Primary chest wall hydatid cyst is a very rare disease in endemic areas. This case report describes a 22-year-old male patient with a 3-year history of chronic left chest pain. He had a history of close animal contact in childhood. Chest computed tomography (CT) scan showed a left upper posterior paravertebral cystic mass with peripheral and intrinsic calcifications. Fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography (PET) scan showed no significant FDG uptake. Magnetic resonance imaging (MRI) showed a left paravertebral cystic mass with daughter cysts and a peripheral low T2 wall, compatible with hydatid disease. Medical treatment was started, and a follow-up MRI showed rupture of hydatid cysts. The patient underwent surgical resection, and a hydatid disease diagnosis was confirmed by histopathologic examination. During the postoperative hospital course, the patient developed pneumothorax which was successfully treated with a surgical procedure. The patient was discharged with medical treatment . In conclusion, this case highlights the importance of considering hydatid disease in the differential diagnosis of chest wall cystic masses, especially in endemic regions, and the value of multimodality imaging in diagnosis and treatment planning. Echinococcus granulosus [Hydatid disease is caused by tapeworm parasites and is prevalent in sheep-rearing regions, such as the Middle East, Mediterranean regions, Africa, South America, and Australia. The most common causative organism of human hydatid disease is anulosus –3. The lanulosus , 2, 4. Tanulosus . Thoracianulosus , 2, 6. W/CT) showed no significant FDG uptake in the lesion  scan of the chest with intravenous (IV) contrast revealed a 4 × 6 × 6 cm cystic mass in the left thoracic paravertebral region extending from T3 to T5 vertebral bodies. The cystic mass had peripheral and intrinsic calcifications, cysts of different sizes and showed remodeling and erosion of adjacent ribs, with extension into the left T3-T4 and T4-T5 neural foramina . Fluorine lesion . The priThe MRI showed numerous and varying sizes of intralesional daughter cysts with low T1 signal intensity and high T2 signal intensity compared to the large mother cyst matrix, which had intermediate T1 signal intensity and intermediate to high T2 signal intensity. The lesion also had a smooth, peripheral rim of low T2 signal intensity with postcontrast enhancement . There wThe imaging finding, specifically the classic appearance of daughter cysts on the MRI, strongly suggested a hydatid cyst. The patient's complete blood count and liver function test were normal. No hydatid serology or skin tests were requested. Oral albendazole was prescribed at a dose of 400 mg twice daily. Five months after starting medical treatment, a follow-up MRI showed the interval rupture of the daughter cysts and the development of low-signal floating membranes . A videoThe histologic examination showed a thick fibrous capsule with a mixed inflammatory infiltrate and granulation tissue and acellular laminated membranous structures with cellular debris and calcifications in the cyst wall. The histologic findings are consistent with hydatid disease, and there was no evidence of viable protoscolices . A folloExtrapulmonary thoracic hydatid disease is uncommon and can involve the mediastinum, pleural space, chest wall, cardiovascular structures, and diaphragm , 2, 6. PPrevious cases of chest wall hydatid disease reported chest pain or chest wall swelling and symptoms lasting from a few months to several years. The chest wall hydatid disease diagnosis was often made postoperatively due to inconclusive or lack of preoperative imaging –11.The MRI played a crucial role in diagnosing this case of hydatid disease by showing the classic appearance of daughter cysts. This triggered further questioning and revealed a history of close contact with animals. The MRI also documented the interval development of the contained rupture of the daughter cysts and the formation of a floating membrane (water lily sign) in response to medical treatment . This caEchinococcus granulosus requires a definitive host, most commonly dogs, and an intermediate host, usually sheep. The parasite eggs are excreted in the host's feces, and humans can become accidental hosts by ingesting contaminated food or water. The larvae are released from the ingested eggs and are absorbed by the intestinal mucosa, commonly spreading to the liver through the mesenteric and portal veins. In around 15% of cases, the larvae bypass the liver filtration and gain access to the lungs [Echinococcus granulosus to any part of the body can also occur with or without liver involvement [The life cycle of he lungs . Hematogolvement , 6, 12.The hydatid cyst consists of three layers: the outer pericyst, the middle ectocyst, and the inner endocyst. The host's reactive inflammatory response forms the outer pericyst, which is a dense fibrous protective layer around the parasite. The ectocyst is an acellular, elastic laminated membrane in the middle. The endocyst is the innermost layer, made up of a single germinal epithelial layer, which houses daughter cysts within the larger mother cyst , 3.Imaging plays a crucial role in detecting and diagnosing hydatid disease, particularly in cases where there is a history of exposure or immigration from an endemic area –3. HydatCasoni's intradermal skin test and indirect haemagglutination test (IHA) can detect the presence of antibodies to the parasite, but they have varying sensitivity (57–93%) and limited specificity. The IHA serology test has a reported sensitivity range of 66-100% and can be used as a screening test . No hemaPercutaneous transthoracic aspiration should be avoided or done with caution as it may cause allergic reactions or spillage of cyst content. Surgical resection is the preferred treatment for most patients with hydatid disease, while medical therapy with albendazole or mebendazole is used in addition to surgery. Medical therapy is the primary option for patients who cannot tolerate surgery or those with recurring hydatid disease or small cysts , 15.Prolonged air leak, wound infection, empyema, seroma, and fistula formation are some of the most commonly observed postsurgical complications following chest hydatid cyst removal. Among all complications, the air leak with residual space and wound infection had the highest frequency, as was seen in our case .Antiparasitic agents are also used as a supplement to surgical treatment. Albendazole, mebendazole, and praziquantel are antiparasitic agents that can be used. We began the albendazole regimen for one standard cycle immediately after surgery , 15.Primary chest hydatid disease is a rare occurrence. We reported a case of primary chest hydatid disease in a young male patient with a history of close contact with goats and camels, who presented with chronic left pleuritic chest pain and a left paravertebral cystic mass showing typical MRI features of a hydatid cyst. The presence of intracystic daughter cysts and floating membranes (water lily sign) on imaging are typical features of hydatid disease. This rare case highlights the importance of including hydatid disease in the differential diagnosis of thoracic cystic masses and the utility of chest MRI, particularly in patients who have a history of exposure to endemic areas or close contact with intermediate hosts.


Acute rupture of the plantar fascia is a rare but potentially debilitating injury in athletes, particularly those involved in running and jumping sports. Early recognition and prompt treatment are crucial for a successful recovery and return to play. Conservative treatment, including rest, immobilization, and physical therapy, may be effective in most cases, while surgical intervention may be required in those that are nonresponsive to conservative treatment.We report a case of plantar fascia rupture in a 22-year-old male semi-professional football player who presented with sudden severe pain in the sole of his right foot during a match, followed by a popping sensation and inability to weight bear. The athlete was healthy and had no history of previous injury in the right foot. MRI confirmed a complete rupture of the plantar fascia. The player was treated conservatively and underwent a rehabilitation program. The player returned to full competition after nine weeks, with no limitations. The plantar fascia is a fibrous tissue that runs along the sole of the foot and helps support the arch. It is a crucial component of the foot anatomy, playing a key role in weight-bearing and stability during walking and other activities .Despite its importance, the plantar fascia is also susceptible to injury, particularly in individuals who engage in repetitive high-impact activities, such as runners, jumpers, and other athletes who put repetitive stress on their feet . AlthougPlantar fasciitis is a well-known disorder, and the most common complaint among patients is pain when taking the first steps in the morning . In athlPlantar fascia rupture is not as common as plantar fasciitis. Plantar fascia rupture in athletes was first described by Leach et al. in 1978 , and mosThe cases described in the literature are scarce and there is no consensus on the best therapeutic strategy to adopt. The baseline treatment is based on conservative therapy such as rest, analgesia, and physical therapy. Surgical treatment is recommended only if conservative treatment fails .We describe a clinical case of a spontaneous acute rupture of the plantar fascia in a 22-year-old football player who was successfully diagnosed with MRI and treated with conservative measures, avoiding surgery.A 22-year-old male semi-professional center-back soccer player of the Portuguese Liga Revelação, with a right dominant leg, experienced sudden pain in his right rear foot as he landed after a jump during a soccer match. The athlete had never received steroid injections and had no history of previous plantar fasciitis.He was evaluated on the pitch during the match and described a popping sensation and a sharp pain in the plantar region and heel. The athlete was incapable of weight-bearing on the right foot, presented an evident gait limitation, and was promptly removed from the field.cavus and varus foot. There was local edema, ecchymosis, and pain on the palpation of the fascia and calcaneus.Physical examination revealed an abnormal alignment of the ankle-foot axis, with bilateral Passive dorsiflexion of the metatarsophalangeal joint of the great toe also produced severe pain. Passive and active ranges of motion were preserved. There was no pain related to other structures of the foot, such as ligaments, tendons, or bone, and there was no anterior or posterior instability. An X-ray of the right foot was requested by the medical team on the same day, and the images did not reveal any signs of osseous lesions.Due to the persistence of symptoms three days after the injury, an MRI was requested. It revealed a rupture of the lateral fascicle of the plantar fascia with edema of the surrounding tissues Figures -3.Conservative treatment was initiated, with initial discharge and immobilization with a Walker boot for two weeks. Non-steroidal anti-inflammatory drugs  were used during the first three days, and cryotherapy and painkillers  were prescribed during the first week.2 to increase blood flow and reduce inflammation in the right rear foot.The rehabilitation program began one day after the diagnosis. The athlete completed a one-hour session of physical therapy every day during the week. For analgesia, the treatment was transcutaneous electrical nerve stimulation at 100 Hz paresthesia-induced intensity and pulsed ultrasound with 20% duty cycle 3 MHz 1.2 w/cmA manual drainage massage was performed. A gentle and progressive stretch of peri-articular ankle muscles and intrinsic muscles of the foot was performed. Strengthening exercises to improve the stability and strength of the foot and ankle were progressively implemented, with a greater focus on eccentric work. Proprioceptive, balance, and motor coordination work was conducted from the early stages along with biomechanical analysis and correction of foot alignment. The final phase of the rehabilitation program consisted of plyometric and sport-specific exercises.There was a favorable and progressive evolution, and the athlete returned to play nine weeks later, without any physical limitations.Acute tears of the plantar fascia are rare injuries in athletes, especially if they occur spontaneously, as in the presented case ,5,6. Acu cavus and varus. In high-arched feet (pes cavus), the strain in the fascia increases and has less mobility to absorb ground reaction forces, increasing the load applied to the foot. This condition has been shown to predispose to plantar fasciitis and plantar fascia rupture [Some risk factors predispose to this kind of injury. One mechanism appears to be due to an excessive load on a weakened structure. Most authors describe that previous fasciitis or local corticosteroid injection seem to injure the plantar fascia, increasing the probability of rupture ,6,8. In  rupture . Another rupture . Many ofpop sound and a plantar hematoma, these signs are missing in acute-on-chronic ruptures [pop sensation in the sole of the foot after a sudden effort (landing in a jump), as well as local ecchymosis and the inability to fully bear weight. In addition to the clinical examination, imaging studies such as ultrasound or MRI should be used to confirm the diagnosis and assess the extent of the damage [The diagnosis is mainly clinical based on medical history and physical examination which are important criteria to distinguish between acute or chronic rupture ,6,8. Altruptures . The plae damage . The type damage , while oe damage . Radiogre damage .Despite no guidelines or other recommendations for the treatment of this condition, most patients are treated conservatively, with surgery performed in only a few cases in the literature .Conservative treatment is based on immobilization, boot brace, and limited weight-bearing . ImmobilPlantar fasciitis is a common disease in athletes but acute plantar fascia rupture is a less common injury that should not be overlooked in the differential diagnosis. With this case report, we intend to raise awareness about the possibility of this pathology and emphasize the importance of the diagnosis based on the clinical history and physical examination and confirmed by imaging (MRI or ultrasound). In this case, recovery was complete with conservative treatment and the player was able to compete at his previous level. We hope that more cases will be reported in the future to facilitate the creation of a standardized treatment protocol.


Tracheobronchial rests are a rare congenital anomaly where ectopic respiratory tract elements may be found in an abnormal site, such as within the esophageal wall. We present a case of a late presentation of an esophageal intramural tracheobronchial rest with complaints of pain in the left chest wall, vomiting, and loss of appetite for one month. The chest X-ray and mammogram were both normal, but an endoscopy could not be performed due to luminal narrowing. A CT scan shows a well-defined, round, non-enhancing hypodense lesion measuring 2.6 x 2.7 cm in the middle one-third of the esophagus.Upon resection, histopathological examination revealed fragments of tissue lined by pseudostratified ciliated columnar epithelium with respiratory mucinous glands admixed with pools of mucin and underlying strands of skeletal muscle. The subepithelium contains esophageal submucosal glands, which confirm the esophageal origin of the choristoma.The usual presentation is congenital esophageal stenosis at birth with over half of these cases being attributed to tracheobronchial rests. Presentation beyond adolescence is even rarer with a relatively benign course and favorable prognosis. Clinical, radiological, and pathological correlation as well as a high index of suspicion are important to avoid misdiagnosis and to institute optimal treatment. Tracheobronchial rests are a rare congenital anomaly, with the first case being described in 1957, and are currently estimated to have an incidence of about 1 in 50,000-100,000 live births and only about 200 documented cases [A 46-year-old female presented to the Department of Cardiothoracic Vascular Surgery with complaints of pain in the left chest wall and heaviness of the left breast for 10 years. She also reported vomiting and a loss of appetite for one month. Initially, a breast lesion was suspected in view of chest pain and heaviness for 10 years and was repeatedly evaluated at other centers with no definitive diagnosis. However, the initial radiological work-up with a chest X-ray and mammogram was normal. Following this, an endoscopy was attempted but could not be performed due to severe luminal narrowing in the middle one-third of the esophagus. A CT lung examination revealed a lesion measuring 2.6 x 2.7 cm in the wall of the esophagus from the middle one-third segment, extending into the para-esophageal region on the left side  epithelium lying on bundles of striated skeletal muscle Figure .Numerous extracellular pools of mucin were also seen with admixed inflammatory cells, chiefly composed of neutrophils, eosinophils, and lymphocytes Figure .The underlying subepithelium also contains submucosal glands, which are suggestive of an esophageal origin Figure .An adjacent lymph node which was also excised along with the mass revealed changes secondary to reactive lymphadenitis. These findings confirm the presence of heterotopic elements within the esophagus, and a final diagnosis of esophageal intramural tracheobronchial rests was made.Tracheobronchial choristomas are collections of heterotopic tissue present within the esophagus which contain various elements of the respiratory tract such as respiratory epithelium, bronchial glands, cartilage, and lymphatic tissue in the submucosa or muscularis propria and occur in the thoracic portion of the esophagus as seen in this case .During embryological development, the trachea and esophagus share a common origin from the tracheobronchial bud which would further divide and develop to form these structures. The tracheobronchial groove, which lies anteriorly, gives rise to the respiratory tract and divides along the coronal plane. Jabari et al. described two predominant theories of division, the aforementioned "septation model" which is more widely accepted, as well as a "tracheal outpouch" model of development -8. SeparThe usual presentation is CES at birth with an incidence of 1 in 25,000 to 50,000 live births, 54% of these being attributed to tracheobronchial rests with an effective incidence of 1 in 50,000-100,000 live births -11. FeweThe diagnosis is made by histopathological examination, which confirms the presence of respiratory components. Clinically, other intramural esophageal tumors may be close differentials, such as leiomyomas and gastrointestinal stromal tumors (GIST), which were ruled out with extensive sampling and thorough histopathological evaluation. Surgical intervention typically involves segmental resection or dilatation, though the former is preferred as dilatation usually produces unsatisfactory results, with an increased risk of recurrence and perforation. The lesion may be resected, such as in our case, where the residual thickness of the esophagus remains unaltered. Rests that involve a larger portion of the body and cause stenosis, on the other hand, may necessitate resection and anastomosis -8.Tracheobronchial rests are rare congenital lesions that can have a varied presentation depending on the size, with larger and more stenotic rests presenting early on in life as CES. The presentation of such choristomas is exceedingly rare in adulthood with non-specific symptoms and requires extensive evaluation for further management. While there is no known direct syndromic associations or genetic mutations, diagnosis of a tracheobronchial rest should be followed by screening for any other gastrointestinal malformations, as some case reports do mention the coexistence of such lesions.Common radiological differentials include other esophageal intramural tumors such as leiomyoma and GIST, all of which may be differentiated microscopically. Surgical intervention typically involves segmental resection or, infrequently, dilatation. A high index of clinical suspicion, as in this case, as well as radiological and pathological correlation, is essential for avoiding misdiagnosis and initiating appropriate treatment.


Although anal cancer remains rarely diagnosed in the world, its frequency is rising, especially in high-risk groups. The prognosis of advanced anal cancer is poor. However, there are still few reports on the endoscopic diagnosis and treatment of early anal cancer and its precancerous lesions. A 60-year-old woman was referred to our hospital for endoscopic treatment of a flat precancerous lesion in the anal canal, which was identified by narrow-band imaging (NBI) and confirmed by pathological examination in another hospital. The pathological results showed a high-grade squamous intraepithelial lesion (HSIL) in the biopsy specimen, and immunochemistry staining showed P16 positive, suggesting HPV infection. We performed pre-resection endoscopic examination for the patient. A lesion with a clear margin and tortuous dilated vessels was revealed under magnifying endoscopy with NBI (ME-NBI), which stayed unstained after iodine spraying. The lesion was successfully removed en bloc using ESD without complications, and the resected specimen was a low-grade squamous intraepithelial lesion (LSIL) with positive immunochemistry staining of P16. The patient underwent follow-up coloscopy a year after ESD, and the anal canal healed well with no suspicious lesions found. From this case, we can learn that ESD is safe and effective for curative resection of precancerous lesions of the anal canal. Anal cancer principally comprises two morphologic variants: squamous cell carcinoma (SCC) and adenocarcinoma, with SCC comprising nearly 85% of all cases . In the ME-NBI facilitates the clear visualization of superficial microvascular structure, which helps the identification of early cancer and precancerous lesions in the pharynx and esophagus , 7, as wA 60-year-old woman underwent colonoscopy because of changes in bowel habits in another hospital, with anal discomfort occasionally, without any other medical, family, or psychosocial history, and she claimed to be physically healthy before. When observing the anal canal using white light, a whitish superficial flat (0-IIb) lesion with scattered reddish spots was discovered . In NBI The patient was referred to our hospital for further examination and treatment. The temperature was 36.2°C, and other vital signs were normal on admission. The physical examination showed no significant abnormalities. The total cholesterol was 5.30 mmol/L (reference range 3.90–5.20 mmol/L), and other laboratory results were normal. The abdominal and pelvic CT scan (plain and enhanced scan) showed multiple cysts of the liver, with no suspicious malignant lesions found.The ME-NBI endoscopy was conducted, and we found a lesion with a clear margin and tortuous dilated vessels usually seen in early SCC of the esophagus ,B. AfterAfter 1 year of the endoscopic treatment, colonoscopy follow-up was performed, and no suspicious lesions were found ， and theAnal cancer is an uncommon disease occurring in middle-aged adults, making up only 4% of cancers of the lower gastrointestinal tract . Anal caAlthough there are no guidelines for the screening of anal cancer, it is reasonable to screen high-risk populations with physical examination, anal cytology, and high-resolution anoscopy (HRA). With the increasing acceptance of endoscopy by the public, screening by colonoscopy should be noticed. There have been several case reports on the use of colonoscopy in the diagnosis and treatment of early cancer of the anal canal , but theIn the aspect of diagnosis, ME-NBI helps to identify suspicious lesions because the abnormal vasculature presenting dilatation, tortuosity, caliber change, and various shapes is similar to the intrapapillary capillary loop patterns of intraepithelial squamous cell carcinoma of the esophagus . In our The specimen resected by ESD was confirmed by pathological examination to be LSIL, which was not consistent with the result of the biopsy specimen. However, it was explainable because the lesion was less than 1 cm, and the biopsy might have resected the HSIL part of the lesion. Considering the HPV infection status, further treatment by ESD is necessary for the prevention of anal SCC.In conclusion, the precancerous lesions associated with HPV infection can progress to SCC, and the screening of early anal cancer and precancerous lesions is necessary. With the development and widespread of colonoscopy, a gastroenterologist should pay attention to the screening of anal lesions, especially with the help of ME-NBI. For early cancer and precancerous lesions with HPV infection in the anal canal, ESD is safe and effective for curative resection.When asked about opinion on the endoscopic diagnostic and treatment process, the patient commented that endoscopic treatment is less traumatic and has a quick recovery, with endoscopy follow-up showing a complete cure, which was very friendly and efficient for patients. We agreed that the minimally invasive and effective operation and regular follow-up colonoscopy can bring more benefits to patients.The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by The Ethics Committee of Beijing Friendship Hospital, Capital Medical University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.HL wrote the manuscript. PL and XS designed the study and supervised the manuscript. HL, LY, and RX collected the clinical data. PL, XS, and HL participated in the diagnosis and treatment of the patient. All authors contributed to the article and approved the submitted version.This study was supported by the National Natural Science Foundation of China (82070575) and Capital’s Funds for Health Improvement and Research (2020–2-2026).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Angiolipoma is a benign soft tissue tumor composed of mature adipocytes and small capillaries. Although it can occur in any part of the body, it is rare in the oral cavity, especially in the lips. We report the case of a 47-year-old male who presented with a painless, slow-growing mass on the right lower lip that had gradually increased in size over several months. The initial diagnosis included lipoma, mucocele, and hemangioma. The mass was surgically excised, and the histological examination confirmed the diagnosis of angiolipoma. Angiolipomas involving the lips are rare and can be easily misdiagnosed. Therefore, clinical suspicion, along with appropriate imaging and histological examination, is essential for an accurate diagnosis and appropriate management. The patient had a smooth recovery after surgery and showed no recurrence of the condition during the one-year follow-up examination. Angiolipoma is a rare, benign soft tissue tumor composed of mature adipocytes and small capillaries . AlthougA 47-year-old male presented to the oral and maxillofacial surgery clinic with a painless, slow-growing mass on the right lower lip that had been present for several months. The patient reported that the lesion had gradually increased in size and was causing some discomfort with talking and eating. There was no history of trauma, bleeding, or infection. The patient had no significant medical history and was not taking any medications.On clinical examination, a soft, compressible, non-tender submucosal mass was palpated on the right lower lip, measuring approximately 1.5 cm in diameter. The overlying mucosa was normal in color and texture, and there were no signs of inflammation or ulceration. The lesion was mobile and not attached to the underlying bone or surrounding soft tissues (Figure Based on the clinical presentation, the initial differential diagnosis included a lipoma, mucocele, and hemangioma. The patient underwent surgical excision of the lesion under local anesthesia. A transverse incision was made through the mucosa overlying the lesion, and the mass was carefully dissected from the surrounding tissues. The lesion was found to be a soft, yellowish, lobulated mass, measuring approximately 1.5 cm in diameter, with a well-defined capsule Figure . The lesThe excised specimen was sent for histopathological examination, which revealed a well-circumscribed lipoma with no evidence of malignancy Figure . The patAngiolipomas are rare tumors that are composed of mature adipose tissue and small capillaries. These tumors are generally slow-growing, painless, and small in size, ranging from a few millimeters to a few centimeters . While aIn the present case, the diagnosis of angiolipoma was confirmed by examining the excised tissue histologically . The hisThe differential diagnosis for soft tissue masses in the oral cavity includes a wide range of benign and malignant conditions . Among tSurgical excision is the preferred treatment option for angiolipomas . These tAlthough angiolipomas are benign tumors, recurrence can occur after incomplete excision . Long-teAngiolipomas involving the lips are rare, benign soft tissue tumors that can be easily misdiagnosed. Clinical suspicion, along with appropriate imaging and histological examination, is essential for an accurate diagnosis and appropriate management. Surgical excision is the most common treatment, and complete excision with care to preserve surrounding tissues can result in excellent cosmetic outcomes.


Fibromatosis colli is an infrequent and self-limiting disorder in newborns with an unknown etiology. It usually presents with an abnormal head position or cervical swelling. The clinical diagnosis of fibromatosis colli is important to avoid unnecessary invasive interventions. The condition is treated conservatively with physiotherapy. In this article, we report the case of a two-month-old infant who presented with an abnormal head position and was diagnosed with fibromatosis colli based on ultrasonographic examination, which is the non-invasive diagnostic intervention of choice. Fibromatosis colli, or congenital torticollis, is an infrequent and self-limiting disorder caused by a nonmalignant tumor in infants' sternocleidomastoid muscles (SCMs). It is a rare condition, occurring in around 0.4% of live births and mainly in males. Most cases affect the right side of the neck . DespiteWe present a two-month-old female brought by her mother to the emergency department to evaluate an abnormal head position. The mother has noticed that the child cries when she tries to move her head. The head of the newborn always tilts to the left. There seemed to be discomfort and limited mobility in the neck, resulting in pain. The mother has noticed these changes whenever she tried to change the baby's clothes for the last two weeks, albeit briefly. There was no history of fever, trauma, or abnormal movements. The mother did not give the baby any medication. There was no history of neuromuscular or congenital disorders in the family. Baby is a product of non-instrumental, normal vaginal delivery; she is a single gestation. Her birth weight was 3.1 kg. The baby looked well and was active without dysmorphic features. The head is inclined to the left side without visible swelling or skin changes. On palpation of the neck, there is no muscle hardening, masses, or enlarged lymph nodes. However, passive movement of the neck made her irritable. Bilateral upper and lower arms moved freely with positive moral reflexes. Other systematic examinations were unremarkable.The differential diagnosis included SMC hematoma, tumor, lymphadenopathy, and fibromatosis colli. The clinical presentation of the infant, including the report by the mother concerning pain and discomfort when she tries moving her head, which leans to the left, raised suspicion for fibromatosis colli. The diagnosis was confirmed via a neck ultrasound, which revealed that the right SCM was thicker than the left, measuring 0.6 cm versus 0.4 cm on the left side Figure . FurtherFibromatosis colli was first described as the sternocleidomastoid tumor of childhood (SCMT) . It is cFibromatosis colli presents mainly during the newborn period with cervical swelling and abnormal head position . PhysicaRegarding detection, if ultrasound results are inconclusive, further evaluation of the pseudotumor can be conducted using CT scans. However, it is important to note that CT scans expose the newborn to ionizing radiation. The CT scan typically reveals an enlargement of the SCM with normal surrounding structures, showing isoattenuation . On the While performing a biopsy on the mass is not recommended, cytology examinations show fibroblasts with mild features, along with degenerated and atrophic smooth muscle. There is no indication of bleeding or inflammation. The background exhibits muscle giant cells, collagen, and bland, bare nuclei . TreatmeThe treatment and management of this condition can be achieved through conservative management, medical intervention, or surgical intervention. Conservative management is done through observation and physiotherapy. Since some minor condition cases resolve over time, a watchful waiting approach is recommended, especially for cases where the condition does not cause significant functional limitations or discomfort . RegardiFibromatosis colli, or congenital torticollis, is an infrequent and self-limiting disorder characterized by a nonmalignant tumor in infants' SCMs. Although its etiology remains unknown, it is believed to stem from injuries sustained either during fetal development in utero or due to birth-related trauma. Although the condition is relatively uncommon (0.4% of live births), most cases occur in males. Clinically, the condition's presentations include abnormal head position, limited neck mobility, and discomfort. Diagnostic evaluation entails clinical assessments conducted through ultrasound, while treatment and management can be through conservative management, medical intervention, or surgical intervention.


Extrapleural solitary fibrous tumors are a rare type of spindle cell neoplasm, which can occur in many locations with different histologic and immunohistochemical findings, making the diagnosis challenging. They are usually indolent and their treatment is based on complete surgical resection. There are still some issues to be clarified regarding systemic therapy  and long-term follow-up. We present a series of clinical cases in the same Department and review this thematic area. Extrapleural solitary fibrous tumors (SFT) are a rare type of spindle cell neoplasm  more comDue to this histologic variability, its rarity and evidence based on retrospective studies and case reports, SFT natural history is not completely known , 3, 4.Therefore, the authors propose a review of this thematic area, through a presented case series.A 73-year-old male with prior history of irritable bowel syndrome presented a 2-week-long abdominal pain, located on the right lower quadrant associated with anorexia and diarrhea, without blood loss or any other symptoms. The CT-scan showed a 9-cm solid preperitoneal lesion, with enhancement following intravenous contrast administration .en bloc excision. The histologic analysis revealed a completely excised SFT of 9 × 7.5 × 4 cm, with no malignant signs.Patient was submitted to After multidisciplinary discussion, the patient was kept under surveillance. No signs of recurrence were reported during the 4 years of follow-up.A 28-year-old male with prior history of symptomatic renal lithiasis. During clinical investigation of a persistent right lumbar pain with no other symptoms, a 54 × 43 × 37-mm non-functional adrenal incidentaloma was detected, with an absolute washout of 64% and relative washout of 56%, suggestive of adrenal adenoma .After pain control with oral therapy, patient was submitted to an elective laparoscopic right adrenalectomy, without complications. The histologic analysis revealed an SFT totally excised, adherent to a normal adrenal gland.Currently, patient is kept under surveillance, with no signs of recurrence during the past 3 years of follow-up.A 59-year-old male presented a multinodular goiter, without hypo- or hyperthyroidism or compressive symptoms. The ultrasound showed a solid, hypoechogenic and well-defined 8 × 6 × 4-cm dominant node. The preoperative cytologic analysis was non-diagnostic. The patient was then submitted to total thyroidectomy, without complications. The histologic and immunohistochemical findings diagnosed an 8 cm completely excised SFT, with no signs of malignancy.Still under surveillance after multidisciplinary discussion, the patient has presented no signs of recurrence during the 2 years of follow-up.We present a table that summarizes the case series description .Extrapleural SFT are more commonly observed between the fifth and seventh decades, with no gender predominance , 2 or knSFT can appear in any anatomic site and its presentation depends on its location , 2:Abdomen: most frequent symptoms include a palpable mass, pain and abdominal distension. Due to the free space of the abdominal cavity and the capacity of distension of its wall, symptomatic patients usually present large tumors, with compressive effect against the surrounding structures .Meninges: generally intracranial tumors, which cause compression of surrounding structures or high intracranial pressure .Head and neck: usually small lesions easily recognized through a painless mass. When symptomatic, they can present as proptosis or reduced visual acuity .Soft tissues of the extremities: generally present as a painless mass.Despite there being no pathognomonic imaging findings, typically SFT present as soft tissue density, homogeneous and well-defined mass, occasionally with cystic areas, calcifications or bleeding, causing displacement, but no invasion of adjacent structures .Definitive diagnosis is based on cellular morphology and immunohistochemical characteristics .Extrapleural SFT are classically characterized by spindle hypocellular areas intercalated with hypercellular areas with collagen bundles and prominent vascularization , 3, 4 F. HoweverThere are some biomarkers that can help diagnosis, although they are not specific for SFT. Usually SFT stain positive for vimentin, Bcl2, CD34, CD99 and STAT6, but not for actin, desmin or S100 [Despite indolent growth of most extrapleural SFT , benign However, some parameters are associated to more aggressive behavior, metastasis and recurrence, namely:size >10 cm>4 mitoses per 10 high-power fieldstumoral necrosispositive margins .The treatment of localized extrapleural SFT is based on complete resection , 3, 4. ARecommendation of systemic therapy in unresectable or metastatic disease is not clearly defined, despite some successful reported cases with antiangiogenic therapy . Hence, The estimated rate of metastatic disease is 6–23%, more frequently to lung, bone and liver .Therefore, long-term follow-up is advisable , 3, due In the reported cases, a semestral clinical evaluation and annual CT-scan in abdominal SFT was performed. The patient with SFT in the thyroid gland underwent annual ultrasound and scintigraphy and MRI 1 year after the surgery.In conclusion, extrapleural SFT remains a rare and challenging disease, raising questions regarding treatment and long-term follow-up.Consequently, an international compilation of reported cases seems necessary, aiming at more detailed study and the further creation of international recommendations.


Small intestinal hemangiomas may present as a severe gastrointestinal hemorrhage associated with a hematologic emergency. In the emergent setting, this may result in more extensive intestinal resection than would otherwise be necessary with elective intervention. The widespread application of capsule endoscopy and double-balloon enteroscopy presents an opportunity to diagnose small bowel hemangiomas prior to symptomatic onset. In one of the first published cases of multiple small intestinal hemangiomas, we highlight the importance of maintaining a broad differential and pursuing a thorough workup, including small bowel imaging, in patients with complaints of chronic abdominal pain and anemia. Small bowel hemangiomas, a rare form of gastrointestinal neoplasms, have a preoperative diagnosis rate of less than 30% ,2. With A 25-year-old male with a history of uncontrolled hypertension, gastroesophageal reflux disease, and fractures of the spine and pelvis secondary to mechanical trauma over five years ago, status post-fixation of the symphysis pubis and bilateral sacroiliac joints, presented for an outpatient gastrointestinal consultation following an emergency department encounter for a six-year history of epigastric abdominal pain. He described the epigastric pain as intermittent, sharp, and progressively worsening. The patient complained of abdominal “fullness,” not associated with his intermittent bouts of constipation. Upon presentation, he denied vomiting, diarrhea, blood in stool, melena, weight loss, change in appetite, recent travel, and sick contacts.On initial examination, lower right abdominal quadrant tenderness to palpation was appreciated. Complete blood count was notable for microcytic anemia (hemoglobin (Hg) 8.6, hematocrit (Hct) 30.2, mean corpuscular volume (MCV) 64.8, mean corpuscular hemoglobin concentration (MCHC) 28.5, mean corpuscular hemoglobin (MCH) 18.5, and red cell distribution width (RDW) 17.2). Computed tomography (CT) abdomen and pelvis demonstrated a 10-mm-diameter soft tissue density filling defect in the ileum, presumed to be a colonic polyp (Figures The patient was started on a senna-based bowel regimen, which provided minimal relief. Follow-up endoscopic ultrasound revealed a subepithelial lesion in the duodenal bulb, which appeared to originate from the superficial mucosal-luminal interface Figure . SubsequThe patient has been started on a bowel regimen and is undergoing watchful waiting. As of today, the patient’s symptoms persist. He has been referred to a small bowel surgical specialist for consultation.Hemangiomas are symptomatic in 90% of cases, typically presenting as anemia of unknown origin secondary to chronic gastrointestinal bleeding . A lack While resection of the affected segment of bowel has become the mainstay of treatment, few have weighed the curative effect of widespread intestinal resection against the drastic consequences upon patient quality of life, which proved to be a critical factor in the decision-making of our patient -5. AlthoIn one of the first published cases of multiple small intestinal hemangiomas that were preoperatively diagnosed, we highlight how the increased availability of new imaging modalities can improve patient outcomes by allowing clinicians to plan more conservative surgical interventions outside of emergent settings. Our patient's diffuse distribution of small intestinal hemangiomas, as well as the surgical challenge posed by balancing the friability of the structures with the consequences of intestinal resection, underscores the need for further surgical literature on this topic. In patients presenting with abdominal pain and microcytic anemia, but without overt gastrointestinal bleeding, it is critical that physicians maintain a broad differential that includes pathologic disorders of the small intestine and utilize adjunctive diagnostic techniques, including endoscopy and small bowel imaging, to reach a conclusive diagnosis.


True uterine artery aneurysms, especially during pregnancy, are a rare entity and not well understood. Clinical symptoms are unspecific pelvic pain and pressure. Diagnosis can be confirmed by transvaginal color-coded-sonography and/or magnetic resonance imaging. Because of potential risk of rupture, immediate interdisciplinary discussion and treatment planning in the best interests of both mother and child is crucial.We present a 31-year-old pregnant woman with increasing pelvic pain and pressure. Diagnosis of an unruptured uterine artery aneurysm was confirmed by color-coded-sonography and magnetic resonance angiography. After interdisciplinary consultation, successful endovascular super-selective coil-embolization was performed by using X-ray fluoroscopy. Thus, fetal radiation dose during treatment with 4.33 mGy  was as low as possible with no immediate harm to the fetus.Unruptured true uterine artery aneurysms can be successfully treated by endovascular super-selective coil-embolization during early pregnancy with no immediate harm to the fetus. Uterine artery aneurysms (UAA) are an extremely rare medical condition –4. The iA 31-year-old patient  presented to the emergency department of an external hospital with sudden left-sided pelvic pain and pressure. Physical examination was unremarkable, but transvaginal sonography and MRI revealed an unknown left parauterine mass with a maximum diameter of 39 mm (Fig. ™ software was 4.33 mGy (Fig. The intervention taking 79 min was performed under local anesthesia with retrograde access via the right common femoral artery. Contrast agent application under X-ray fluoroscopy secured the diagnosis of a true left UAA Fig. A-C. EmbomGy Fig. G, so thaThis case is an example of a rare diagnosed, unruptured true UAA during pregnancy and highlights the importance of a well-cooperating interdisciplinary team. Diagnosis is challenging, especially with regard to nonspecific clinical symptoms or asymptomatic patients. Lower abdominal- or back-pain and sensation of pressure as one of the main symptoms may give a hint to the condition , 3, 5. DConsequently, a coil embolization of experienced radiologists is an effective and feasible treatment for the pregnant women and furthermore safe for the fetus.


Bilateral spontaneous quadriceps tendon rupture is a rare condition characterized by the simultaneous tear of the fibrous tissue connecting the quadriceps muscle to the patella bone. Prompt diagnosis is crucial for appropriate treatment and optimal outcomes. We present a case of a 70-year-old male with bilateral knee pain and an inability to walk, resulting from a trivial fall. Despite initial misdiagnosis, a thorough evaluation, including physical examination and imaging, revealed bilateral quadriceps tendon rupture. Surgical repair was performed, followed by a comprehensive rehabilitation program. At the four-month follow-up, the patient showed significant improvement in pain and function. This article provides a comprehensive review of the existing literature on bilateral quadriceps tendon rupture, emphasizing the challenges in the diagnosis and management of this rare condition. Early diagnosis, prompt surgical intervention, and a tailored rehabilitation program are crucial for successful outcomes. Bilateral spontaneous quadriceps tendon rupture is a rare but physically exhausting condition that can cause difficulties in movement and stability. This condition occurs when the fibrous tissue connecting the quadriceps muscle to the patella bone tears simultaneously. The tensile strength of the quadriceps tendon is related to its thickness, making it unlikely to be injured following minor trauma without preexisting degeneration. The diagnosis of bilateral simultaneous rupture of the quadriceps tendon can be challenging due to its rarity, and a timely diagnosis is essential for appropriate treatment and optimal clinical outcomes. In this article, we will be presenting a case managed at our institution, as well as a comprehensive review of the existing literature on the topic.A 70-year-old male patient presented to our clinic with bilateral knee pain and an inability to walk. The patient reported that his chief complaint had surfaced three weeks before the clinic appointment, after a seemingly trivial fall from a standing height. During the fall, the patient landed on his back with his knee flexed, rendering him unable to stand. At the time of injury, the patient promptly sought medical attention at a primary care facility, where he received analgesics and was referred to our orthopedic clinic as a case of knee osteoarthritis. The patient’s medical history was unremarkable, with no previous history of medication intake or prodromal knee pain before the injury. Despite his advanced age, the patient was a physically active individual who routinely engaged in physical exercise. Upon conducting a clinical examination, we identified a palpable gap in the suprapatellar region and bilateral loss of knee extension, as depicted in An X-ray of the patient’s knee was obtained, which shows bilateral patella infera, as depicted in The results of the laboratory analysis indicated that the individual’s kidney profile, lipid profile, Hemoglobin A1c(6.1), serum uric acid, parathyroid hormone, vitamin D, serum calcium, and serum phosphorus were found to be within the normal range. Additionally, the rheumatology workup did not show any abnormalities. The individual’s body mass index (BMI) was recorded as 32, which falls under the category of obesity class 1 as per the standard BMI classification.Z-score at the lumbar area 1.6.Dual Energy X-ray Absorptiometry (DEXA) scan for osteoporosis was normal with a total Following a thorough evaluation of the patient’s condition, a bilateral primary tendon repair procedure was carried out. This involved the careful debridement of the distal stump of the quadriceps tendon, which exhibited signs of fragility and degeneration, and measured approximately 1 cm in length from the superior pole of the patella. Subsequently, the proximal stump of the tendon was reattached to the superior pole of the patella using two anchor sutures, each 4.75 mm the size, as depicted in the accompanying Following the surgery, the patient was put on a comprehensive rehabilitation program, which included immobilization in a hinge knee brace locked in extension for 1 month, along with non-weight-bearing exercises. The patient’s rehabilitation program progressed to involve a gradual increase in passive flexion for the second month until he reached 90° of flexion.In the third month, he began a gradual increase in active range of motion exercises. In the final month leading up to the final follow-up, he commenced quadriceps muscle strengthening exercises. At the four-month follow-up, the patient reported significant improvement in knee pain and function. He was able to stand and walk and return to his normal daily activities, albeit with minor limitations in certain activities requiring more knee strength and stability .Bilateral spontaneous quadriceps tendon (QT) rupture is a rare phenomenon, as indicated by a UK study reporting an incidence rate of 1.37 per 100,000 individuals annually . AnotherIt is a physically exhausting condition that occurs when the fibrous tissue connecting the quadriceps muscle to the patella bone tears simultaneously. The quadriceps tendon is responsible for transferring the force generated by the quadriceps muscle to the knee joint, which enables movement and provides stability.2 has a tensile stress value of 37 N/mm2 [The tensile strength of the quadriceps tendon is related to its thickness with a study showing that a quadriceps tendon with a cross-sectional area of 65 mm37 N/mm2 . With suRecent academic inquiries have shed light on the intricate vascularization patterns of the quadriceps tendon, positing the involvement of vascular imbalances in the genesis of ruptures. The quadriceps tendon typically receives vascular supply from three distinct systems: the medial arcade, nourishing its medial edge; the lateral arcade, supplying its lateral border; and the peripatellar vascular ring, an elaborate vascular network enriching the tendon’s distal 1 cm. The tendon was further categorized into three zones, Zone 1 is located between 0 and 1 cm from the superior pole of the patella, Zone 2 lies between 1 and 2 cm from the superior pole of the patella, and Zone 3 is located >2 cm from the superior pole of the patella. Zone 2 was found to be less vascular than Zones 1 and 3. This disparity can be attributed to the peripatellar ring supplying Zone 1 and the medial and lateral arcades, with a plentitude of vessels at the musculotendinous junction, catering to Zone 3 , 7. AddiMany conditions have been implicated as predisposing factors for tendon rupture, altering the tendon ultrastructure or impacting its vascularity . These cHowever, it is noteworthy that cases of quadriceps tendon rupture occurring without any discernible risk factors are exceptionally rare. To highlight this rarity we have curated a detailed table summarizing cases reported in the literature where quadriceps tendon rupture occurred in the absence of any identifiable risk factors .In light of the rarity of these injuries, a timely diagnosis can be challenging for the treating physician with misdiagnosis at initial presentation reported to occur in 67% of patients . This caThe inability to detect the injury at the time of initial presentation can lead to a delay in providing appropriate treatment, which in turn can result in suboptimal clinical outcomes . Thus, iImaging can be employed to validate a diagnosis, and in case of doubt, plain films, ultrasound (US), and MRI are effective and viable options. Plain films are easily accessible in emergency settings and are typically obtained as a standard diagnostic measure to eliminate potential differential diagnoses, such as fractures, especially patellar fractures. Careful observation of subtle findings on the plain films, such as soft tissue defects, and avulsed bone fragments at the distal end of the quadriceps muscle, patella baja, knee effusion, and the presence of patellar spurs which was reported as a risk factor  can faciThe management strategy primarily involves reattaching the ruptured tendons to the patella. Various surgical techniques have been delineated for primary repair: direct end-to-end suture repair  is recomDespite biomechanical and clinical studies indicating no significant disparities between these techniques, it is essential to highlight the scarcity of substantial data from extensive series or comparative studies in the existing literature. This scarcity hampers the ability to conclusively affirm these findings .Various other techniques have been described, particularly for chronic ruptures with tendon retraction and a considerable gap between the tendon and patella . These tThere are several graft options available for augmentation of the quadriceps tendon, such as autografts, allografts, or synthetic grafts. Autograft options may include the semitendinosus or gracilis tendon . In the Therefore the choice of surgical technique depends on the extent and quality of the tendon tissue, as well as the patient’s underlying medical conditions and physical abilities.Rehabilitation after surgery is critical for a successful outcome, which typically involves a combination of physical therapy and progressive weight-bearing exercises. Published literature on rehabilitation protocols following surgical repair of ruptured tendons recommends a period of restricted weight bearing or flexion for at least 6 weeks , 36. HowIn conclusion, bilateral spontaneous quadriceps tendon rupture is an uncommon condition and the likelihood of misdiagnosis during initial evaluation is high due to factors such as obesity, medical conditions, and insufficient examination. As a result, it is imperative to conduct a thorough medical evaluation that encompasses a detailed medical history, physical examination, and imaging to ensure a precise diagnosis and timely intervention as early surgical repair showed to be more favorable for better prognosis as compared to delayed repair , 40.


Thalamic tumors are rare and uncommonly manifest as movement disorders, including hemidystonia. Despite this association, little is known about the evolution of hemidystonia.We report on a 11-year-old boy who complained of hypaesthesia and fine motor problems in the left hand. A magnetic resonance imaging showed a large mass in the right thalamus. Stereotactic biopsy revealed a WHO grade 4 astrocytoma, and the patient underwent normofractioned radiochemotherapy with proton-beam radiation and temozolomide. Three months later, a spastic hemiparesis developed on the left side, which progressed over months. Over the following months, the hemiparesis slowly improved, but hemidystonia in the same side developed. This was accompanied with radiological evidence of tumor regression, showing a persistent lesion in the ventral posterolateral and the intralaminar thalamus.This case illustrates the unusual and complex temporal course of appearance and disappearance of hemidystonia along with the regression and growth in glioblastoma involving the thalamus.The online version contains supplementary material available at 10.1007/s00381-022-05698-y. Thalamic tumors account for about 1% of all intracranial tumors, appearing only rarely as glioblastoma –4. HemidHere, we report on the transient appearance of hemidystonia in a child with a thalamic glioblastoma and its complex relationship both with tumor growth and hemiparesis.A 11-year-old right-handed boy complained of headaches and nausea, followed by hypaesthesia in the left hand and fine motor problems. Magnetic resonance imaging (MRI) showed a large mass (28 × 30 × 35 mm) in the right thalamus  with tumor extension to the subthalamic region and compression of the internal capsule with massive edema Fig. B.Over the following months, the hemiparesis slowly improved, but hemidystonia developed. A MRI 16 months post-biopsy showed tumor regression (18 × 19 × 14 mm) with a focal lesion in the ventral posterolateral and the intralaminar thalamus Below is the link to the electronic supplementary material.


To the Editor,We report the case of a 28-year-old male with no medical history presenting with cervical pain over a month. Initial MRI and CT findings showed a lobulated and cystic lesion of the fourth cervical vertebra with thin cortical walls, around 2,2 × 3,5 × 4,2 cm, with blood-fluid levels consistent with an aneurysmal bone cyst (ABC) Fig. . The verThe intervention was performed under conebeam CT (CBCT) and fluoroscopy guidance (Siemens Artis zee), under general anesthesia and in a prone position. Two 18G needles were placed into each cystic chamber and digital subtraction angiography confirmed their correct position. Doxycycline (20 mg/ml) and human albumin (20%) were mixed 1:1 with air in equal proportions to produce doxycycline foam, which was then applied via 3 ml luer-lock syringes into each cyst . While the foam was injected via one needle, the other served as a drain to avoid overpressure. Post-interventional CBCT depicted a foam distribution in 50% of the tumor volume with minor reflux into the epidural and periradicular venous plexus. A second session was carried out five months later targeting the untreated parts of the ABC. One year after the procedure, CT imaging depicted almost complete ossification of the ABC with minor cystic remnants (Fig. ABCs are rare entities comprising blood-filled spaces separated by connective or osteoid tissue with high activity of giant osteoclast cells. A diagnostic biopsy is mandatory to define whether the ABC is a primary lesion—which was the case, since a biopsy was performed prior to the intervention—or secondary to underlying conditions such as osteosarcomas and chondroblastomas. The cysts are directly connected to the venous system, which could be illustrated in this case by the reflux into the epidural and periradicular venous plexus. The broad therapeutic spectrum includes en bloc resection and stabilization, radiotherapy, coagulation, cryosurgery, and selective arterial embolization , 2. SclePercutaneous doxycycline foam therapy might be a viable option for complex vertebral ABCs. The major limitation is the lack of robust data, since the current evidence level derives mainly from case reports and case series.


Mycobacterium tuberculosis (MTB) otomastoiditis was made using MTB polymerase chain reaction from the Bezold’s abscess. The patient was started on anti-MTB therapy. Follow-up imaging showed resolution of abscesses and otomastoiditis. An indolent course of otitis media along with poor response to conventional antibiotics regimen should raise the suspicion of rare and unusual infectious etiologies.Primary tuberculous otomastoiditis is a rare condition. Mastoiditis is an infection of the mastoid part of the temporal bone that often happens as a complication of otitis media. The spread of infection from the middle ear and mastoid to adjacent structures might result in rare but serious complications. We present a case of an 8-year-old female with recurrent episodes of acute otitis media and foul-smelling yellowish discharge with hearing loss. Imaging revealed multiple abscesses. Intraoperatively, samples were taken from the abscesses and sent for complete analysis revealing a tuberculous infection. A diagnosis of primary  Mycobacterium tuberculosis (MTB). Primary tuberculous otomastoiditis is a rare condition as it comprises only 0.04–0.9% of all chronic otitis media cases [Tuberculous otitis media is a rare extrapulmonary manifestation of ia cases . Mastoidia cases , 6. The ia cases . In thisAn 8-year-old female patient presented with recurrent episodes of acute otitis media (AOM) and foul-smelling yellowish discharge from the left ear with hearing loss, after receiving multiple courses of antibiotics with only slight improvement. Otoscopic examination showed left small central perforation with minimal granulation tissue and right middle ear effusion. The patient was afebrile with no constitutional symptoms. A CT scan of the temporal bone revealed signs of bilateral mastoid and middle ear opacification with left mastoid cortical erosion, an overlying soft tissue swelling, and a parapharyngeal hypodense collection that likely represents an abscess . TherefoA contrasted CT scan  confirmeIn view of the findings, the patient was taken to the operating room for left tympanomastoidectomy with bilateral tympanostomy tubes insertion and intraoral drainage of the left BA. Intraoperatively, the left tympanic membrane was already healed; however, it was significantly thickened and inflamed during myringotomy. The middle ear space was full of granulation tissue with no purulent discharge that could be retrieved .The mastoid bone had no bony erosion of the septations. There was only granulation tissue in the antrum, sigmoid sinus area and the tip air cells. Also, necrotic tissue at the tip of the mastoid was noticed. The sigmoid sinus was partially dehiscent covered with granulation tissue. Similarly, inflammation and granulation were seen while performing the right myringotomy. The left parapharyngeal abscess was drained using an 18-gauge needle aspiration followed by a small incision and thorough irrigation of the abscess.Intraoperative samples taken from the abscesses were sent for complete analysis, including MTB polymerase chain reaction (PCR). Results from the MTB PCR came back positive. Then, a full MTB work-up was initiated to exclude pulmonary MTB. The patient was switched to anti-MTB therapy . With the absence of pulmonary tuberculosis, the patient was discharged with a diagnosis of primary MTB otomastoiditis complicated with Bezold’s, postauricular, and subdural abscesses. Meanwhile, more investigations were done ruling out the presence of HIV or primary immune deficiency.Following the completion of anti-MTB regimen, the patient developed a persistent right tympanic membrane perforation and left middle ear effusion after the tympanostomy tubes extrusion, which will be addressed at a later stage. Pure tone audiometry revealed right moderate conductive hearing loss with left mild conductive hearing loss. The patient was fitted with hearing aids. Follow-up imaging showed resolution of abscesses and otomastoiditis with a residual mastoid air cells partial opacification.Streptococcus pneumoniae, Haemophilus influenza and Moraxella catarrhalis being the most common, respectively [A common presentation of AOM is otorrhea which is usually accompanied by fever unlike otomastoiditis which presents with significant pain, postauricular swelling and tenderness . Also, iectively . On thisectively ; howeverectively . Primaryectively . TherefoThe MTB work-up initiated in our case was negative. Nevertheless, it has been reported previously that real-time PCR can detect MTB in 28.6% of the cases with a negative AFB smear . SimilarPrimary tuberculous otomastoiditis is rarely seen in modern medicine. A chronic and indolent presentation of otitis media with poor response to conventional antibiotics regimen should raise the suspicion of rare and unusual infectious etiologies such as MTB. A high index of clinical suspicion is required to narrow down the differential diagnosis to establish an early diagnosis and initiate the appropriate treatment to prevent serious complications.


Human hydatid disease typically occurs in organs such as the liver and kidney. Primary solitary intramuscular hydatid disease, however, is rare.We report a case of a giant muscle hydatid in the lower extremity, with neurological symptoms as the first manifestation. The symptoms specifically manifested as intermittent pain in the right lower extremity and numbness in the sole of the right foot. However, there were no obvious abnormalities detected in electromyography and lumbar MRI. Subsequent ultrasonography and calf MRI showed that the patient had cystic lesions in the calf. The patient was initially diagnosed with a muscle hydatid cyst. Treatment involved complete surgical excision of the lesion, and the diagnosis of a hydatid cyst was confirmed through macroscopic and microscopic histopathological examination after the mass was excised. The patient was given oral albendazole, and no recurrence was observed during the 12 months of follow-up.This case underscores the need to consider hydatid disease when diagnosing soft tissue masses in muscles, particularly in endemic areas. Patients may initially present with atypical symptoms like peripheral nerve issues. Hydatid disease is a zoonotic parasitic infection prevalent in pastoral areas. It can affect any human organ, such as the liver, lungs, kidney, bone, and other tissues. However, their presence in muscle tissues is rare, representing about 0.7-0.9% of cases . Muscle A 62-year-old retired female nurse from Urumqi, Xinjiang, who had lived in the city since childhood, experienced intermittent pain in her right lower limb and numbness in the sole of her right foot for over ten days. No significant abnormalities were found in electromyography and lumbar MRI. The physical examination revealed that the patient’s right calf was slightly swollen, with noticeable tenderness, but no foreign body was detected; the patient dismissed the issue of calf swelling, attributing it to obesity.A hematological examination showed that the patient’s liver and kidney function, and blood cell indicators, were within the normal range. Only the erythrocyte sedimentation rate (76.00 mm/h) and C-reactive protein (70.70 mg/L) were outside the normal range. An ultrasound examination revealed a mass approximately 4.5 cm in depth, 20.3 cm in length, and 3.0 cm in width in the patient’s right calf posterior tibial muscle, soleus muscle, and other muscle bundles. The mass had clear boundaries and was divided internally by a hyperechoic light band, with cyst-like structures of varying sizes. The small sac demonstrated good sound permeability and changed in a “honeycomb” shape.The patient’s calf X-ray showed no evident abnormalities; the right lower limb MRI showed irregular columnar long T1 and long T2 signal changes in the posterior tibialis and soleus muscle spaces behind the right calf. The size was approximately 24.76 cm*3.56 cm*3.82 cm, and it displayed multiple vesicle-like changes. Multiple lines of slightly longer T1 and short T2 signal separation and vascular void signals existed. Slightly high signals were visible in the muscle groups and subcutaneous soft tissues of the upper right calf during the fat suppression sequence (Fig. The patient was initially diagnosed with echinococcosis of the right calf and decided on a treatment plan that combined surgery and postoperative medication. The surgical plan involved the gentle separation of the outer capsule, aiming for complete resection while keeping the outer capsule intact to ensure that the capsule fluid does not spread in the surgical area Fig. D. PostopHydatid disease is a zoonotic disease caused by tapeworms, with the most common type being Echinococcus granulosus. It is primarily found in Mediterranean countries, the Middle East, South America, and East Africa , 3. WhilIn cases of soft tissue echinococcosis, a palpable slow-growing mass is the most common clinical finding. The clinical manifestations are caused by compression of the affected organ . HoweverPreoperative diagnosis of hydatid disease is critical to avoid cyst rupture and dissemination, leading to recurrence. When evaluating this patient, we considered several potential etiologies based on clinical presentation and imaging findings. Differential diagnoses included soft tissue tumors such as fibrosarcoma which typically demonstrate distinct morphologies . ChronicIn general, imaging evaluation is critical for the preoperative diagnosis of hydatid disease. Serology alone is insufficient to diagnose echinococcosis . The diaThe choice of treatment modalities depends on the cyst’s anatomical location, its relation to major anatomical structures, the number of cysts, the patient’s general health status, and the surgeon’s experience. Surgery is the preferred therapeutic approach for muscular hydatid disease. During the operation, the surgical field should be fully exposed, and the outer capsule should be gently separated for complete resection while keeping the outer capsule intact. Care must be taken to prevent anaphylactic shock caused by cyst fluid leakage. Scar tissue can be removed as well. Additionally, thoroughly rinsing the surrounding soft tissues with hypertonic saline helps prevent recurrence. Apart from anaphylactic shock, complications associated with muscle hydatid cyst primarily involve local dissemination upon rupture . AdditioBased on the findings of this case, we emphasize considering hydatid disease in the differential diagnosis of soft tissue masses in muscles, particularly in endemic areas. Patients may seek medical attention with atypical complaints, such as peripheral nerve symptoms.


Nevus sebaceous of Jadassohn (NSJ) is an inborn, cutaneous hamartoma that is presented as a round-oval, or linear, yellowish-orange hairless plaque with an excess of sebaceous glands, typically localized to the head or neck. NSJ disease progresses slowly in three general stages. Due to its embryological origin, it yields an already documented potential for a variety of epidermal and adnexal tumors. The incidence of secondary neoplasms within NSJ is 10-30%, and the risk of neoplastic transformation increases with age. The majority of neoplasms are benign. Regarding malignant tumors, NSJ is usually associated with basal cell carcinoma. All neoplasms are typically encountered in long-standing lesions. Owing to NSJ’s ample variety of associations with neoplasms, its management demands a case-driven tailored treatment. We present the case of a 34-year-old female with NSJ. Considered an epidermal nevus variant, nevus sebaceous (NS) or organoid nevus is an inborn, cutaneous hamartoma first described in 1895 by German dermatologist Josef Jadassohn . A more A 34-year-old female patient of Caucasian-Hellenic origin with no prior medical history was referred to the Plastic Surgery Outpatient Department, complaining about an innate verrucous plaque on her scalp that had been discovered since she was born, increased in size in puberty, and had almost doubled in width over the last five years, becoming slightly pruritic. On physical examination, a yellowish, waxy, hairless, well-defined, L-shaped lesion measuring 3.3 cm × 1.4 cm was noticed at the right temporal region  was made. There was no recurrence of the lesion two years after surgery.NSJ disease progresses slowly in three general stages . Until pSince NSJ presumably originated from pluripotent primary epithelial germ cells, it yields an already documented potential towards a variety of epidermal and adnexal tumors . In addiThe diagnosis of NSJ is usually clinical and confirmed by histopathologic examination; large sebaceous glands associated with hyperkeratosis, papillomatosis, acanthosis with hypergranulosis, defective hair follicles, and heterotopic apocrine glands are the typical histologic features. The differential diagnosis of NSJ includes entities such as colliding xanthogranulomas , epidermodysplasia verruciformis (which mainly manifests as multiple verrucous cutaneous lesions), seborrheic keratosis (which mainly manifests as multiple verrucous cutaneous lesions), congenital nevus , syringocystadenoma papilliferum (with its surface pinkish and nodular rather than yellow and velvety), and solitary mastocytoma . Histopathologic examination clearly identifies all the aforementioned disorders. . Owing tIn conclusion, NSJ is a rare, congenital skin lesion that necessitates close monitoring as it may be the precursor to various malignancies. Even though its precise pathophysiology is yet to be unveiled, early detection and tailored treatment can have a positive effect on a patient’s outcome. Physicians should always have a high level of awareness for optimal treatment to be achieved.


A full-term infant with an unremarkable prenatal course presented at birth with a large midline facial mass and smaller masses in the head and neck. In addition, multiple diffuse flesh-colored nodules spread along all the upper and lower limbs. An extensive evaluation to cover a broad differential diagnosis of infectious, lymphatic/vascular, and oncologic etiology was undertaken. The initial suspicion was confirmed by biopsy of the skin lesion as congenital alveolar rhabdomyosarcoma (RMS). RMS is the most common soft tissue sarcoma that occurs in childhood. However, neonatal RMS is exceedingly rare. The infant’s initial treatment included vincristine, dactinomycin, and cyclophosphamide in addition to salvage ifosfamide and etoposide, which were dose-adjusted for age. Herein, we present a case of an infant with RMS who showed initial improvement before relapsing and succumbing to her disease at 5 months of age. A review of the limited literature available on this rare condition and newer treatment regimens with improved mortality rates is performed. The mother received appropriate routine prenatal care with reportedly normal ultrasound scans. Upon the initial examination of the infant, multiple smaller masses in the head and neck region, as well as diffuse flesh-colored nodules covering all four extremities, were noted, in addition to the large midline mass. The initial differential diagnosis was broad and included infectious, lymphatic/vascular, and oncologic causes, prompting laboratory and imaging work-up, which led to a diagnosis of congenital alveolar rhabdomyosarcoma (RMS) confirmed by a biopsy review by pathology. RMS is a high-grade malignant neoplasm with a morphologic appearance that resembles a developing skeletal muscle , 2. It iHerein, we describe a rare case of an infant with FOXO1 fusion-positive congenital alveolar RMS presenting with multiple cutaneous lesions. To the best of our knowledge, this is only the seventh reported case of congenital alveolar RMS presenting as diffuse multifocal cutaneous lesions, also described as a “blueberry muffin baby” in the literature –10. In a2.A full-term infant was admitted to our tertiary hospital for evaluation of masses. She was born to a 19-year-old gravida 1 with appropriate prenatal care. During the second trimester of pregnancy, the mother had elevated liver enzymes requiring hospitalization. During hospitalization, she was evaluated for infections, preeclampsia, cholecystitis, and hepatic injury, and magnetic resonance imaging (MRI) was also done. Her abdominal MRI was normal apart from biliary sludge. Her serology did not reveal an acute hepatic infection or evidence of an intrauterine infection, and her liver enzymes normalized in 1 week. Prenatal fetal ultrasound scans performed at routine intervals showed no abnormalities.The infant was born via an uncomplicated spontaneous vaginal delivery with no requirement for resuscitation. Her initial physical exam was significant for a large midline mass distorting her eyes and nose with additional mass above her right parotid gland . She alsImaging evaluation was initiated with an MRI of the brain and face, which showed three large mixed cystic and solid lesions on the mid-face and bilateral parotid regions. The mass lesions were primarily subcutaneous, along with deep tissue involvement and some mass effect of the right carotid space. No evidence of calvarial or intracranial involvement was reported . A faciaA biopsy of a right lower-extremity skin nodule showed a dermal and subcutaneous infiltrate of small round blue cells . FocallyShe experienced early mass effects secondary to rapid progression of the facial lesion, including obstruction of the bilateral eyes, occlusion of the right nostril, superior vena cava (SVC) syndrome (secondary to compression from the masses during this phase of rapid growth), and stridor. She ultimately required a tracheostomy to secure her airway, given the concerns for possible mass compression. After extensive multidisciplinary meetings and counseling about all treatment options, the infant’s family decided to proceed with chemotherapy, which was started on day 20 of life. She received systemic chemotherapy with vincristine, dactinomycin, and cyclophosphamide at 50% weight-based dosing. Doses escalated with each cycle if tolerated. Her regimen was derived from the standard treatment for RMS as per the Children's Oncology Group with modifications made from previous case series of infants with RMS. Because of her tenuous nature, initial lumbar puncture, bone marrow biopsy, and PET scan were not performed. In addition, her staging would not have been affected by these results as she was already at stage IV at the time of diagnosis. Although surgery and radiation are typically performed in conjunction with chemotherapy, the multifocal nature of her lesions and the large size and vascularity of the facial lesion prohibited these steps for debulking. After the first cycle of chemotherapy, the lesions began to rapidly reduce in size, and she was able to open her eyes spontaneously .The patient tolerated dose escalation, achieving 100% of dosing by cycle 3. Post-cycle 3 imaging showed a decrease in the size of soft tissue lesions throughout her face, neck, and right orbit. However, numerous new enhancing lesions throughout the brain parenchyma and leptomeninges were concerning for brain metastases. Imaging of the chest, abdomen, and pelvis revealed a decreased size, number, and conspicuity of the diffuse metastatic disease. Lumbar puncture and bone marrow aspiration performed at this time were negative for the disease.Her therapy was then transitioned to salvage treatment with 50% weight-based ifosfamide and etoposide, which was started in week 12 of life. She tolerated two cycles with continued improvement of all superficial lesions and an almost complete resolution of intracranial metastases .Klebsiella oxytoca. Clinically, the facial lesions began to increase in size, and imaging confirmed diffuse disease progression with extensive intracranial metastases and an increase in the size of the midline nasal bridge/frontal scalp mass, right premolar soft tissue mass, and right anterior parotid mass, with development of internal necrotic changes (Post-salvage cycle 2, she was admitted for fever in the setting of neutropenia with a positive blood culture for  changes . After a3.RMS is the most common soft tissue sarcoma that occurs in childhood. However, neonatal RMS is exceedingly rare –3. RMS tTo the best of our knowledge, our case is the seventh reported case of congenital alveolar RMS presenting as a “blueberry muffin baby,” but it also describes extensive non-cutaneous disease not described in other cases –10. The This case highlights the importance of a broad differential for cutaneous lesions in infancy, the need for prompt tissue diagnoses, cooperation among a large subspecialty team, and family-centered care. This case also highlights the aspects of changing goals/treatment options to best align with the family's requirements for their children at different stages in the disease process. Future research should include further expansion of chemotherapy protocols and options for infants such as the one presented in this study, in whom radiation and surgery could not be performed.Parental permission for this case review and for the publication of images was obtained.


Prepancreatic postduodenal portal vein (PPPV) is a rare congenital variation, with only 17 cases reported in the literature and five of them undergoing pancreaticoduodenectomy (PD). Of these, four were L-shaped PPPV with a thin wall that was difficult to isolate, while only one normal-shaped PPPV was reported previously. For patients undergoing PD, recognizing this variation is important to prevent PPPV injury, which could lead to liver ischemia or intraoperative hemorrhage. We here present a case of normal-shaped PPPV who underwent PD.A 68-year-old woman underwent PD for bile duct carcinoma at our hospital. Preoperative enhanced CT revealed that the portal vein was located anterior to the pancreas and posterior to the duodenum, and the L-shaped splenic vein was longitudinally located posterior to the pancreatic neck. During surgery, there was a loose tissue area between the PPPV and the pancreatic head, and the PPPV could be isolated safely. The morphology of PPPV was similar to normal portal vein. Due to the presence of the PPPV, a superior mesenteric artery (SMA)-first approach from the anterior was at high risk of vascular injury, and the pancreatic neck could not be dissected at the dorsal face of PV. Therefore, the SMA was revealed by the classic right posterior approach after transection of the pancreatic neck on the dorsal surface of L-shaped spleen vein, and the specimen was successfully resected without significant intraoperative bleeding. The patient was discharged 18 days after surgery without complications. The final pathology was bile duct carcinoma with R0 resection.PPPV is a rare variant that can be diagnosed by preoperative imaging. In PD procedure, knowledge of PPPV helps in surgical decision-making, approach selection and avoid major bleeding due to PPPV injury. The origin of normal-shaped and L-shaped PPPV might be different. Normal-shaped PPPV can be safely isolated in this case. Prepancreatic postduodenal portal vein (PPPV) is a rare congenital variant of portal vein system, with only 16 cases reported in the literature and five of them undergoing pancreaticoduodenectomy (PD) . RecogniA 68-year-old Chinese female was admitted to our hospital with abdominal pain and jaundice as the chief complaint. Her medical history included a hysterectomy for uterine fibroids 20 years ago, a history of hypertension with well-controlled blood pressure, left ventricular dilatation with complete left bundle branch block detected 2 years ago, and good physical activity. No other significant findings were noted in terms of family history, psychosocial history, and lifestyle history. On physical examination, the vital signs were normal, the skin and sclera were yellowish, no mass was palpable in the upper abdomen, no tenderness was found in the abdomen, and Murphy’s sign was negative. Laboratory tests revealed elevated total bilirubin (136.1 umol/L), carbohydrate antigen (CA) 19-9 (210.62 IU/mL), and N-terminal pro-B-type natriuretic peptide (NT-ProBNP) levels .A contrast-enhanced CT scan of the abdomen revealed a tumor located at the lower bile duct with dilated intrahepatic bile ducts . The portal-phase imaging showed that the portal vein (PV) was located anterior to the pancreatic head and posterior to the duodenum, and the L-shaped splenic vein (SV) was longitudinally located posterior to the pancreatic neck –C, with Moreover, an accessory right hepatic artery (ARHA) originated from gastroduodenal artery GDA) was found to be located posterior to the portal vein, whereas the right hepatic artery (RHA) was located anterior to the common bile duct (CBD) and PPPV . More deA was fouThe echocardiogram showed an enlarged left heart with diffusely reduced systolic amplitude and a left ventricular ejection fraction (LVEF) of 24%. A 24 h dynamic electrocardiogram (Holter) revealed a sinus rhythm with occasional premature polymorphic ventricular beats and complete left bundle branch. After cardiologist consultation, coronary angiography was performed without obvious coronary stenosis and the LVEF was 36% as suggested by LV angiography. Following multidisciplinary discussion including cardiologist and anesthesiologist, it was concluded that there was no absolute contraindication to surgery. Consequently, the preoperative diagnosis was common bile duct cancer, obstructive jaundice, intrahepatic bile ducts dilatation, post-hysterectomy, hypertension and chronic cardiac insufficiency.A laparoscopic pylorus-preserving pancreaticoduodenectomy (PPPD) was performed as planned. After dissection of the duodenum, the PPPV was found to be located anterior to the pancreatic head, posterior to the duodenum, and on the right side of the common bile duct , which wThe patient experienced no postoperative complications, including pancreatic fistula. The amylase level of the drainage fluid was normal on postoperative day (POD) 3 and no postoperative pancreatic fistula was observed. The abdominal drain was removed at POD 12 and the patient was discharged at POD 18. The postoperative pathology was confirmed as intermediate differentiated cholangiocarcinoma with R0 margin. At 12 months postoperative follow-up, the patient survived without tumor recurrence.PPPV is a rare variant of the portal vein system, and this is the 17th case reported worldwide and the sixth case of PPPV undergoing PD. Unlike the previously reported L-shaped PPPV, the present case has a normal-shaped PPPV which could be isolated safely. To our best knowledge, this is the second case of a normal-shaped PPPV undergoing PD with successful isolation of the PPPV.The embryonic development of the portal system was described by Marks . At 4–6 PPPV was first reported by Brook and Gardner , and a tIn addition, the existence of PPPV may affect the selection of surgical approach and the site of pancreatic neck dissection. The SMA-first approach should be avoided due to the altered anatomy anterior to the SMA and the unclear relative position to prevent vascular injury. Additionally, the post-pancreatic tunnel on the surface of PV cannot be established due to the absence of PV posterior to the pancreatic neck. In this case, the L-shaped SV was longitudinally located posterior to the pancreatic neck , so the post-pancreatic tunnel was established on the dorsal surface of splenic vein to dissect the pancreatic neck. The SMA was revealed by a classic right posterior approach (through Kocher’s incision), which is not affected by the variation of the portal vein system, thus minimizing the risk of variant vessel injury and ensuring patient safety.This study has several limitations. Firstly, due to the rarity of reported cases of PPPV, the distinction between L-shaped and normal-shaped PPPV needs to be further confirmed. Secondly, the distinction between the origins of L-shaped and normal-shaped PPPV was not discussed in this study. Finally, the mechanism for the coexistence of normal PV in some reports is unclear and not discussed in the current study. The value of this study is the report of the second case of normal-shaped PPPV undergoing PD and the suggestion that normal-shaped PPPV can be safely isolated.In conclusion, PPPV is a rare portal vein anomaly that can be easily diagnosed by preoperative imaging. Awareness of PPPV may prevent injury or dissection of this variant vessel, which could result in fatal hemorrhage and liver ischemia. Preoperative diagnosis of PPPV is essential for surgical planning, including the selection of approach and site of dissection of the pancreatic neck, and the choice of resection/reconstruction or isolation depending on the PPPV morphology. Our experience suggests that normal-shaped PPPV can be safely isolated.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.BT and SL wrote the first draft of the manuscript. PW, JS, and XW contributed to conception and design of the study. XW revised the manuscript. JM collected the data. All authors contributed to the article and approved the submitted version.This work was supported by the grants from the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences [grant number: 2019-I2M-5-056] and National Natural Science Foundation of China .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In this report we present a rare case of pancreatoblastoma in an adult patient. Whilst they are amongst the most common malignant pancreatic tumours in children, presentations in adults are exceedingly rare, with a small number of reported cases. Its presentation is often non-specific in terms of clinical examination, and subsequent imaging can show similar findings to those seen in benign neoplasms. This report highlights the difficulty of achieving a diagnosis and subsequent treatment of such an uncommon disease. Biopsy and resultant histology are essential in diagnosis and surgical resection remains the preferred modality of treatment. However, the use of chemotherapy and its efficacy in adults remains unclear, and the prognosis documented in existing literature for adults is worse when compared to paediatric presentations. This case emphasises the need to consider pancreatoblastoma as a differential diagnosis when suspecting pancreatic or abdominal malignancies to achieve early detection and diagnosis, in order to provide optimal treatment and improve patient outcomes. Pancreatoblastoma is a rare type of malignant pancreatic tumour more commonly found in childhood in comparison to adults ,2. They This case report presents a rare example of a pancreatoblastoma presenting in an adult and demonstrates the difficulty of diagnosing such a malignancy, as well as the challenges of treating this disease. There remains a lack of universal guidance in the management of pancreatoblastoma in adults. Whilst surgical resection remains the primary treatment of choice where possible, the role of adjuvant chemotherapy and which regimens to use still needs to be firmly established.A 75-year-old male with an Eastern Cooperative Oncology Group (ECOG) performance status score of 0 presented to the Emergency Department in September of 2022 with chest pain that was also associated with abdominal pain and nausea, these symptoms began in August of 2022. His observations and routine bloods were unremarkable at the time of this presentation, and his symptoms were thought to be due to the patient’s known history of irritable bowel syndrome. The patient also had a past medical history of hypertension and benign prostatic hyperplasia. These symptoms persisted and he presented once again in November of 2022 with intermittent chest pain and abdominal pain, as well as a reduction in appetite and weight loss. Routine blood tests and observations were once again normal, and subsequent CEA and Ca 19-9 testing were also unremarkable. The patient was then listed for a gastroscopy given his persistent symptoms, which did not show any sign of malignancy. A subsequent Computerized Tomography (CT) scan  imaging confirmed the size and location of the disease, as well as extensive superior mesenteric vein (SMV) and portal vein involvement with solitary liver metastases. Subsequent endoscopic ultrasound (EUS) guided core biopsy confirmed pancreatoblastoma. Since the mass was locally advanced and involved several blood vessels it was deemed inoperable due to the complexity of its location and the concern of liver metastases.The patient was offered a FOLFIRINOX regimen of chemotherapy and managed to complete one cycle before complications arose, and a subsequent admission occurred in March 2023. An interim CT scan during this period showed local disease progression which resulted in a malignant stricture of the common bile duct (CBD), this led to a biliary stent insertion due to CBD obstruction caused by the increased size of the malignancy. The CT scan also showed significant progression in the size of the pancreatic head tumour and the size of the liver metastases despite one cycle of chemotherapy.Following the patient's recovery from his endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion, the second cycle of FOLFIRINOX was attempted and unfortunately suspended as the patient could no longer tolerate the treatment due to side effects such as poor appetite, nausea and vomiting, and excessive weight loss. A decision was then made in conjunction with the patient that he would be for best supportive care. Five months after this decision was made the patient remains stable and currently has palliative care input in the community from his local hospice to manage his symptoms.Pancreatoblastomas are slow-growing tumours that originate from the exocrine cells of the pancreas. They frequently present in a non-specific manner and given their slow growth by the time patients often present, the tumours can grow to a significant size. As a result, symptoms such as abdominal pain or distension can often be the primary presenting complaint . Whilst This report highlights the presence of a pancreatic head tumour, which is the most common site for a pancreatoblastoma. Despite this, it can be found at any point of the pancreas, as case reports have shown findings of tumours both in the body and tail also . Due to Due to the rarity of this disease, much remains unknown about its aetiology with links being made with syndromes such as familial adenomatous polyposis (FAP) or Beckwith-Wiedemann syndrome . AchieviSurgical resection is the main and most effective treatment modality. However, this is dependent on several factors, such as the progression of the disease, its location, and the presence of metastases. Resection can result in a distal pancreatectomy including a splenectomy, depending on whether lesions are present on the body and tail. Prognosis can be positive with a complete resection of the tumour, as surgery has been shown to be associated with a survival time of 15 months in comparison to just five months in patients who had unresected tumours ,11. SurvWhilst chemotherapy has been shown to have a role in both pre- and post-surgery there remains a distinct absence of universal treatment guidelines for adults in this area. Chemotherapy plays a significant role, particularly when the disease is unresectable, involves local blood vessels, or has metastasised, all of which occurred in our case. Although chemotherapy was given and unfortunately not tolerated in this case, at present there remains no clear optimal regimen. Despite this chemotherapy does appear to be of some benefit in palliating metastatic or recurrent disease .Whilst pancreatoblastoma is a rare malignancy especially in adults, given its non-specific presentation both on clinical and imaging examination it can be very difficult to diagnose without a successful biopsy. Therefore, it must be considered as a differential diagnosis when suspecting atypical pancreatic malignancies, in order to achieve as early detection and diagnosis as possible. Early detection is critical, as often patients will present once the tumour has grown to a substantial size and achieved a significant degree of local infiltration. This can pose a challenging scenario for surgeons, as was shown in this case with the malignancy being deemed inoperable.There remains a lack of an optimal standardised treatment regimen in adults due to the rarity of this disease highlighting the need for further research and analysis. This case emphasises the importance of early detection and diagnosis, as they play a key role in maximising the possibility of surgical resection as a treatment option and ultimately improving patient outcomes.