treatment includes chemotherapy with or without radiation therapy depending on disease subtype and stage. For patients with DLBCL who have a partial response or progressive disease following initial chemotherapy, second-line chemotherapy regimens are initiated if the patient is a candidate for autologous hematopoietic stem cell transplantation. Otherwise, palliative involved-site radiation therapy (ISRT), clinical trial enrollment, or supportive care is pursued .R. planticola is a potential emerging pathogen which may produce serious infections involving different organs systems. The most likely source in our case was the oral microbiome secondary to the tooth extraction. Clinicians should be alert to the possibility of encountering CRRP, which may portend a poorer prognosis. A thorough history and physical examination, together with a low index of suspicion, will help prevent a delayed diagnosis of primary NHL involving bones. Fortunately, our patient had an infection at the same site that led to the diagnosis of DLBCL. Initiating treatment in DLBCL is time-sensitive.


It may be associated with kidney cysts too and is frequently diagnosed accidentally in images studies as a non symptomatic condition. However, some patients can develop symptoms due to mass effect of multiple and big sized cyst such as abdominal pain, gastric compression, palpable mass and biliary obstruction,,Surgical treatment is the only option available in order to resolve those symptoms and could varies from minimally-invasive surgery to liver transplantation. Once diagnosis is made, surgical strategy and timing to operation can be a challenging situationWe present a rare familiar case of three sisters with APLD in different grades and also with very different form of presentation in which every case was analyzed separately in order to choose best treatment option and timing to operation as well.A 49 year old woman, very symptomatic, suffering high quadrant abdominal pain, nausea, dyspepsia, dorsal pain and constant episodes of cough leading to impossibility to sleep and rest, conducing to a very decreased quality of life. Cysts were discover by ultrasound and patient was then referred to our service. CT-Scan was later performed . CT showth post-operative day with no further complications.Laparoscopic left lateral sectionectomy associated with fenestration and partial resection of giants cysts located in right lobe was performed. A very low debit and auto-limited biliary leak was observed and patient was discharged at 8After more than five years of follow up patient remains without related symptoms and CT-Scan shows only few cysts and hypertrophy of the remanent liver parenchyma. Blood test and liver function were normal.Woman 46 year old with grade III APLD went for consultation as soon as her sister was discharged. She already knew having the same liver condition. CT-Scan and MRI showed more aggressive disease in segments 2 to 8, leaving a portion of caudate lobe with visible parenchyma . PhysicaFurther regular controls showed increasing of weight loss, abnormal low BMI, and severe bilateral lower limb varicose veins and edema due to IVC compression. Patient still refuse to surgical treatment.Few months later was admitted in emergency room due to double incarcerated hernia due to intra-abdominal hypertension and both hernias were successfully repaired urgently. Patient then accepted go through liver surgery.Regarding complete compromise of left lobe and most of the symptoms were related to gastric compression, left open liver resection was planned in association with several non anatomic resection and fenestration in order to make space for the future remanent parenchyma to grow.Bilateral sub-costal incision was elected and open left lateral sectionectomy associated with several non anatomic resections and fenestration were performed. Patient underwent re-laparotomy for lavage due to hemorrhagic liquid in the abdomen causing acute abdominal pain. Then was discharged with no other complications.After more than three years follow up, she remains without digestive symptoms. She gained weight and has no longer palpable abdominal mass. Inferior members edema disappeared. CT-Scan showed huge hypertrophy of remanent liver and small sized remaining cysts Woman 52 year old with severe grade III APLD came in consultation. She was also aware of her familiar condition. Liver transplantation was offered to her in another center but she refused. Previous MRI from another center showed multiple giants cysts compromising the whole abdominal cavity. Cysts reached hypogastric area and both inferior quadrants. Higher segments of the liver seemed to be respected. Globulous deformation of the abdomen was clearly observed. Despite aesthetic and mild abdominal pain symptoms were not as significant as they were in her two sister so she did not want to underwent liver resection too. However she kept coming to consultation every six months.Two years later she came back presenting jaundice with serum levels of FAL>1700 mg/dl. Bilirrubin 9,8/7,9 mg/dl. New MRI showed cyst compression of the hepatic pedicle including common bile duct and portal vein  A and 3Bth day with decreasing levels of FAL and bilirubin. Late follow up imaging control are still to come.Surgery was soon programed and approach was discussed. We decided laparoscopic approach but being aware room will be very reduced even after pneumoperitoneum. We decided to start by performing aspiration and evacuation of the big lower and anterior cysts to intend reducing the mass and make new space for the laparoscopic procedure. By performing this gesture followed by several fenestration and partial cysts resections space was increased within the abdominal cavity so laparoscopic liver resection could be then performed. Once gallbladder was located, we then identified two cysts that seemed to be responsible for hepatic pedicle compression. Fenestration was done and, then, intra-operative cholangiogram showed no further compression of the common bile duct with adequate passage of contrast to duodenum. Standard cholecystectomy was completed and later laparoscopic left lateral sectionectomy was done in association with several more cyst fenestration. Post-operative course was un-eventful and patient was discharged at 6Management of APLD can be a very challenging situation. Radiological findings and also clinical presentation can varies from asymptomatic or very simple cases to severe ones compromising quality of life and developing life threatening events.This congenital condition rarely compromise liver function. Coagulation and the rest of blood test are usually normal. If not associated with polycystic kidney disease probably will remains stable for long periods. However, clinical presentation may be diverse and its mostly related to mass effect due to hepatomegaly and huge sized cysts. Abdominal pain, palpable mass, gastric compression and weight loss are most frequently observed, but VCI syndrome, intra-abdominal hypertension, bowel obstruction and biliary obstruction can be also observed as in this particular case.Liver transplantation is the only definitive curative treatment but still remains as an extraordinary option because, as said before, patient usually did not compromise liver function so MELD score used to be low. Listed in low places and lack of donors world wide make liver transplantation as a far and distant option for these patients. Exceptional points can be achieved by demonstration low quality of life but still remains difficult. In addition liver transplantation could be a very aggressive treatment taking into account that liver resection can be performed safely and immediately when needed.,The goal of liver resection associated with multiplies fenestration is to reduce liver massPlanning the strategy for a successful liver resection in APLD is not simple. Current anatomy pedicles and vessels have often changed their places because of cysts. Recognizing structures in this altered situation can be challenging in imaging studies and barely impossible during surgery. Even normal parenchyma is replaced by cysts, vessels and bile ducts are still somewhere within cysts walls, that can make liver transection really difficult and a prepense situation for bleeding or bile leaking. Planning type of hepatic resection is not the only thing to discuss once surgical treatment is decided. Timing to surgery is often an issue that can remain unclear. Most of these patients must go to a programed procedure. As every chronic disease patients are used to be tolerant with symptoms and some times they may be not decided enough for an aggressive treatment. Usually acceptance came along when symptoms became stronger or less tolerated. Long delay between diagnose and surgical treatment was already published in different series. ,,Concerning about the approach, laparoscopy seems to be safe and feasible in selected patients. It provides all advantages of minimally invasive access without compromising the standard technique. In experienced hands also grade III can be benefited with this approachIn summary, although is not a curative treatment, liver resection associated or not with fenestration could be the best option for patient with APLD. In selected patient this strategy would achieve palliation of all symptoms and also provide space allowing hypertrophy of remanent liver parenchyma.


Cardiac papillary fibroelastoma (CPF) is one of the most common neoplasms of the cardiac valvular structures that are associated with complications such as systemic stroke, embolism, and arrhythmias. We present a case of an incidentally discovered left ventricular mass in a 75-year-old Caucasian woman. Primary cardiac tumors occur infrequently. Approximately 80% of those that do occur are benign and the remaining 20% are malignant . CardiacA 75-year-old Caucasian woman with a past medical history significant for hypertension, dyslipidemia, and depression was admitted to our hospital for evaluation of an incidentally discovered left ventricular mass. The patient denied having a history of stroke, peripheral embolization, or myocardial infarction. The patient reported compliance with her medications and had been taking furosemide 20 mg, amlodipine/benazeprilat 5/20 mg, rosuvastatin 40 mg, aspirin 81 mg, sertraline 100 mg, zolpidem 5 mg, and omega-3 fatty acids/fish oil. The patient reported food allergies to bananas, pecans, and walnuts. The patient denied any significant surgical history. Her social history was significant for tobacco abuse in the past but denies current use of tobacco products, alcohol, and recreational drugs. Transthoracic echocardiography (TTE) was performed for shortness of air and revealed the left ventricular mass. The patient then underwent a transesophageal echocardiogram (TEE) for further evaluation, which localized the mass to the subchordal apparatus of the anterior mitral valve leaflet  for better identification and visualization of the mass. CMR revealed a 1.8 x 1.0 x 0.3-cm lesion on the anterior leaflet of the mitral valve  was mildly elevated at 19 mm Hg, indicative of mild diastolic dysfunction. Preoperative electrocardiogram (EKG) was normal and showed that the patient was in normal sinus rhythm. During the surgery, gentle retraction of the aortic valve leaflets allowed visualization of the mass.The mass was located within the left ventricle attached to the papillary muscle and chordae tendinae of the anterior leaflet of the mitral valve. The mass was shaved off without difficulty. The tumor was flushed in appearance, rubbery to spongy in texture, and 1.7 x 1.1 x 0.4 cm in size. No residual tumor was left behind. The tumor was thought to be a myxoma upon macroscopic inspection. No complications were encountered during the surgery. Histological examination of the mass from the pathology revealed narrow, elongated, and branching papillary fronds composed of central avascular collagen and variable elastic tissues surrounded by acid mucopolysaccharide and lined by hyperplastic endothelial cells (Figure The surface lining cells were highlighted with CD-34, and the intermediate cells stained with vimentin and S-100 Figure . These fImmediately post-op, the patient was confused, light-headed, and complained of dyspnea on exertion. These problems resolved by post-op day two. Following this, the patient’s post-operative course was uneventful. She was discharged to home on post-op day six with home health care.CPFs are the second most common benign cardiac tumors but are still six times less likely to occur than atrial myxomas, which occur most frequently . PrimaryAlthough CPFs themselves are benign, serious complications may arise from embolization of the tumor, leading to stroke, transient ischemic attack, acute myocardial infarction, angina pectoris, ventricular arrhythmia, and even sudden death . Such coThus far, studies have been done to characterize CPF. The next step is a retrospective study in which the risk factors for cardiovascular diseases, such as hypertension and dyslipidemia as seen in our patient, are assessed against the presence of CPF. Furthermore, longitudinal follow-up studies are needed to determine the rate of recurrence of CPF following surgical resection.


A 72-year-old patient was admitted in the emergency room with an 18-hour history of increasing abdominal pain in the right flank and iliac fossa. Laboratory tests showed anemia with hemoglobin at 97 g/l and renal failure with creatinine level at 21 mg/l.Unenhanced abdominal computed tomography (CT) showed signs of cirrhotic dysmorphism of the liver (not illustrated) and diffuse ascites  are exceedingly rare events related to bleeding of small secondary abdominal arteries or veins.Only rare cases of spontaneous omental haemorrhage have been reported. They are usually preceded by trauma or occur in the context of adhesions, torsion, neoplasms, vasculitis, varices, anticoagulation or ectopic omental pregnancy .The implication of epiploic appendages in acute abdominal emergencies is greatly dominated by appendagitis due to acute torsion or infarction. The vast majority of epiploic appendagitis are self-limiting events with only localized peritoneal inflammatory reaction and with characteristic imaging features.To the best of our knowledge a spontaneous hemoperitoneum related to bleeding of an epiploic appendage has never been reported before. In our case the presence of a very long peduncle may have favoured a possible traction with tearing of a small vessel of the epiploic appendage.


Inverted papilloma (IP) with malignant transformation is rarely seen in the middle ear. Up to now, there have been 16 primary middle ear IPs reported in the English literature. Even though it is very rare in the middle ear, this pathology should be kept in mind for the differential diagnosis of middle ear masses. In this case, we report a 77-year-old female who had recurrent IP with malignant transformation and complication. Inverted papilloma (IP) is a rare benign tumor that can show recurrence. It constitutes 0.5–4% of nasal tumors –3. It maA 77-year-old female patient who had right tympanomastoidectomy operations twice in another hospital with the diagnosis of chronic otitis media with cholesteatoma was admitted to our clinic with a complaint of discharge in the right ear. The right external auditory canal was filled with a cholesteatomatous mass. On diffusion-weighted temporal bone MRI, soft tissue images showing peripheral contrast enhancement were seen in the right mastoid cells, mastoid antrum, and middle ear. There was no restriction in diffusion-weighted imaging of this lesion, and thus, cholesteatoma was not considered as a diagnosis Figures  and 2. TAbout 6 months after the operation, the patient came back because of recurrence of ear discharge. There was a cholesteatomatous mass observed by otomicroscopic evaluation. Revision surgery was performed, and partial petrosectomy and cavity obliteration of the fatty tissue were done. Histopathologic evaluation of the cleaned tissues was reported as cholesteatoma.Two months after the operation, the patient was admitted to the clinic with a vegetative mass in the postauricular scar area. She also had grade 5 facial paralysis according to the House–Brackmann classification on the right side. The patient was hospitalized again, and revision surgery was performed under general anesthesia. There was an ulcerovegetan mass filling the mastoid area  and erodIP generally originated from the epithelium of paranasal sinuses. , 19, 20.The etiology of IP is not clearly understood. Allergic rhinitis, chronic sinusitis, and human papilloma virus (HPV) infection have been discussed as etiologic factors , 3. BlanIP is a locally aggressive tumor, and transformation to squamous cell carcinoma may be seen –23. VoraMiddle ear or mastoid cavity IP may be in 2 forms. Sinonasal IP may extend into the middle ear, or it may be middle ear-based without any history of sinonasal IP . PrimaryThe mean age of these 17 primary middle ear- or mastoid-originated cases is 51 years. Malignant transformation occurred in 23.5% of cases, and the recurrence rate was 17.6% in these 17 patients. These rates are higher than the rates which were reported as 7% for malignant transformation of sinonasal IP and 15% for the recurrence rate of sinonasal IP . Both reAlthough the pathogenesis of IP in the middle ear and the mastoid cavity is not clearly understood, two hypotheses have been discussed. One of them is direct extension of sinonasal pathology, and the other is abnormally displaced embryonic Schneiderian membrane into the middle ear . In the Surgery is the preferred method of treatment for middle ear and mastoid IP , 3, 19. In conclusion, even though it is very rare, IP can be seen in the middle ear. This pathology with local recurrence and malignant transformation potential should be considered in the differential diagnosis of recurrent middle ear diseases.


Mesenchymal hamartoma is a benign tumor of the liver with a poorly understood pathogenesis. It is uncommon in older children, especially after 2 years of age. The signs and symptoms may be nonspecific; therefore, a high index of suspicion is required for diagnosis and treatment. We report a 5-year-old previously healthy male who presented with acute abdominal pain, fatigue, and fever. He was diagnosed with pneumonia initially and treated with antibiotics. A computed tomography (CT) scan done for evaluation of his persistent abdominal pain demonstrated a hepatic mass. Follow-up magnetic resonance imaging (MRI) of the liver demonstrated multiple serpiginous tubular-type structures, read as possible Caroli syndrome. He had a normal abdominal examination and normal biochemistries including alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, and alpha-fetoprotein. He was referred to our institution for second opinion. On further review of his imaging studies, the lesion was thought to be a mesenchymal hamartoma. He subsequently underwent resection of the mass. Pathology confirmed the diagnosis of mesenchymal hamartoma. Mesenchymal hamartoma (MH) is a benign tumor of the liver. It is the second most common benign pediatric hepatic tumor after infantile hemangioma and usually derives from mesenchymal tissue components . More thEntamoeba histolytica and Echinococcus were checked and were negative. Because of persistent abdominal pain and no clear diagnosis of his liver mass, the patient was then referred to our institution.A 5-year-old previously healthy male was referred to our institution for further evaluation of a liver mass. By history, he developed fatigue after participation in a fishing tournament 4 weeks prior to presentation followed by abdominal pain the next day. He was taken to the local hospital for evaluation of his symptoms where he was found to have a fever of 38.9°C. His evaluation included routine laboratory testing and chest X-ray. Based on chest X-ray findings and his symptoms, he was diagnosed with pneumonia and was treated with antibiotics. His abdominal pain at that time was thought to be referred pain. He completed a course of antibiotics but continued to have mild abdominal pain. A CT scan of the abdomen was done for further evaluation of his persistent abdominal pain, and it showed a multicystic-appearing lesion within the inferior aspect of the right hepatic lobe. Subsequently, a magnetic resonance imaging (MRI) exam of the abdomen was performed to further evaluate the hepatic mass. The MRI showed multiple serpiginous tubular-type structures predominantly within segment 5 with questionable peripherally located foci of T2 signal hyperintensity seen within the structures. These findings were thought to be consistent with possible focal Caroli syndrome. At that time, laboratory evaluation showed normal liver function tests with a prothrombin time (PT) of 11.6 sec; international normalization ratio (INR) 1.1; fibrinogen 435 mg/dL; alanine aminotransferase (ALT) 21 U/L; aspartate aminotransferase (AST) 26 U/L; and gamma-glutamyl transferase (GGT) 10 U/L. His inflammatory markers were slightly elevated with CRP 5.4 and ESR 30. His alpha-fetoprotein (AFP) was normal (0.8 IU/mL). Antibodies to The review of the MRI at our institution showed clusters of multiple T2-bright circumscribed cystic lesions in segment 6 measuring <2 cm in greatest dimension which was suggestive of mesenchymal hamartoma . PediatrBenign tumors of the liver are relatively rare in children. Mesenchymal hamartoma was first described in the literature by Edmondson in 1956 . AlthougThe diagnosis of mesenchymal hamartoma still remains a challenge. Children can present with nonspecific symptoms such as abdominal pain, fatigue, and fever. Laboratory findings may also be normal. In some cases, an elevated alpha-fetoprotein may be seen . The diaDifferentiating between mesenchymal hamartoma and other tumors such as an undifferentiated embryonal sarcoma is difficult based on imaging alone . The preMesenchymal hamartoma may have nonspecific signs and symptoms. Advanced imaging and expertise in interpretation of imaging findings is necessary for the diagnosis as routine investigations may be normal. Complete surgical resection is the standard of care for both diagnosis and treatment.


Ganglioneuroblastoma is an uncommon malignant tumor of the sympathetic nervous system, which is considered a disease of children with the majority of cases in patients less than four years old and it rarely occurs in adults. We encountered a very unusual case of a posterior mediastinal ganglioneuroblastoma that developed in a 17‐year‐old male adolescent who underwent successful excision of the mediastinal mass and remained stable postoperatively. However, he developed lumbago one year after the surgery. Radiographic findings revealed osteolytic lesions in the lumbar vertebra and histological analysis confirmed bone metastasis of ganglioneuroblastoma. Here, we report the clinical course and present a review of the literature regarding adolescent and adult onset mediastinal ganglioneuroblastoma. Ganglioneuroblastoma (GNB) is an uncommon malignant tumor of the adrenal gland or sympathetic nervous system. GNB has two histological features of ganglioneuroma (benign) and neuroblastoma , thus showing malignant or potentially malignant behavior.MYCN oncogene amplification.A 17‐year‐old male adolescent was admitted to hospital with an abnormal shadow detected on chest radiography in a school survey. He had no relevant past history, including his birth and development. He had been asymptomatic and physical examination revealed no abnormal findings. Chest radiography and computed tomography (CT) Fig a and no 123I‐MIBG) examination were performed every six months after surgery and no abnormal findings were detected. However, he presented with lumbago one year after surgery. Magnetic resonance imaging (MRI) showed multiple osteolytic bone metastases, especially in the lumbar vertebrae (L3 and L5)  Fig . FDG‐PETThe patient again developed lumbago again and palliative radiotherapy  was added for bone metastasis (L3). The patient is currently alive, two years after the initial recurrence.Here, we present the clinical course of mediastinal GNB discovered in a 17‐year‐old male adolescent. As GNBs occur almost exclusively in the pediatric population,et al.et al.Adam and HochholzerCT and MRI are the most commonly used imaging modalities for assessment of GNBs.Early and radical surgery is the best treatment available for mediastinal GNBs.The present case developed bone metastasis, which is the most common site for metastases in patients with GNB.et al.Information about the role of chemotherapy and optional therapeutic agents in GNB is limited. Drugs used in pediatric patients are cyclophosphamide vincristine, doxorubicin, and combinations with platinum and etoposide. Raina In summary, we describe a rare case of adolescent posterior mediastinum GNB with the development of bone metastasis one year after radical thoracotomy. The observations in this case suggest that GNB should be considered to be a posterior mediastinal tumor even in adult patients. Based on our experience in this case, we emphasize that long‐term follow‐up and/or careful examination are necessary in patients with GNB, especially with a large‐sized tumor.None of the authors have any potential conflicts of interest.


Tumor-induced osteomalacia, also known as oncogenic osteomalacia, is a rare, acquired paraneoplastic disease characterized by hypophosphatemia and renal phosphate wasting.We report on the case of a 52-year-old-man admitted to our hospital for bone and muscular pains and difficulty in walking. He underwent a computed tomography (CT) scan of the legs that documented fractures in the right tibia, femur, and fifth metatarsus. Laboratory findings showed hypophosphatemia and elevated levels of parathyroid hormone (PTH). The first diagnosis was osteomalacia, treated with calcium and vitamin D, without any benefit. So he underwent a whole body CT scan, showing a small expansive lesion occupying the left frontal sinus. Furthermore, we found high serum levels of fibroblast growth factor 23 (FGF23) using the enzyme-linked immune sorbent assay (ELISA) assay. The patient underwent endoscopic surgical resection of the frontal tumor with complete clinical remission and the histopathological diagnosis of an ossifying fibromyxoid tumor.This is a rare case of oncogenic osteomalacia due to a paranasal sinus tumor. The main symptoms are not associated with nasal sinus involvement but with over-expressed FGF23. To conclude, physicians should never underestimate the chance of paraneoplastic syndrome in the head and neck district, even if such an occurrence is uncommon in this location. The clinical symptoms may be aspecific and not related to nose problems, making the differential diagnosis very difficult. Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia (OOM), is a rare, acquired paraneoplastic disease characterized by hypophosphatemia and renal phosphate wasting. TIO can be associated with mesenchymal tumors, which may be benign or malignant in rare cases. These mesenchymal tumors over-express fibroblast growth factor 23 (FGF23), responsible for hypophosphatemia and phosphaturia. Physiologically, FGF23 is the key regulator of phosphate metabolism . ExcessiA 52-year-old-man was admitted to our hospital for bone and muscular pains and difficulty in walking. He underwent a computed tomography (CT) scan that documented fractures in the right tibia and femur, some ribs, and the fifth metatarsus. Laboratory findings showed hypophosphatemia and elevated levels of parathyroid hormone (PTH). The first therapeutic approach was administering calcium and vitamin D without success. So he underwent a complete serum examination panel, which found high serum levels of FGF23, and a whole body CT scan showing a small expansive lesion occupying the left frontal sinus with a shell of bone detectable around the lesion. A subsequent whole-body 18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) showed a small lesion in the left frontal sinus with intense FDG uptake  showed a 7 mm mass protruding the frontal sinus Figure .The patient underwent endoscopic removal of the lesion Figure .Histopathologic images of the excised nasal mass are shown in Figure A histological examination of the removed lesion revealed respiratory mucosa and cell neoplasm constituted by small, round, and oval elements, with nuclear pleomorphism and scant cytoplasm immersed in the stroma with abundant collagen, a chondroid pattern in some areas, and osteoid formation. There was diffuse cytoplasmic positivity for vimentin, focal and weak positivity for S100 protein, and negativity for NSE, CD10, GFAP, CD31, CD34, LCA, ASMA, SMMHC, desmin, CD99, bcl2, and AE1/AE3. Morphological and immunohistochemical features were compatible with an ossifying fibromyxoid tumor.The patient underwent functional endoscopic sinus surgery, including frontal sinusotomy, with resection of the tumor and consequent clinical improvement, normal values of serum phosphate, and FGF23 disappearance.Since the lesion may be classified as a mesenchymal tumor of borderline malignancy, a clinical-radiological follow-up with FDG PET/CT and laboratory findings was started. After two years, all findings were negative.The differential diagnosis for an isolated sinus mass with recurrent fractures and muscular pain may include a paranasal sinus tumor with bone metastases, osteoporosis associated with a paranasal tumor, or a paranasal tumor in case of rickets and oncogenic osteomalacia. Paranasal sinus tumors rarely metastasize in bones -7. GenerConcerning the diagnosis, imaging modalities, such as octreotide scintigraphy, CT, MRI, and PET, are helpful to locate the tumor responsible for TIO. The specific biochemical pattern consists of hypophosphatemia, elevated levels of alkaline phosphatase, normal or low levels of 1,25-dihydroxyvitamin D, and normal circulating levels of calcium. PTH level is normal but, sometimes, it can be particularly high, reflecting secondary hyperparathyroidism, which is a normal response to low 1,25-vitamin D caused by elevated FGF23. Patients with TIO present progressive and nonspecific symptoms: bone pain, muscle weakness, reduced height, and multiple fractures, primarily in the ribs, vertebral bodies, and femoral neck . The diaThe treatment for TIO is surgical tumor removal, but recurrences have been reported . TherefoIn conclusion, physicians should never underestimate the chance of paraneoplastic syndrome in the head and neck district, even if such an occurrence is uncommon in this location. The clinical symptoms may be aspecific and not related to nose problems, making the differential diagnosis very difficult.


Benign prostatic hyperplasia, bladder outlet obstruction, and overactive bladder are major causes of lower urinary tract symptoms (LUTS). Tumor compression of the urinary bladder resulting in LUTS was clinically observed. Gastrointestinal stromal tumors (GISTs) presenting with LUTS have not been reported before. Herein, we report a patient with extraluminal GIST of the ileum who had LUTS without gastrointestinal symptoms during the clinical course.A 68-year-old man visited the genitourinary outpatient department because of frequent urination with mild dysuria. He also complained of poor appetite, fatigue, and body weight loss of 10 kg over 6 months. A large presacral solid mass lesion compressing the bladder and surrounded by the bowel with gas content was identified through abdominal computed tomography.GIST of the ileum with mesenteric invasion was revealed by pathological examination.Exploratory laparotomy with removal of the pelvic tumor and segmental resection of the ileum was performed.Now, he received adjuvant imatinib target therapy for 1 year with stable condition.Extravesical compression or invasion of the urinary bladder by a pelvic mass lesion is common but is rarely accompanied by GISTs of the ileum. Specific findings identified through imaging should alert the surgeon to this specific entity and prepare thoroughly before surgical intervention. Benign prostatic hyperplasia and bladder outlet obstruction are the commonest causes of LUTS.–5During the 1990s, nonepithelial tumors of the gastrointestinal tract were called “gastrointestinal stromal tumors” (GISTs). They originate from the interstitial cells of Cajal and constitute less than 1% of all gastrointestinal tumors. GISTs are most commonly located in the stomach (40%–60%) and jejunum/ileum (25%–30%). The duodenum (5%), colorectum (5%–15%), and esophagus (≤1%) are less common sites.–5Up to 75% of GISTs are discovered when they are less than 4 cm in diameter and are either asymptomatic or associated with nonspecific symptoms. Patients may complain of nonspecific abdominal pain or discomfort, a sensation of abdominal fullness, palpable abdominal mass, malaise, fatigue, or exertional dyspnea with significant blood loss or focal or widespread signs of peritonitis due to perforation.22.1This report presents a 68-year-old man who initially had experienced poor appetite, fatigue, occasional mild lower abdominal discomfort, and body weight loss of 10 kg over 6 months but no nausea, vomiting, diarrhea, or tarry or bloody stool symptoms occurred. Afterward, he noticed frequent urination with mild dysuria. Therefore, he visited the outpatient department for further management in our hospital. Cystoscopy was performed, and the findings were normal in addition to external compression of dome and posterior wall of bladder was seen. Abdominal sonography revealed a solid mass nearby the bladder. Computed tomography (CT) of the abdomen revealed a large, presacral, solid mass lesion (13 × 11 × 9 cm) surrounded by the bowel with gas content that compressed anteriorly against the bladder  is highly sensitive at detecting GISTs and their metastases, since patients with LUTS but no signs of gastrointestinal obstruction are frequently misdiagnosed.In such cases, intravenous urography, cystoscopy, or urine cytology can be performed initially; subsequently, CT or MRI may be considered, since GIST screening and staging must be performed through CT or MRI. Primary tumor resection should be performed through standard management and the diagnosis should be confirmed by pathology. Complete resection is possible in most cases of localized GISTs; however, only approximately half of cases remain recurrence free for 5 years or more with surgery alone.Preoperative biopsy is not usually recommended for resectable lesions that display a high suspicion of GISTs.–11 and CD117 and Dog-1 are highly specific for GIST.Approximately, 80% of GISTs have a mutation of the KIT protooncogene, a member of the receptor tyrosine kinase family,14 In this study, the patient underwent imatinib treatment for 1 year without complications.The GISTs were treated using adjuvant and neoadjuvant small molecule tyrosine kinase inhibitors such as imatinib. Following imatinib introduction, the median survival of patients with advanced GIST was 60 months.LUTS occurred by ileal GIST tumor compression of bladder is very rare. Clinicians should keep in mind the possible existence of GIST and select appropriate procedures or imaging for diagnosis and proper treatment.Conceptualization: Sheng-Tang Wu.Data curation: Hui-Kung Ting, Chien-Chang Kao, Wen-Chiuan Tsai.Supervision: Sheng-Tang Wu.Writing – original draft: Chung-Hao Yu, Dah-Shyong Yu.Writing – review & editing: Chung-Hao Yu.


A 24-year-old man presented to the emergency service with fever, malaise and a large abscessed tumor located in the left inguinal region.He had a history of hydrocele and varicocele treated surgically in childhood.One year before admission, a small nodule approximately 1 x 2 cm appeared in his left inguinal region; this nodule increased in size and was accompanied by a weight loss of approximately 15 kg. On arrival, a large abscessed and ulcered adenopathy 20 x 18 x 11 cm with purulent secretion was seen in the area associated with a 5 cm left testicular tumor. Imaging studies revealed a 1 cm left subpleural lung nodule on short axis. A radical left orchiectomy and a biopsy of the abscessed adenopathy were performed and the histopathologic report showed a mixed germ cell tumor. Tumor markers after orchiectomy were LDH 1124 IU/L, β-hCG 197mIU/mL, AFP 172 ng/mL. Wide spectrum antibiotics were started in addition to wide surgical debridement of the abscess with a favorable clincial response. After surveillance, the patient was discharged to receive ambulatory chemotherapy. Inguinal ganglionic metastasis associated with testicle cancer is a rare finding.The history of inguinal and/or scrotal surgery could explain this phenomenon as a result of an alteration of regional lymphatic drainage.When this group of patients develops testicular cancer, involvement of an inguinal node is described in up to 2-10% of cases.Despite this, routine inguinal lymphadenectomy is still controversial in this scenario.


We present a rare case of bilateral Morgagni hernias in an elderly female patient. She initially presented with coffee-ground vomiting and underwent an OGD from which she was given a diagnosis of oesophagitis. On her second presentation (a year later), CT was performed after OGD to evaluate what was thought to be a complex hiatus hernia causing haematemesis, at which point a diagnosis of bilateral Morgagni hernias was made. Surgical management with laparoscopic mesh repair was performed and she made an uneventful recovery. An 83-year-old lady initially presented to hospital a year prior to diagnosis with a 3-week history of dyspepsia and a single episode of coffee-ground vomit. She was haemodynamically stable at that time and physical examination was unremarkable. She was admitted under gastroenterology and received an inpatient OGD, which reached the D2 duodenal segment and demonstrated distal oesophagitis. Subsequently, she was started on omeprazole and recommended for repeat OGD as an outpatient. No imaging was performed at this admission. In absence of any further symptoms she was discharged.Repeat OGD was performed 2 months later and also reached the D2 duodenal segment, demonstrating good resolution of the oesophagitis and making note of a new hiatus hernia.A year after the last OGD this lady re-presented to ED with severe, sharp, left-sided abdominal pain, with an episode of coffee-ground vomit. Once in ED she had a further four episodes of coffee-ground vomiting amounting to roughly 750 ml. On physical examination she was haemodynamically stable, with unremarkable chest auscultation and a soft, non-tender abdomen. Blood tests were unremarkable, except for a slightly raised WCC (15.4) which was felt to be in keeping with her history of concurrent coryzal illness. Past medical history comprised of poorly controlled hypertension and nil else of note.She was again admitted to gastroenterology and OGD repeated. On this occasion the scope could not be passed beyond the stomach due to twisting of the presumed hiatus hernia complicating the anatomy.Gastric volvulus;Gastric outlet obstruction;Diaphragmatic hernia.The patient’s care was passed to the General Surgeons who requested CT imaging. Prior to this the patient had undergone no thoracic or abdominal imaging either with CT or plain radiography. CT demonstrated bilateral anterior diaphragmatic (Morgagni) hernias, with herniation of the stomach into the left defect and herniation of small bowel and mesentery into the right defect .With gastric decompression via NG tube and NBM her symptoms settled and initially conservative management was planned with reference to her anaesthetic risk. However, after several days she remained unable to tolerate oral intake and bilateral laparoscopic mesh repair was performed. Recovery was uneventful and she was discharged home after several days.Anterior diaphragmatic hernias were first described in 1769 by Italian anatomist and pathologist Giovanni Battista Morgagni. They are located posterolateral to the sternum and arise through an area of diaphragmatic weakness (Larry space). Most commonly they contain omentum or less frequently transverse colon or stomach.5Congenital diaphragmatic hernias are uncommon and within this group anterior (Morgagni) hernias are the least common type, accounting for only 3% of presentations. Right-sided Morgagni hernias are by far the most common subtype at 90% of cases. Bilateral Morgagni hernias in adults are very rare, with only a handful reported in the last decade.3 This is thought to be due to episodes of raised intra-abdominal pressure such as coughing or vomiting eventually causing herniation through the congenital weakness.4 As such, obesity, pregnancy and abdominal trauma are risk factors.5 In the few prior case reports of bilateral hernia in adults the age of presentation is typically lower (4th to 5th decade); our patient was unique in presenting so late in life, having been completely asymptomatic up until her 9th decade.7Despite being classified as ‘congenital’, anterior diaphragmatic hernias more commonly present in adulthood, with an increasing number of case reports of unilateral hernias in elderly patients.8 However a larger case series more recently has shown that the majority of patients (over 70%) do present with symptoms related to their hernia, usually respiratory related from mass effect of herniated abdominal organs into the thoracic cavity. Other presentations include bloating, vomiting and more acute presentations with abdominal pain, GI haemorrhage, obstruction or strangulation.9It was believed that the majority of Morgagni hernias are asymptomatic and detected incidentally.While often more helpful than imaging in primary investigation of GI complaints, OGD is unable to rule out a diagnosis of Morgagni hernia. This is true even when stomach has herniated through the defect and particularly so when the hernial sac contains omentum or other abdominal viscera. In our patient repeated endoscopies over a year produced a range of outcomes, from essentially normal to suggested gastric volvulus.11 Though the diagnosis of Morgagni hernia is most commonly made incidentally on plain radiography, in the acute setting the findings are insufficiently sensitive or specific to be relied on in isolation. Thus where there is diagnostic uncertainty or a clinical suspicion of diaphragmatic hernia, CT is the gold standard for investigation due to the near-perfect sensitivity and allowing for detailed surgical planning.1,10Plain radiography may show air fluid levels in the herniated loops of bowel or stomach ; however the radiographic features are variable and depend on the contents of the hernia—omental contents will produce more subtle finding such as increased density at the cardiophrenic angles which can be misinterpreted as an epicardial fat pad. In prior case reports the frontal chest radiograph is often non-specifically abnormal, such as demonstrating a unilateral pleural effusion. Contrast fluoroscopy may also be normal.9Once discovered, even if incidentally, it is recommended that Morgagni hernias are fixed due to the risk of future complications and the increased difficulty and poorer outcomes associated with acute repair. Laparoscopic mesh repair has become favoured in recent times with low complication rates and reduced hospital stays over the traditional laparotomy or thoracotomy approaches.Despite being a relatively rare entity and classified as “congenital”, there are a growing number of case reports of elderly patients symptomatically presenting with anterior diaphragmatic (Morgagni) hernias. In many patients, as with this lady, the diagnosis is delayed as it is rarely considered as a potential cause and this can lead to poorer outcomes. Plain radiography may detect the diagnosis incidentally, however findings are dependent on the hernia contents and often equivocal in the acute setting. CT provides definitive diagnosis and allows for surgical planning.This lady was unusual in that she had bilateral Morgagni hernias which were asymptomatic until her 9th decade, prior to which she had not undergone any thoracic or abdominal imaging. Indeed, even during her first admission she had no imaging performed (instead an OGD was done which appeared to have found the cause of the bleeding—only on later OGDs was the complex anatomy appreciated and imaging sought).It is important to be aware that these “congenital” hernias can present later in life. As life expectancy and risk factors such as obesity increase we are likely to see a commensurate rise in the number of diaphragmatic hernias presenting in adulthood. Where there is clinical suspicion of diaphragmatic hernia imaging with CT should be first line. Plain radiograph is less definitive and cannot be solely relied upon in the acute setting. While often first line for GI complaints, endoscopy is unable to rule out this diagnosis.Morgagni hernias are an uncommon form of congenital hernia which typically present in adulthood and are an important, rare cause of bowel obstruction and strangulation.Endoscopy cannot exclude the diagnosis. In the acute setting plain radiography may be abnormal but non-specific. CT is the gold standard.There are increasing case reports in the literature and with increased life expectancy and obesity they are likely to become more prevalent.Diagnosis is often delayed, particularly in older patients, with associated detrimental impact on outcomes.Written informed consent was obtained from the patient for publication of this case report, including accompanying images.


Cyst with relatively high recurrence and having nature to invade the underlying tissue is “odontogenic keratocyst (OKC).” Radiographically, OKC can appear as different varieties, such as follicular, replacemental, extraneous, envelopmental, and collateral. Each radiographic variety of OKC varies in biological behavior, prognosis, recurrence, and therapeutic approaches.Many studies done till date have not established any relationship between markers of proliferation and aggressiveness in regard to radiographic varieties of OKC. The present article reports a case of follicular OKC in an 8-year-old boy which was concluded as a dentigerous cyst by radiographic features.How to cite this article: Madhireddy MR, Prakash AJ, Mahanthi V, Chalapathi KV. Large Follicular Odontogenic Keratocyst affecting Maxillary Sinus mimicking Dentigerous Cyst in an 8-year-old Boy: A Case Report and Review. Int J Clin Pediatr Dent 2018;11(4):349-351. About half of all OKCs occur at the angle and ramus of the mandible and present as unilocular or mul-tilocular radiolucencies, but other odontogenic lesions may show similar radiological findings.6 Thus, a few clinical and radiographic features are specific for OKCs. The final diagnosis depends on histological examination.5Follicular keratocyst is a variant of OKC in which cyst surrounds the crown of an unerupted tooth and is attached to the neck of the tooth. Follicular OKC accounts for about 25 to 40% of all OKCs.An 8-year-old male patient reported to a dental clinic with the chief complaint of swelling in the upper right front tooth region since 1 year. Extraoral examination showed slight swelling was present on the right side of face, causing elevation of right ala of nose . GeneralThe panoramic radiograph of the patient showed mixed dentition with tooth buds at different developmental stages. A large radiolucent lesion of 2 × 2 cm in size was found in the right side of face area in relation to periapical region of 54 and 55. Tooth bud of 14 was being pushed close to the region of floor of the orbit and tooth bud of 15 being pushed posteriorly .The borders of the lesion are ill defined. Coronal computed tomography showed a radiolucent lesion in relation to right maxillary sinus area with tooth bud being displaced close to the region below the floor of the orbit . ConsideThe patient underwent surgery under general anesthesia . A mucopThe basal epithelial layer was composed of palisaded columnar cells. There was also presence of small satellite cystic islands of odontogenic epithelium seen in the fibrous connective tissue. Histopathological features were suggestive of KCOT .7 It is very aggressive in nature and known for its high recurrence rate and is associated with NCBS. The NCBS syndrome, first delineated by Gorlin and Goltz (1960), is characterized by basal cell carcinoma, OKC, palmar, plantar pits, and ectopic calcification of falx cerebri; 75% of patients affected by NBCS show multiple bilateral keratocysts.The OKC was named by Phillipsen in the year 1956. However, it was renamed as keratocystic odontogenic tumor by the WHO in the year 2005. They are noninflammatory developmental tumors and odontogenic in origin.8 It is more common in females and occurs over a wide range of age. In our case, the patient is in his first decade. The tumor most commonly occurs in molar region; however, in the present case, there was maxillary involvement with displacement of tooth bud superiorly into the maxillary antrum. Clinical features include pain, soft tissue swelling expansion of bone with gross facial asymmetry.Mainly located in premolar area, it may displace teeth with consequent malocclusion.9 Radiographically, most KCOTs are unilocular, presenting a well-defined radiolucency with peripheral rim with scalloped borders. In the present case, the radiographic evaluation revealed an aggressive osteolytic lesion which has not only involved the maxillary sinus but also caused displacement of tooth bud of 44 into the sinus up to the extent of floor of the orbital cavity.The PTCH1 mutations and dysregulation of sonic hedgehog pathway have a definite part in the development of OKCs in both isolated and syndromic cases.10 Expression of high epidermal growth factor receptor in KCOTs has supported its intrinsic growth potential, which is not present in other odontogenic cysts.11 Treatment of KCOTs includes many surgical modalities, such as enucleation with primary closure, enucleation with open packing, marsupialization, enucleation with use of Carnoy’s solution, or cryotherapy, with a marginal or radical section.Histopathologically, it is composed of a palisade, polarized layer of cuboidal cells which are often hyper-chromatic and described as picket fence or tombstone appearance with folding of epithelium into capsule by active proliferation.12 Even though KCOTs are most aggressive and recurrent form of tumors, there are few cases where KCOTs have been treated by enucleation. The case discussed here also has been treated with the enucleation procedure. However, a long-term follow-up is required to establish nonrecurrence of the tumor.Electro cauterization is used as a good adjunct for enucleation of KCOT lesions.Clinical and radiographic features of some cases can mimic each other and cause diagnostic dilemmas in arriving at a final diagnoses. Histopathological examination is a gold standard for the final diagnoses.


Introduction: Hemangiopericytoma is a rare vascular tumor representing about 1% of all vascular tumors and approximatively 5% of all soft tissues sarcomas that arises from the pericytes of Zimmerman surrounding capillaries and postcapillaries vessels. Retroperitoneal hemangiopericytomas are rare among the localisations as it usually occurs in lower and upper extremities.Presentation of case: We present a case of 31-year-old man with a well-defined retro peritoneal mass measuring about 105 × 73 × 83 mm at right lower quadrant of the abdomen anterior to right psoas muscle. Intraoperatively, an large mass measuring 10 × 8 cm was found arising from the retro peritoneum. A monobloc excision was performed. The postoperative course was uneventful. Histopathological examination with immune histochemistry revealed that tumoral cells were positive for desmin, CD34, smooth muscular antigen. Final diagnosis of hemangiopericytoma was made. On the last follow up at one year, he was symptom free.Discussion: Hemangiopericytoma is a rare tumor. It takes origin from pericytes presenting as intervals along the walls of capillaries and post-capillary venules. Retroperitoneal hemangiopericytoma is a rare location. It is often discovered at late course, and can be revealed by various symptoms with the compression of the adjacent organs by the tumor Surgical resection should be considered in symptomatic cases or in case of diagnostic dilemma.Conclusion: Retroperitoneal hemangiopericytoma can be benign but it should be treated the same way as aggressive tumors. It requires a careful and long term follow up. The rar2A 31 years old patient presented with right-sided L5 radiculopathic pain of three months duration. There was no family history or features of neurofibromatosis. The patient did not have other symptoms including nausea, vomiting, bowel habit changes, fever, or weight loss.Physical examination showed no positive finding. Computed tomography (CT) showed a well-defined retroperitoneal mass with measuring about 105 × 73 × 83 mm at right lower quadrant of the abdomen anterior to right psoas muscle. After contrast injection, tumoral mass was enhanced intensely . Magneti3Hemangiopericytoma is a rare tumor. It takes origin from pericytes presenting as intervals along the walls of capillaries and post-capillary venules and first described by Zimmerman in 1923 . Stout aRetroperitoneal hemangiopericytoma is a rare location. Enginzer and al.  reportedPlain radiography and ultrasound findings are non specific and in terms of imaging, CT scan is superior to ultrasound, and plays an important role in the predictive diagnosis. They display as well defined lobulated masses, large with speckled calcifications, haemorrhage and areas of necrosis . It is pkit) [But the pathologic findings associated to immune histochemistery remain the only tool to confirm the diagnosis. The pathologic features describe hemangiopericytoma as soft, rubbery with irregular surface. On dissection, extensive haemorrhage and necrosis can be found. Microscopally; we find cells partially or completely enveloped by a basement membrane and basement membrane-like material. These cells express a prominent cytoplasmic filaments; with sometimes interdigitating cytoplasmic processes, and pinocytotic vesicles. Nunnery and al. with a review of 19 cases of hemangiopericytoma found the presence of a basal lamina or basal lamina-like material either partially or completely surrounding tumor cells and separating endothelial cells from pericytes as the most consistent feature . The prekit) . McMastekit) . Preoperkit) . AuthorsThe treatment of choice for this kind of tumor is a wide resection of the whole tumor. Preoperative biopsy of the tumor as well as the enucleation of the tumor are not recommended as the tumor is hypervascularized and do not have a proper capsule . GoldmanIn terms of survival, it ranges between 47% and 86% in 10-year survivals with complete resection of the hemangiopericytoma . This di4Hemangiopericytoma is today a well defined entity with its clinical; radiologic and especially pathologic characteristics. Large tumors found in the retropeitoneum are usually malignant associated with high mortality rates. Although retroperitoneal hemangioperictyoma can be benign, it should be treated the same way as aggressive tumors; by a wide excision as described in the literature. The literature established in the past the inefficacy of adjuvant radiotherapy; but it may has now a valuable and bigger role in the management of post operative retroperitoneal hemangiopericytoma.The authors declare that they have no conflict of interest.This study has not received any funding.The study was approved by Ethics Committee of Hospital Sahloul.Written informed consent was obtained from the patient.Amine chhaidar-data collection, Editing of manuscript.Skandar Zouari– Data collection, Editing of the manuscript.Ahlem Bdioui – Drafting of manuscript.Moncef Mokni–Editing of the manuscript.Ali ben Ali-Editing of the manuscript.As this was a case report and not a clinical trial, this study does not require registration.Amine Chhaidar.Not commissioned externally peer reviewed.


Radiofrequency ablation is a common and minimally invasive procedure used to treat liver tumors. However, the potential threat of heat injury to adjacent structures if the hepatic lesion is near the diaphragm is often overlooked and misunderstood. Rare cardiovascular complications have been reported. How best to identify the patients at risk to allow for prompt treatment is an important issue.A 56-year-old man with underlying oral cancer received radiofrequency ablation for a metastatic liver tumor at segment II. Pleuritic chest pain developed on the day after radiofrequency catheter ablation. Diffuse ST elevation and echocardiography showed the new onset of small to moderate pericardial effusion without tamponade sign. Inflammatory markers were also elevated. Acute pericarditis due to heat penetration and stimulation was favored. His symptoms and signs resolved after treatment with anti-inflammatory medication.Potential cardiovascular complications are possible after radiofrequency catheter ablation for liver tumors located at segment II. Artificial ascites with normal saline before radiofrequency ablation may separate the liver and diaphragm to prevent cardiac complications. During the procedure, electrocardiographic monitoring and close observation of the patient’s symptom are required. Echocardiography can be used to confirm cardiac complications. Radiofrequency ablation (RFA) is a common procedure used to treat both primary and metastatic liver tumors in patients who are not going to receive surgical treatment , 2. MajoA 56-year-old male patient with a history of paroxysmal atrial fibrillation was diagnosed with hypopharyngeal squamous cell carcinoma in June 2011. The disease progressed with pathology-proven metastatic liver tumor, for which he first received RFA in October 2012. In June 2014, abdominal sonography disclosed a mixed echogenic tumor of about 5 × 4 × 4 cm located in the left lobe just below the heart. A computed tomography scan showed a recurrent liver tumor of around 3.6 cm in the S2 segment  showed diffuse ST elevation except for leads AVR and V1 Fig. , and thePericarditis is the most common form of pericardial disease with causes including idiopathic, infectious , systemic inflammatory diseases , cancer, metabolic , drugs , traumatic, iatrogenic, and post-cardiac injury syndrome. The diagnosis is based on clinical criteria including chest pain, pericardial rub, ECG changes, and pericardial effusion .A few case reports have indicated that delayed tamponade with Dressler’s syndrome can occur after radiofrequency catheter ablation to isolate the pulmonary vein for atrial fibrillation or after radiofrequency catheter ablation for atrial flutter, AV node, or accessory pathway –7. In adPericarditis or cardiac tamponade after RFA for a liver tumor is also a rare complication. Allgaier et al. treated 12 consecutive patients with inoperable hepatic carcinoma with radiofrequency interstitial thermal ablation in 1998, and considered it to be an effective and safe palliative therapeutic strategy [Cardiac hemorrhagic tamponade during RFA is an extremely uncommon but potentially fatal complication . SilvermIn addition to hemorrhagic tamponade, small pericardial effusion can occur due to the adjacent tissues and organs being damaged during RFA as the result of pericarditis. For tumors located at the liver capsule on the left hepatophrenic side close to the diaphragm, the thermal conduction during RFA may cause damage to the diaphragm and pericardium. This may then lead to localized pericardial edema causing compression of the suprahepatic vena cava, and eventually resulting in pericardial effusion .In our case, similar to the previous cases, the liver tumor was at segment II. The symptoms and signs of pericarditis may have been masked by the fever, chills and leukocytosis, all of which can occur after RFA for a liver tumor. However, the abrupt elevation of serum C-reactive protein level and the widespread ST elevation with new onset of pericardial effusion strongly supported the diagnosis of acute pericarditis. Since the clinical course was relatively benign, the mechanism may have been the result of pericardial/myocardium damage due to heat injury through the diaphragm and indirect inflammatory reactions rather than vessel perforation. The complication of pericarditis or left pleural effusion may be predicable and should be carefully considered before the procedure if the hepatic lesion is at segment II. Artificial ascites with normal saline before RFA may separate the liver and diaphragm to prevent cardiac complications. The procedure should be conducted under echo or computed tomography guidance to confirm the location of the tumor. During the procedure, electrocardiographic monitoring and close observation of the patient’s symptom are required. The procedure should be stopped if arrhythmia or hemodynamic changes occur. Echocardiography can be used to confirm cardiac complications.In summary, we present a rare complication of acute pericarditis following RFA for a liver tumor in whom the symptoms and ECG almost resolved. Adequate timely management is important in such cases. Although the minimally invasive RFA has become a preferred approach with an increasingly significant role in the field of multidisciplinary comprehensive treatment for liver tumors, the possibility that adjacent tissues and organs may be damaged during treatment still exists. Clinicians should be fully aware of all potential complications related to RFA. Timely recognition and prompt management of pericarditis and pericardial effusion are important, and the prognosis is relatively good if tamponade does not occur.


Involvement of the ear and temporal bone in acute leukemias are uncommon. We report a case of atypical mastoiditis with bilateral facial paralysis in a child diagnosed with Acute Lymphoblastic Leukemia (ALL). A 20-month-old male child was diagnosed with ALL and developed otorrhea unresponsive to antimicrobial treatment during the first week of chemotherapy followed by hearing loss, loss of balance, and bilateral facial paralysis. A CT scan of the mastoids showed cortical erosion of the temporal bone and presence of soft tissue contents filling the mastoid cells and external auditory canal bilaterally. Mastoidectomy was performed to collect material for analysis. Histopathologic examination of the material revealed an active chronic inflammatory process, with a moderate amount of plasma cells. Chemotherapy was reintroduced 3 weeks after the surgical procedure, and progressive improvement of otorrhea and imbalance was noted. Grade III House–Brackmann peripheral facial paralysis persisted on 6-month follow-up, and the patient is in rehabilitation program. Acute lymphoblastic leukemia (ALL) accounts for 30% of all childhood malignancies. It involves malignant transformation and proliferation of immature lymphoid cells in the bone marrow, blood, or extramedullary sites . ApproxiInvolvement of the ear and temporal bone in acute leukemias is uncommon and may present as skin lesions, changes in the tympanic membrane, effusions in the middle ear, otitis media, hearing loss, or mastoiditis. Pathophysiology may be due to bleeding, leukemic infiltration, or opportunistic infection at these sites , 6. FaciWe report a case of atypical mastoiditis with bilateral peripheral facial paralysis in a child diagnosed with ALL.A 20-month-old male child was admitted to the emergency room with fever, associated with cutaneous-mucosal pallor, inappetence, irritability, and bruises in the lower limbs at the onset 11 days ago. He did not present any otological complaint, loss of balance, or signs of central nervous system involvement.9/L with a differential of 8% lymphocytes and 92% blasts; hemoglobin was 7.9 g/dL, and platelet count was 79,000 × 109/L. The patient referred to children's hospital for complementary exams. The myelogram revealed acute lymphoid leukemia (ALL), with 98% of lymphoblasts. Immunophenotyping was compatible with CD10 + cytoplasmic IgM + B-cell precursor acute lymphoblastic leukemia (pre-B ALL), karyotype 45, XY, -21. Cerebrospinal fluid (CSF) analysis did not show the presence of leukemic cells, and a computed tomography (CT) scan of the head at that time showed no cranial abnormality.Laboratory analysis showed a white blood cell count of 79,300 × 10Chemotherapy treatment was initiated with the AIEOP-BFM 2009 protocol: prednisone, daunorrubicin, vincristin, peg-asparaginase, and intrathecal methotrexate . On the Although fever resolved, the patient maintained serosanguineous otorrhea. On the 27th day of chemotherapy, the parents reported that the child was unable to smile or locate sounds, besides presenting difficulties walking. The patient was then referred to otorhinolaryngology. Otoscopy showed bilateral purulent otorrhea and an opacified, apparently bulging, tympanic membrane bilaterally. There was no spontaneous or semispontaneous nystagmus, but the child was unable to walk without support. Severe facial mimic dysfunction was noted bilaterally (House–Brackmann grade IV), with no other cranial nerve impairment. A complete blood count revealed a hemoglobin level of 6.9 mg/dL, platelet count of 286,000/dL, and white blood cell count of 15,890/dL with 56% of polymorphonuclear leukopcytes, 28% of lymphocytes, and 15% of monocytes.A CT scan of the ear and mastoids showed bone erosion of the temporal bone and mastoid and presence of soft tissue contents filling the mastoid cells, involving the ossicular chain with extension to the external auditory canal in both ears Figures  and 2.A right mastoidectomy and left tympanotomy were performed and a whitish fibroelastic friable lesion was found both in the mastoid extending to the tip of the mastoid and the middle ear with partial erosion of the posterior wall of the external ear canal. Large tympanic perforations were seen bilaterally with “hyperplasic” lesion filling the middle ear. The cortical part of the temporal bone and the underlying tissues were infiltrated in appearance Figures –5. HistoThe patient restarted chemotherapy after 3 weeks of the surgical procedure and progressively improved of balance complaints and otorrhea.At 2-month follow-up Brainstem Evoked Response Audiometry (BERA) with click and tone burst stimulation revealed severe bilateral sensorineural hearing loss with absence of response in 90 dB in both ears .At a 6-month follow-up, the patient was in the maintenance phase of chemotherapy and presented mild improvement of the facial paralysis on the left side (grade III House–Brackmann). A new CT scan of the ears and mastoid showed no ossicular chain bilaterally, with apparent content of soft parts in the mastoid cells. He was referred to auditory rehabilitation program, but use of hearing aids has not shown recognizable improvement. No central nervous involvement of ALL has been identified.In the pioneer study by Druss in 1945, it was observed that patients with leukemia had a significant number of secondary otologic complications. He reviewed the medical records of 148 patients with different apresentations of leukemia and found that almost 17% experienced secondary complications such as hearing loss, nystagmus, vertigo, facial paralysis, and tympanomastoid infections [In 1973, Paparella et al. conducted the first large study with temporal bones of leukemia patients. The authors analyzed 45 temporal bones of 25 patients with chronic and acute leukemia. They found that all clinical otologic problems occurred only in patients with acute form of leukemia, particularly in acute lymphocytic leukemia. The histopathological findings were leukemic infiltration, hemorrhage, and infection in middle ear more frequently than inner ear or external auditory canal [Okura and Kaga in 1994 also described the histopathological findings of the middle ear in 19 patients with leukemia. He observed middle ear effusion in 8 of 35 ears analyzed, and in 4 of these ears effusion floating tumor cells were found. The study suggests that the major causes of middle ear effusion in patients with leukemia are infection related to immunological deficiency, obstruction of the Eustachian tube with infiltration of tumor cells, and a tendency to bleed due to hematological problems .In our case, bilateral serosanguineous otorrhea associated with fever initially led to the suspicion of suppurative acute otitis media. Signs of an active bacterial infection with pus and local inflammatory reaction were not present at this time probably due to the absence of polymorphonuclear cells caused by leukemia and chemotherapy. The change in the aspect of otorrhea is associated with its maintenance even during treatment with antibiotic therapy and the appearance of other symptoms such as loss of balance and facial paralysis alerted to an atypical presentation of mastoiditis. Pediatric acute mastoiditis of noninfectious etiology is much rarer than true infectious mastoiditis. It should be suspected in every atypical, persistent, or recurrent case of acute mastoiditis . AccordiThe case presented by Todd and Bowman raises questions regarding the role, timing, and extent of surgery in atypical acute mastoiditis in leukemia patients. According to the author, surgery is appropriate when the patient's course indicates more bacteriologic and pathologic information is needed. When tumor is encountered in the ear and intraoperative histopathologic study is inconclusive or not available, the extent of surgery must be limited to obtaining sufficient tissue for histopathologic diagnosis, reducing tumor bulk (to facilitate the subsequent usefulness of radiation or chemotherapy) and preserving function of the ear . In the Bilateral facial paralysis and profound sensorineural hearing loss presented by the patient may have occurred due to the facial and acoustic nerve involvement by leukemic infiltration or severe local inflammatory reaction triggered or not by infection. Bilateral facial paralysis is an unusual clinical entity that occurs in less than 1% of patients with facial paralysis. Bilateral facial paralysis is even more rare in children, and establishing its etiology can be challenging . The casA database search of Medline, PubMed, BVS-BIREME, Web of Science, Embase, and SCOPUS, from 1984 to December 2018, was performed for studies that reported facial paralysis in child population with acute lymphoblastic or myeloid leukemia. The search terms used in database searches were “Facial Paralysis” AND “Precursor Cell Lymphoblastic Leukemia-Lymphoma” OR “Acute Myeloid Leukemia” AND “Infant” OR “Preschool” OR “Child” OR “Adolescent”. We found five case reports of children or adolescents with acute lymphoblastic leukemia presenting with bilateral facial paralysis. Two cases , 16 had A concise review of the literature is presented in The patient discussed in this study presented unusual symptoms rarely and diversely reported in the literature. The involvement of the temporal bone in acute leukemias in children, although rare, should always be remembered either as initial symptomatology or during the course of chemotherapy when apparently major inflammatory response associated or not to infection may result in complications. Patients who present atypical mastoiditis, symptoms of imbalance or facial paralysis  should be referred to the otorhinolaryngologist. A broad investigation and active discussion amongst the treating oncologist and otolaryngologist, with laboratory tests, imaging exams, and if necessary surgical intervention, are necessary in order to establish a diagnosis and provide the best treatment.


Carcinoid tumors usually arise in the gastrointestinal tract. Immunocytohistochemical and radiologic studies are important in detecting the primary tumor site. Primary carcinoid tumors of the testis are particularly rare with a high malignant potential warranting long-term follow-up. We present the case of a primary carcinoid tumor of the testis with long-term surveillance. Primary carcinoid tumor of testis is a rare type of testicular cancer accounting for less than 1% of all testicular tumors. It is associated with teratomatous components  and can Macroscopically, carcinoid tumors are well circumscribed with calcifications seen in 10% of cases . They arDifferentiation between primary and metastatic carcinoid tumors of testis is of utmost importance for it correlates with the prognosis. The presence of teratomatous elements indicates a primary origin whereas bilateral involvement, multifocal tumors, or extratesticular extension is indicator of metastatic origin. Tumor size and the presence of carcinoid syndrome are the two important predictors of metastasis which might reach 16% roughly and hence the need for follow-up. Primary tumors have good prognosis and are usually cured by orchiectomy , 10.Follow-up consists of imaging (CT or Magnetic Resonance Imaging) and urinary 5-hydroxyindoleacetic acid (5-HIAA) every three to four months in the first year. If asymptomatic and complete macroscopic resection was achieved, watchful surveillance can be adopted with yearly urinary 5-HIAA level and imaging only when level is positive .We present the case of a primary carcinoid tumor of the testis with a long follow-up.A 36-year-old male patient presented with painless enlargement of his right scrotum of few weeks duration. History did not reveal any trauma or previous infections. Physical exam showed diffuse right scrotal nontender and firm mass with no palpable inguinal lymph nodes. Ultrasonography showed isoechogenic solid mass of 42x28.7 mm with two calcified foci at the apex posteriorly, the largest measuring 6.7x7.6 mm. Patient underwent right radical orchiectomy. Chest abdomen pelvis Computed Tomography (CT) scan was negative for metastasis. Patient has been followed up for 7 years and did not develop any recurrence on his yearly follow-up CT scan and urinary 5-HIAA.Histopathologic study showed, macroscopically, parenchyma of the testis partially occupied by a solid, well circumscribed, nonencapsulated mass measuring 5x4x3.5cm with a homogenous tan gray to “creamy” color. Grossly visible areas of hemorrhage and necrosis were absent. Within the center of the mass, there was a 0.4 cm calcified nodule. Tumor is grossly separated from the tunica albuginea and from testicular hilum by a grossly unremarkable, light brown, spongy soft testicular parenchyma.Microscopically, the neoplasm is composed of cohesive, uniform, cuboidal cells with minimal cytoplasm, arranged in nests and cribriform structures of variable size and shape, separated by moderate amount of fibrotic dense stroma . At the The term “carcinoid” was used to indicate a group of tumors in the small intestine arising from neuroendocrine (NE) cells having low malignant potential . There iWang et al. presented 29 primary testicular carcinoid cases and reported metastases in none of the 20 carcinoid cases with typical features and in 1 of 4 cases with atypical morphology . MetastaIt was reported that primary testicular carcinoids are CDX-2 negative on immunocytohistochemical staining ; howeverIn a gross appearance, testicular carcinoids have been found to measure between 1 and 9.5 cm and are solid, lobulated with yellow to dark-tan and may or may not have calcifications . Grade 1The mainstay treatment of a localized testicular carcinoid tumor is by focal excision or radical orchiectomy, although chemotherapy and adjuvant radiotherapy have been used in metastatic cases . Most caTesticular carcinoid tumors are rare, different in presentation, and affecting all age groups. Primary carcinoid neoplasms have good prognosis but the metastatic potential exists and may be delayed; hence a long-term follow-up is warranted.