Esophageal foregut duplication cysts are a rare congenital anomaly predominantly diagnosed in children. With possible growth foregut duplication cysts may cause compression on thoracic or mediastinal structures, respectively. Due to the presence of ectopic gastric mucosa and its potential malignant alteration resection of foregut duplication cysts is recommended. More recently, the use of a thoracoscopic approach for resection has shown to be an advantageous alternative to a conventional open approach. A case of a complete thoracoscopic resection of an esophageal foregut duplication cyst using a 5-mm stapling device is presented. Esophageal duplication cysts are a rare congenital anomaly predominantly found in children with a male prevalence. Aside from possible compression on the trachea and its expansion into the lung, there is a possibility of malignant alteration of the mucous cells. Therefore, a surgical excision is highly recommended.Video-assisted thoracoscopic surgery has been established for resection of mediastinal masses in pediatric surgery.A 19-month-old male toddler with prenatal suspected cystic pulmonary mass was referred to our department. At the age of 1 year a contrast magnetic resonance imaging showed a 2 × 2 × 1.5 cm hyperintense fluid-filled cyst on the left paravertebral side with contact to the esophagus in the posterior mediastinum, adherent to the bronchial hilum cranially and to the descendent aorta. A thoracoscopic resection was anticipated. The preoperative computerized tomography showed a progression of the mass to 3.0 × 3.3 × 4.0 cm .The patient was operated in a slight prone position with elevated left hemithorax and single-lung ventilation. A 5-mm camera trocar was brought in below the inferior angle of the scapula. Insufflation with 5 mm Hg was initiated. A second and a third 5-mm port were placed ventrocaudal and dorsal. The cyst could be easily identified, then was dissected from the left lower pulmonary lobe with hook electrocautery. Careful dissection of the surrounding pleura along the cystic mass was performed in the same fashion. To the medial side the mass was adherent to the thoracic aorta and the pulmonary hilum. The cyst was dissected in this part again using hook cautery and in addition with a 3-mm vessel sealing device . A broad base connection to the esophagus was displayed . MacrosHistopathology confirmed a foregut duplication cyst with a two-muscle layer cover and mucinous cells.Resection through thoracotomy has been the standard of care for excision of foregut duplication cysts. In recent years a thoracoscopic approach has been described for this indication and proven to be safe.9described the successful resection of an esophageal duplication cyst using a stapling device in a 53-year-old patient.In literature tissue dissecting devices using ultrasound or thermal energy for removal through enucleation or partial resection have been described.As foregut duplication cysts are arising from the esophageal wall they have to be removed entirely without perforating the esophagus. The use of a 5-mm linear stapler to remove a foregut duplication cyst may benefit the patient by minimizing the risk of iatrogenic esophageal rupture and incomplete removal in a small operative field due to its smaller size and therefor can be placed more accurate.During dissection with meticulous hemostasis and exact placing of the stapling device in the exact plane a clear visualization of the esophagus is of outmost importance for safe and successful resection.Besides single-lung ventilation we preferred positioning the patient in a slightly prone position allowing for a better visualization of the posterior mediastinum. A chest tube should not be placed as standard procedure.Thoracoscopic resection of foregut duplication cyst with a 5-mm stapling device proved to be safe and successful in an 18 months old patient.


Varicocele is a common condition, estimated to be present in 15% of the general male population. It consists of abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus of the spermatic cord. In adults, varicocele repair may be considered in cases of scrotal pain, or of infertility associated with impaired sperm parameters. Microsurgical varicocelectomy is currently a common method for varicocele repair.Superficial penile vein thrombophlebitis has been previously reported to occur after microsurgical varicocelectomy but has not been well recognized as a possible complication of this surgery.We present three cases of superficial penile vein thrombophlebitis after microsurgical varicocelectomy. Diagnosis on this condition was based on physical examination, mainly a palpable cord-like structure along the involved vein, without overlying redness. Signs and symptoms of superficial penile vein thrombophlebitis resolved after a 4-8-week course of aspirin at the dose of 325 mg daily.Awareness of this possible post-operative complication and its possible management could be helpful to the clinicians involved in the care of patients with varicoceles. Varicocele is an abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus of the spermatic cord. Varicocele is a common condition, estimated to be present in 15% of the general male population.Varicocele has been reported to be possibly associated with scrotal pain ,2, as weMicrosurgical varicocelectomy is currently a common method for varicocele repair. This procedure involves exposure of a segment of the spermatic cord through an inguinal or subinguinal approach, followed by the positioning of an operating microscope over the surgical field, allowing for isolation and subsequent ligation of the dilated veins within the spermatic cord under optical magnification, while sparing the testicular artery and lymphatic channels.Possible complications of microsurgical varicocelectomy include hydrocele formation, testicular artery injury, and varicocele recurrence . HydroceWhile a single series published in 2011 reported superficial penile vein thrombophlebitis after subinguinal varicocelectomy [We present three cases of superficial penile vein thrombophlebitis after microsurgical varicocelectomy.Case 1A 35-year-old male presented with a history of left varicocele associated with left-sided scrotal pain. He underwent a left microsurgical varicocelectomy in October 2016. At his one-month follow-up, he reported complete resolution of the left-sided scrotal pain that he was experiencing for several years pre-operatively. He did feel, however, that the left testicle is somewhat more tender to the touch than before. He also noted some increased prominence of a superficial vein of the penis, with some discomfort in that area with erections. Erections were otherwise normal. Genital exam revealed both testicles to be normal in consistency without palpable masses, mild tenderness to palpation along the left epididymis without associated swelling or skin changes. There was a palpable thin cord within the superficial dorsal vein of the penis without associated erythema or tenderness. A surgical incision in the left groin was well healed. He was then prescribed a 10-day course of ciprofloxacin 500 mg BID, as well as a one-month course of aspirin 325 mg daily.Three weeks later, he reported that the penile vein prominence was less prominent than before, but still felt slightly more pronounced than at baseline, with some persistent mild discomfort with erections. He denied any difficulty with urination. On exam, the previously noted cord within the superficial vein of the penis has almost completely resolved and was barely palpable, with no appreciable tenderness to palpation along with the testicle or epididymitis bilaterally. He was instructed to complete a month’s course of aspirin and return to the clinic on an as needed basis.Case 2A 22-year-old man presented to our clinic with left varicocele, oligospermia, and history of microscopic hematuria. He underwent left microsurgical varicocelectomy and cystoscopy in December 2017. Cystoscopy was unremarkable. He called after surgery and reported a thin cord-like structure felt superficially at the base of the penis. He was started on a course of daily aspirin. At a one-month follow-up, he reported that this has been slowly improving with aspirin. On exam, there was a thin cord-like structure felt superficially at the base of the penis, suggestive of superficial thrombophlebitis. He was then instructed to continue aspirin for one month.At his follow-up four months post-operatively, his penile symptoms had resolved, and he had no hematuria. On exam, there were no varicocele and no evidence for superficial penile vein thrombophlebitis. Semen analysis showed sperm concentration of 11.9 million/mL and motility of 54.6%, improved from pre-operative 6.5 million/mL and 29.2%, respectively. The patient was about to graduate and move elsewhere; he was advised to have urinalysis and semen analysis in one year at his new location.Case 3A 32-year-old gentleman presented with a history of right laparoscopic inguinal hernia repair in 2016 at which time he was noted to have a large left varicocele. The varicocele was not associated with any scrotal pain. He presented to our clinic for evaluation of primary infertility. He and his wife have been attempting to conceive for 15 months with no success. Pre-operative semen analysis showed low sperm concentration and motility at 1.8 million/mL and 2.9%, respectively. He underwent a left microsurgical varicocelectomy in December 2018.One month after surgery, he reported that he noticed a hard vein on the dorsal shaft of the penis, without any pain or difficulty with erections. Physical exam revealed a hard superficial vein on the dorsal penile shaft with no signs of infection. He was placed on a six-week course of aspirin.Four months after surgery, he reported that the hard vein on the dorsal penile shaft has completely resolved. Semen analysis showed sperm concentration of 9.8 million/mL and motility of 20.6%, improved from pre-operative 1.8 million/mL and 2.9%, respectively. The patient and his wife elected to attempt conception naturally and follow up in six months if no pregnancy is achieved by that time.The notable incidence of varicocele and its possible association with fertility impairment and scrotal pain makes varicocele repair a fairly common intervention, especially in younger men. While various methods for varicocele repair exist, microsurgical varicocelectomy is currently a common method for varicocele repair, particularly in the setting of infertility. Possible complications of this surgery that involve the genital organs could be concerning to men who are seeking fertility, especially if perceived as having the potential to compromise sexual function.We present three patients who developed superficial penile vein thrombophlebitis following microsurgical varicocelectomy. The diagnosis of superficial penile vein thrombophlebitis after microsurgical varicocelectomy was based on the constellation of symptoms and physical examination findings. The mainstay of the latter was a palpable cord-like structure along the involved vein, without overlying redness and with no interruption of erectile function. In the absence of clinical evidence for a superimposed infection, these three patients were treated with a course of aspirin at the dose of 325 mg daily. The length of such a course varied from four to eight weeks, depending on the extent and duration of symptoms. In all three patients, signs and symptoms of superficial penile vein thrombophlebitis resolved after a course of aspirin.A single series of superficial dorsal penile vein thrombosis following subinguinal varicocelectomy was published by Arango et al in 2011 [The mechanism for the development of superficial penile vein thrombophlebitis or thrombosis after microsurgical varicocelectomy is not clear, especially as this particular procedure involves the ligation of dilated veins within the spermatic cord at the subinguinal or inguinal level, without any obvious involvement of the penile vessels. It is possible that the vein ligation at the time of microsurgical varicocelectomy, perhaps more at the early post-operative period, causes alteration in testicular venous drainage, which in turn could transiently affect adjacent venous systems. Further studies of the underlying mechanisms for the development of this type of post-operative thrombophlebitis are needed and could possibly offer ways to avoid this complication.Mondor's disease (MD) is a rare condition that manifests with a palpable cord-like induration on the body surface. MD involving the anterolateral thoracoabdominal wall has been generally considered as original MD. Penile MD (PMD) is recognized as a variant of MD. The vast majority of MD cases were reported to be thrombophlebitis of a superficial vein, although some were reported to represent lymphangitis or a combination of both etiologies. Reported risk factors for PMD include vessel-wall damage , blood stasis (such as prolonged erections), and conditions of hypercoagulation . Of note, none of the three patients included in our case series had a history of clotting disorders, hypertension, diabetes mellitus, a history of thrombophlebitis elsewhere, or any of the above risk factors for PMD. The lack of such risk factors could possibly support the assumption that this type of thrombophlebitis or thrombosis is related to a transient impact of the alteration in testicular venous drainage following varicocelectomy, rather than to an underlying systemic condition.Our case series presents three patients who developed superficial penile vein thrombophlebitis after microsurgical varicocelectomy. This condition was previously reported but has not been well recognized as a possible complication of this surgery. Awareness of this possible post-operative complication, as well as its natural history and possible management, could be helpful to the clinicians involved in the care of patients with varicoceles.Clotting in superficial penile veins following microsurgical varicocelectomy is a rare occurrence.Our case series suggests the effectiveness of a course of aspirin in the management of this condition. However, further research is needed to better understand the mechanism and risk factors for thrombophlebitis in this region as well as the best way to treat it.


Traumatic injuries are one of the leading causes of morbidity and mortality. Precise diagnosis and management in the golden hour are key to decrease morbidity and mortality. History and physical examination alone are insufficient to avoid misdiagnosis. In this article, we tried to determine the role of a radiologist and an appropriate imaging modality in a trauma setting.We conducted a literature review of published research articles. We used the keywords imaging, trauma, imaging and trauma, and trauma imaging essentials were used on PubMed and Google Scholar. The articles published in the English language from 2015 to 2020 with full free text available were included. Using the medical subject heading (MeSH) strategy, "diagnostic imaging" (Major {Majr}) and "multiple trauma/diagnostic imaging" (Mesh) on PubMed, we identified 34 papers after applying the inclusion and exclusion criteria. Twenty articles were finally selected which included studies from 2015 to 2020 with articles focusing on the adult population and acute cases.A radiologist and imaging modalities are the essential parts of a trauma setting to lower morbidity and mortality. X-rays and Extended Focussed Assessment with Sonography for Trauma (eFAST) are the first-line imaging modality in the acute trauma setting. However, the CT scan is the most sensitive modality that should be done to avoid misdiagnosis depending upon the patient's history and physical examination. According to World Health Organization (WHO), there are around 14,000 deaths per day due to traumatic injury worldwide, i.e., one death every six seconds. Among traumatic injuries, road traffic accidents are the leading cause. Other causes of injuries include falls, drowning, burns, sports injuries, acts of violence, and wars [Around 20-50% of patients with blunt polytrauma are misdiagnosed without radiological imaging . With thSince 1980, FAST has been used to detect free fluid in abdominal trauma patients as a first-line modality. Free fluid is detected in perihepatic space and Morrisson's pouch, perisplenic space, the pouch of Douglas, and pericardial space. Recently, the right pleural space, the left pleural space, and two anterior pleural spaces have also been added in FAST, which modified the term into eFAST (extended FAST) -7. Non-cHowever, despite the advancements in radiology, there is still no unanimous decision as to which imaging modality is best for which type of trauma and body part to avoid misdiagnosis. Other areas that need further research include "can a radiologist change clinician's perspective of thinking?" "How radiological errors can affect a patient's fate?" "Is there a necessity for more coordination between clinician and radiologist to avoid unnecessary radiation exposure?"In this review article, we tried to determine which imaging modality is best for which type of trauma and body part and what essential role a radiologist can play in a trauma setting to change a patient's outcome.We conducted a literature review of published research articles to determine the role of radiology in the trauma setting.MethodsWe searched the articles published in the English language from 2015 to 2020 with full-text on PubMed and Google Scholar. Keywords used on PubMed included imaging, trauma, imaging and trauma, and essentials of trauma imaging. Using the keywords "imaging" showed 1,88,727 results; "trauma" showed 61,393 results; "trauma and imaging" showed 14,163 results; and "essentials of trauma imaging" showed 285 results. Out of these results, 22 articles were selected that seemed to be relevant after reviewing the abstract. By using the medical subject heading (MeSH) search strategy, keywords, "diagnostic imaging" (Majr) and "multiple trauma/diagnostic imaging" (Mesh) were built and then searched on PubMed using the same filters as mentioned above. It showed 34 results. Out of these 34 results, three articles were selected after reviewing the abstract. Duplicates papers were removed and inclusion and exclusion criteria were applied. After the further screening of the identified articles in detail, 20 research papers were finally chosen to be reviewed.Inclusion and Exclusion CriteriaWe chose the articles that were published in the last five years from 2015 to 2020 and those focused on the adult population. The articles focusing only on acute trauma cases were included. The articles mainly discussing radiological diagnostic imaging techniques and that were relevant to the research question were finalized for the review.We did not include any research papers that focused on the pediatric population. Gray literature and unpublished research were also not included in our review. Papers that had only abstracts available were also excluded.ResultsOut of these 20 selected studies, six of them discussed the role of ultrasonography. Nine were related to CT scans. One study was about the combined role of CT and MRI. Two studies examined polytrauma imaging. The remaining two were about errors in a trauma setting and imaging in limited resources. Table DiscussionMost of the difficult-to-diagnose life-threatening injuries included head and neck, thorax, and abdomen. To avoid misdiagnosis and for identifying them accurately, different imaging modalities are needed.Role of X-rays and UltrasonographyAccording to O׳Keeffe et al., the constituents of trauma series of radiographs are cervical spine X-ray , chest X-ray (anteroposterior view) in the supine position, and a pelvic X-ray (anteroposterior view) Figure . HoweverFor thoracic injury, a chest X-ray (AP view) is helpful. It is taken in the supine position due to the uncertainty of a diagnosis of the cervical spine injury in an unstable patient. A portable chest X-ray can be useful in the early diagnosis of pneumothorax or hemothorax. Pelvic X-rays probe into any fracture linked with a major source of bleeding from vascular injuries. X-rays can be a useful tool to aid in the history and physical examination, but there are likelihoods of misdiagnosis due to its low sensitivity . TherefoAccording to a study by Wongwaisayawan et al., ultrasonography (USG) is widely used, as it has numerous benefits like no radiation exposure, easy availability, noninvasive, and financially inexpensive. So, to rule out life-threatening thoracic injuries in an unstable patient, portable X-rays and eFAST are the mainstay imaging modalities. However, in a stable polytrauma patient, CT should be the preference. Although chest X-ray is specific for rib fractures, sensitivity is low specifically in a non-displaced fracture. USG is more sensitive than X-rays in such cases. Similarly, in pneumothorax, hemothorax, and pleural effusion, the sensitivity and specificity of USG are more than Chest X-rays .A study by Bagheri-Hariri et al. revealed that the addition of the eFAST and physical examination increased the sensitivity to diagnose hemoperitoneum from 38.5% to 76.9%. While in the case of hemothorax, sensitivity increased from 20% to 80% .Elbaih and Abu-Elela discussed the role of FAST for abdominal trauma. According to this study, all those cases with findings on the FAST scan ended up in an exploratory laparotomy. However, there was a 7.4% misdiagnosis . According to this study, the FAST examination cannot detect solid parenchymal damage, diaphragm injury, and retroperitoneal injuries . FAST isRole of CT and MRICT scan is an advanced version of X-rays in which cross-sectional images of body tissues are taken using a sequence of X-ray images taken from multiple angles. At the same time, MRI uses magnetic fields to image the body organs. A study by Iacobellis et al. narrated that in the case of blunt chest or abdominal trauma, multidetector CT (MDCT) should be used to detect any suspected vascular injury as MDCT can affect management protocol from conservative management for a simple intimal tear to surgical intervention for vascular injuries. Moreover, detecting the actual vessel injured and finding out whether the arterial or venous type of vessel is injured affect the ultimate management. The arterial injury needs immediate intervention while venous injury can be managed initially conservatively. As in the case of aortic intramural hematoma , any delay in the diagnosis can lead to aortic dissection. In this way, a radiologist plays a key role to avoid unnecessary intervention or preventing worse outcomes .A study by Dreizin et al. depicted the role of the MDCT in a case of mandibular fracture. According to this study, a radiologist plays a key role in the decision-making process of a reconstructive surgeon as MDCT plays a vital role in the diagnosis and the management process . GuarnieLolli et al. showed that CT is the investigation of choice not only for an acute head injury but also for subsequent follow-up. However, if the patient's condition deteriorates despite no abnormality found on CT, then MRI is recommended . MRI is Abdominal and mesenteric injuries are a challenge for a radiologist as the delay in diagnosis or misinterpretation can cost a patient's life. According to Patlas et al. the spleen, liver, kidneys, small bowel, mesentery, colon, diaphragm, bladder, pancreas, and vascular injuries are the most commonly misdiagnosed. In hemodynamically stable cases of abdominal trauma, a CT is the investigation of choice, particularly to detect pancreatic injuries. According to a study by Panda et al. CT has a sensitivity of 96.7% for gastrointestinal tract injuries. The most commonly misdiagnosed part of the abdomen, even on CT, is the colon. Intraluminal air, extraluminal air, hypo enhancement, hyper enhancements, and wall discontinuity are the signs to detect and localize bowel injury. Furthermore, having sound knowledge of anatomy and common complications is critical for a radiologist to alter the patient's fate ,15-17.Solazzo et al. particularly focussed on gastric injuries. They formulated a grading score depending upon the radiological findings to triage the patients requiring surgical or conservative management. According to this study, CT is the gold standard investigation for abdominal injuries . O׳KeeffCauses of Radiological ErrorsCommon causes of radiological errors include incomplete and inappropriate history, complex injuries, lack of knowledge of a radiologist, poor selection of imaging modality, and lack of communication between radiologists and clinicians due to urgency of rapid diagnosis and management. The most common errors include non-displaced fractures .Imaging in Limited ResourcesAlbeit USG and X-rays have less sensitivity, still, in the case of limited resources, both X-rays and USG have reaped a standpoint. Proper history, physical examination, low dose X-rays (LODOX), USG, laboratory investigations, and adequate monitoring can provide valuable information in the absence of a CT scan facility . Figure LimitationsThis study did not include the pregnant and pediatric population therefore cannot discuss the best imaging modalities in these population groups. Moreover, most of the studies that were included were either retrospective observational studies or review articles. More randomized controlled trials (RCT)s are needed to explore this topic as there are so many questions that need to be answered.This review article indicates the significance of using different imaging modalities in trauma settings that are more accessible to use and have a higher diagnostic sensitivity, thus decreasing post-traumatic mortality and morbidity. Although CT is the most sensitive modality in acute trauma, X-rays and eFAST are widely used in trauma settings due to the easy availability, low radiation exposure, the ability to perform at the patient's bedside. If the patient is hemodynamically unstable, then it is better to start with X-rays and USG to get a clue about further management. Still, in a hemodynamically stable patient, WBCT should be preferred according to the patient's history and physical examination to avoid misdiagnosis.A trauma setting cannot be run without radiological imaging and a radiologist. Similarly, a radiologist needs proper history to reach a definitive diagnosis. Both clinician and a radiologist need to work together to achieve the best patient care. Moreover, a radiologist should recommend the best imaging modality according to a patient's condition if required. More RCTs are still required, including both clinicians and radiologists, to simplify the trauma algorithm further and decrease patient radiation exposure. The role of MRI in a trauma setting is still unexplained. As a CT scan exposes the patient to radiation so it is needed to find out whether we can use MRI in the trauma setting or can we somehow decrease its operating time to get a rapid diagnosis.


Sigmoid volvulus (SV) recurrence more than 10 times is an extremely rare clinical entity and spontaneous detorsion is a rare outcome of SV. In this paper, we report a case with 19 previous SV attacks, in last of which spontaneous detorsion occurred. Such a multiple-episode history as well as an unexpected recovery was unique in a 1,036-case clinical profession of Ataturk University with SV over a 54.5-year period. Sigmoid volvulus (SV), a closed-loop colonic obstruction, is a rare disease worldwide, while it is relatively common in some Asian, African, South American, and Eastern European countries.A 72-year-old man presented with abdominal pain, distention, and obstipation for 12 hours. He was previously diagnosed with coarctation of aorta and coronary disease. In anamnesis, a history of 19 volvulus attacks was present. All SV episodes including the first one in childhood, had been decompressed endoscopically. Physical examination revealed asymmetrical abdominal distention more prominent in left upper quadrant , abdominSV tends to recur in about one fourth of all cases. The recurrence rate principally depends on the treatment method, and it is more common in patients treated with endoscopic or surgical detorsion alone. Similarly, pediatric SV is considerably disposed to recurrence.The sigmoid colon occasionally twists and untwists, and these are accepted physiologically. Torsions less than 180° are generally asymptomatic and result in spontaneous untwisting. If the torsion exceeds 180°, intestinal passage is blocked and complications including bowel ischemia, necrosis, and perforation may occur.It is clear that every volvulus attack carries some risks of mortality and morbidity.Regarding the treatment options in patients with poor general conditions, like the presented case, in our opinion and experience, observation is generally preferred by both physicians and the patients to avoid unintended consequences. Neither emergency nor elective surgical sigmoid colectomy is thought as the optimal choice due to their poor prognosis, which consists of 10-30% of mortality and 20-40% of morbidity rates.10SSA: Data collection, manuscript writing.ED: Data collection, revision of the final draft.CTA: Revision of the final draft.RSA: Revision of the final draft.SSA: Is responsible for responsible and accountable for the accuracy or integrity of the work.


Primary nodular chest wall amyloidoma, in which a solitary mass of amyloid is deposited in and around the lungs with no evidence of systemic amyloidosis, is extremely rare, most often asymptomatic, and may resemble primary bronchogenic carcinoma. As a result, there are fewer than 100 cases published in the literature and no controlled clinical trials. Primary nodular chest wall amyloidoma is typically diagnosed either as an incidental radiological finding or after very serious and destructive mass growth at which point late-stage respiratory and pain symptoms finally develop, most often in elderly patients. We present imaging studies of a 61-year-old male patient with an unusually massive and destructive chest wall mass, originating in the chest wall, diagnosed as chest wall amyloidoma by histopathology analysis. Our CT, MRI, and PET scan findings are consistent with and contribute to the developing pattern of imaging characteristics seen in other case studies, which can be used to identify amyloidoma before it becomes destructive using non-invasive imaging analyses. Amyloidosis is a rare disease, characterized by the deposit of an abnormal insoluble protein, amyloid, in extracellular tissues and organs, resulting in serious dysfunction and potentially death, if untreated Primary nodular pulmonary amyloidoma is typically diagnosed either as an incidental finding or after very serious and destructive mass growth at which point late-stage respiratory and pain symptoms finally develop, most often in elderly patients A 61-year-old male was transferred from an outside facility for worsening shortness of breath while performing yard work over the prior three weeks. The patient had a past medical history of hypertension, congestive heart failure, severe chronic obstructive pulmonary disease (COPD), smoking (until age 46), and a right apical lung mass confirmed to be a plasmacytoma (at age 50). Upon arrival at our facility, the patient was afebrile with heart rate of 76 and blood pressure of 156/92. Routine labs including complete blood count with differential as well as basic metabolic and liver function panels were unremarkable. His venous blood gas revealed a mild respiratory alkalosis. COVID-19 test was negative. The patient was admitted for further evaluation.Radiographs demonstrated a large right apical lung mass with foci of intramural calcifications . ComputeMagnetic resonance imaging (MRI) of the right brachial plexus , Fig. 6 Differential diagnoses of the chest wall mass, based upon imaging studies, included plasma cell neoplasm , plasmacytoma, or amyloidoma. An image-guided biopsy was performed to clarify the diagnosis. Multiple 16-gauge core biopsies of the soft tissue component of the right lung mass were obtained . PatholoImage-guided cardiothoracic and neurosurgical resections were performed to reduce the impact of the mass on thoracic structures including right-sided T1-T3 hemilaminectomies and facetectomies. Pathology confirmed the diagnosis of amyloidoma. The surgeries were successful and the patient was discharged to outpatient follow-up care. Our last medical contact with the patient was two months after surgery, when he tested positive for COVID-19. Follow-up two months later determined that he recovered from COVID-19 and is doing well.The term amyloid was first used by Rudolf Virchow in 1854 Diagnosis of localized pulmonary amyloidoma is extremely rare, in part due to the unusual nature of the condition, but also because the patients are often asymptomatic and the mass is very slow-growing. While respiratory symptoms, such as cough, dyspnea, and hemoptysis are seen in certain forms of localized pulmonary amyloidosis, such as tracheobronchial, which facilitates detection Only one case with a clinical course similar to our patient has been reported recently by Desai et al There have only been a few published case reports of patients with pulmonary amyloidoma and plasmacytoma Therefore, regular imaging studies are suggested, especially for patients with presenting respiratory symptoms, such as shortness of breath, cough, dyspnea, and hemoptysis, as well as known pulmonary conditions including COPD, plasmacytoma, and amyloidosis, in order to identify the development of expansile and destructive pulmonary nodes. Primary nodular pulmonary amyloidoma mimics a variety of serious lung diseases including malignant tumors as well as interstitial, granulomatous or inflammatory respiratory diseases Case reports in the literature suggest that preliminary evidence of primary nodular pulmonary amyloidoma may be revealed as incidental findings on chest radiographs, though differential diagnosis is limited In the most recent and detailed analysis of CT chest scans in 41 patients with nodular pulmonary amyloidoma, Brandelik et al. found that all patients presented predominately with a nodular parenchymal pattern, with 39 of them exhibiting solitary or multiple pulmonary nodules Only a few studies have described the MRI findings in patients with primary pulmonary amyloidoma Several cases have been published with PET/CT scan findings for solitary nodular pulmonary amyloidoma. One of the first case reports showed increased metabolic activity of the calcified mass with numerous osseous lytic lesions (1)Unusually large solitary destructive mass in and around the lungs that is not detected until the patient is elderly, in part, due to slow asymptomatic growth over the years, most often initially identified as an incidental finding on a radiograph.(2)CT scans have generally shown lobulated margins with calcifications in a heterogeneously enhancing mass and unusual cystic radiological features.(3)MRI analyses generally demonstrate heterogeneously enhancing mass with highly variable signal intensities; specifically, the lung mass may appear isointense relative to skeletal muscle on T1-weighted axial MRI, but relatively low intensity on T2-weighted MRI.(4)PET/CT scan may show pathological utilization of the glucose analog and hypermetabolic activity with unusually high SUV, along with lytic lesions.In summary, imaging features that may suggest primary nodular amyloidoma include the following characteristics, which may be useful in differentiating it from bronchogenic carcinomas, other tumors, and infectious or inflammatory diseases:While the diagnosis of slow-growing asymptomatic pulmonary nodular amyloidoma can be challenging, we have provided evidence that routine imaging studies, using our expanding knowledge of specific imaging patterns, may be useful to identify growing masses before they become destructive as well as avoid unnecessary invasive procedures. Once imaging studies are suggestive of amyloidoma, pathohistological diagnostic confirmation is still required by a pulmonary biopsy and demonstration of apple-green birefringence with congo red stain under polarized light.Excision of the pulmonary mass is often recommended in the management of these patients, especially for large amyloidoma lesions, in order to reduce the destructive impact on adjoining organs, tissue, and bones as well as to improve respiratory functioning. Radiotherapy can be a viable option for the treatment of solitary pulmonary amyloidoma Primary pulmonary nodular amyloidoma is an extremely rare diagnosis. Our case report of an unusually massive chest wall amyloidoma, with a history of plasmacytoma, contributes to the accumulation of specific imaging features regarding diagnosis of rare pulmonary diseases as differentiated from more commonly seen disorders, which is critical in developing appropriate treatment plans and prognostic guidance. Early imaging detection is critical in order to avoid serious displacement and destruction of adjoining organs, tissues, and bones.Written informed consent was obtained for this Case Report including publication of imaging studies.


Carotid web has been identified as one of the missed causes of recurrent stroke. The diagnosis and management of such cases impose a challenge to medical practitioners. This etiology should be kept in mind, especially in case of recurrence of stroke in a similar cerebral territory. A high index of suspicion toward unusual etiologies should be raised in cases of recurrent stroke in same cerebral territory. One of these usually missed causes is carotid web. The initial Doppler ultrasound (U/S) showed a small, calcified plaque at the left bulb without causing significant carotid stenosis, and the magnetic resonance angiogram (MRA) on the first visit was reported as right common carotid artery (CCA) and proximal right internal carotid arteries (ICA) atherosclerotic plaques attached to the posterior wall. Workup for ischemic stroke including an echocardiogram and a 48‐hour Holter was unremarkable. The patient was discharged to inpatient stroke rehabilitation on dual antiplatelets (DAPTs) for 2 weeks and subsequently discharged home with total recovery and modified Rankin Score (mRS) of zero.Six weeks after the first visit the patient was readmitted with left‐hand weakness, that occurred suddenly, with no associated symptoms. Magnetic resonance imaging (MRI) head was repeated and showed new foci of infarction in the right junction of both territories of anterior and posterior cerebral arteries. Doppler U/S of the carotids was repeated, which did not show any change in comparison to the previous U/S. MRA was also repeated and was discussed with stroke neurology and neuroradiology, and suspicion of right ICA web was raised given the discrepancy between the Doppler and the MRA Figure . This waBoth carotid endarterectomy (CEA) and stenting were offered to the patient, and the patient opted for stenting of the right ICA Figure  and was Patient has been followed in stroke clinic till day of publishing this paper, which is seven months after discharge. During this period, he had no recurrence of stroke.3Carotid web is frequently seen in cryptogenic strokes, occurring in young patients with little or no risk factors.3.1p = 0.0003). No clinical trial has been done to compare CTA with MRA.Computed tomography angiogram (CTA) is considered the modality of choice for the diagnosis of carotid web.In Zhu et al, eight carotid web cases have been identified retrospectively. Strangely, CTAs of three cases were reported negative initially. However, US was able to detect carotid web in these cases. U/S was also shown to have superiority in detecting thrombus on top of the web.Evidence regarding MRA for carotid web detection is very scarce, there is a case series and two case reports that investigated the MRI findings of carotid webs. In Boesen et al,In the case report they used T1W and TOF images, the former showed a crescentic hyperintense lesion. Flow abnormality suggestive of turbulent flow pattern was seen on 2D TOF images.3.2As per literature, the proposed treatment modalities for such cases are either by CEA, stenting, or medical treatment with antiplatelets.Aggressive therapy is required if a CW is detected ipsilateral to an acute stroke given the high rate of stroke recurrence while on antiplatelet therapy.Joux et al,Anticoagulation is attractive academically with reports of clots uncovered from the web akin to the left atrial appendage; however, there are scarce clinical data to recommend its habitual use.Both CEA and stenting have been used for CW treatment. While CEA appears to be a more definite treatment in terms of reducing recurrence, it poses a higher upfront risk of complication, whereas stenting is less invasive, with less upfront risk. However, it is sometimes associated with a long‐term risk of recurrence.4CW should be kept in mind as a cause of recurrent stroke, even in patients with multiple risk factors for cerebrovascular accidents, especially if recurrence happened in the same territory.Moreover, the presence of a discrepancy between U/S and CTA/MRA should increase the index of suspicion for CW as a culprit for recurrence. Till now, the literature review showed that CTA is superior to US for CW diagnosis, and aggressive intervention is warranted in such cases as the recurrence rate even with DAPT is unacceptably high.This manuscript has not been submitted for publication elsewhere. All authors have reviewed and approved the manuscript before submission. None of the authors have any conflict of interest to declare.Mohammed Alnajjar involved in manuscript writing, literature review, review, and approval of the final manuscript. Yahia Z Imam involved in manuscript writing, literature review, revisions in manuscript, review, and approval of the final manuscript. Ayman Zakaria involved in case identification, radiological imaging interpretation, literature review, and approval of the final manuscript. Elmukhtar Habas involved in manuscript revisions, literature review, critical review, and approval of the final manuscript. Naveed Akhtar involved in case identification, manuscript revisions, literature review, critical review, and approval of the final manuscript.Ethics approval was taken from Medical Research Center (MRC) Qatar before submission of this manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal on request.


Scant literature is available regarding in vivo jejunal diverticulosis, in part due to its typically asymptomatic course. This is made more difficult by the difficulty in establishing its diagnosis. This case series examines a number of patients presenting to our hospital with jejunal diverticular disease, and their varying clinical courses.A number of cases that had presented to our hospital with jejunal diverticulosis were reviewed retrospectively in keeping with PROCESS guidelines. Their presentations, investigations, and management rationale are discussed in brief.The presentation of jejunal diverticulosis is varies significantly along a spectrum, with a number of symptoms similar to other common intra-abdominal pathologies. The imaging modalities of choice are a barium small bowel series, CT scans, and enteroclysis, varying in sensitivity and complexity. Decision making with regards to operative vs. non-operative management is typically in line with that of colonic diverticulosis, though no strict guidelines have been established.Jejunal diverticulosis is an uncommon, with scarce data available on the appropriate investigation and management pathways. Its presentation is difficult to differentiate from other intra-abdominal pathology, and its investigations either poorly sensitive or costly and technically challenging. The general consensus on its management is similar to that of colonic diverticula, though more research needs is warranted. •Jejunal diverticulosis is an uncommon cause for non-specific abdominal pain.•It is infrequently suspected due to the difficulty in its diagnosis.•Presentations range from pain, to bleeding, to an acute abdomen.•Diagnostic modalities include barium small bowel series, enteroclysis, and CT scans.•Management is similar to that of colonic diverticula. The cases are presented in keeping with the PROCESS guidelines . Their p3A 55 year old gentleman presented with abdominal pain, vomiting, and constipation (without obstipation). He was incidentally noted to have had dysphagia of 12 months, and had undergone a recent gastroscopy and colonoscopy, both of which did not identify any abnormalities. Her background included multiple lipoma excisions, but was otherwise unremarkable. He had markedly raised inflammatory markers. His CT scan identified small bowel intussusception , Fig. 2.A decision was made to undertake a diagnostic laparoscopy to assess the nature of his intussusception. Intraoperatively, a constriction was noted 30 cm from his duodenojejunal flexure on a small bowel run, and the procedure was converted to a laparotomy. Innumerable enlarged, firm lymph nodes were noted in a thickened mesentery. The intussuscepted segment was resected. The remnant bowel was anastamosed primarily. 4 jejunal diverticulae were noted incidentally during the remaining small bowel run, adjacent to each other, in the mid jejunal region, with each measuring approximately 1 cm in diameter. Given the nature of the ongoing procedure, they were handled with care, but otherwise left intact.Post-operatively, the patient experienced a slow but uneventful recovery. His pathology returned as a T4 poorly differentiated adenocarcinoma.4A 74 year old lady presented with pain in the right iliac fossa over the course of 1 week, with associated nausea and vomiting. Her background medical issues included hypothyroidism. She had raised inflammatory markers. Her examination revealed tenderness in the right iliac fossa without peritonism. A CT scan was performed to identify a cause for said pain, which identified acute jejunal diverticulitis with a localised perforation. This appeared as a 33 × 22mm inflammatory mass containing a small volume of gas, localised to the left iliac fossa. She was haemodynamically stable throughout her presentation, prompting a decision to undertake non-operative management of her diverticulitis.In line with the local hospital policy, she was commenced on ceftriaxone and metronidazole. Her recovery was uneventful, and she was discharged home to follow up with gastroenterology to organise an outpatient gastroscopy and colonoscopy.5A 69 year old lady presented with abdominal pain, vomiting, and low grade fevers of 1 day. Her background medical issues include ulcerative colitis, for which she was on a biological agent; chronic lymphocytic leukaemia; and hypertension. Her inflammatory markers were chronically raised, making interpretation difficult. Her examination revealed a peritonitic abdomen, prompting an urgent CT scan, which revealed a faeculent walled off collection measuring 56x58 × 60mm abutting the small bowel loops in her pelvis. She remained haemodynamically stable, albeit borderline hypotensive with IV fluid resuscitation.This clinical picture prompted an immediate transfer to theatres, during which the patient underwent a laparotomy. This revealed a contained perforation attached to the proximal jejunum on its anti-mesenteric border . Its conHer recovery was uneventful, and she was discharged home 1 week post-operatively.6The above cases serve to illustrate the different ways in which jejunal diverticulosis present, from a benign incidental finding to a surgical emergency requiring prompt intervention. While non-exhaustive, it serves to demonstrate how spectrum and appropriate forms of management of the disease.The vast majority of these cases remain asymptomatic  and are While not commonly symptomatic, jejunal diverticulosis can present with a variety of symptoms, the mildest of which include vague abdominal pain , distensA decision of operative vs. non-operative management is unclear at present. As most asymptomatic and minimally symptomatic cases documented resolve spontaneously with no sequelae, this author advises a conservative approach and treatment of complications as they arise. However, there have been suggestions  for moreDecision making becomes further complicated when the perforated portion of bowel is not identified during laparotomy, despite the presence of multiple diverticula. In these scenarios, limited evidence suggests washout and closure of the abdomen , to whicUltimately, this disease is likely to present as an indolent longstanding abdominal pain. As such, future research should be undertaken in the outpatient setting, ideally in a prospective fashion for non-specific abdominal pain, though limitations in case number will necessitate initial utilisation of retrospective data.7Jejunal diverticulosis is an uncommon, with scarce data available on the appropriate investigation and management pathways. Its presentation is difficult to differentiate from other intra-abdominal pathology, with non-specific symptoms that could be mistaken for colonic diverticulitis, appendicitis or any number of common presentation. Its investigations are either poorly sensitive or costly and technically challenging, requiring a high index of suspicion before any investigations are undertaken. The general consensus on its management is similar to that of colonic diverticular disease, though more research needs to be done with regards to a pathway for its management. It is hoped that this paper is to increases awareness and consideration of this clinical entity as an alternative diagnosis in oft found non-specific abdominal pain.Written informed consent was obtained from the patient for publication of this case report and accompanying images, in line with local ethical approval requirements. No other requirements were stipulated.This research did not receive any specific grant from funding agencies in the public, commercial, ornot-for-profit sectors.-Case report design-Data collection-Data interpretation-Writing the paperDouglas Chung - Corresponding author.N/A.The corresponding author is the guarantor of this manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Not commissioned, externally peer reviewed.No conflicts of interest were identified in the writing of this case report.


Spontaneous spinal epidural hematoma (SSEH) is a serious but infrequent cause of profound neurological compromise of acute onset. It is often an atraumatic occurrence, and in around half of the cases, no etiology is identified. However, several causes such as arteriovenous malformation in the spine, use of anticoagulants in various cardiovascular diseases, and spinal trauma have been incriminated for its development. Here we encountered a case of SSEH following unregulated use of anticoagulants after a mitral valve replacement surgery. The patient had complete paraplegia with bowel and bladder involvement. The case was treated with decompressive laminectomy with regularization of her coagulation profile. Although she presented late to the healthcare center for the treatment, she showed a remarkable neurological improvement with gaining power worth near independent ambulation after one year of follow-up. Spontaneous spinal epidural hematoma (SSEH) is a relatively rare condition, yet it is a sudden and profound atraumatic cause of neurological compromise. It is accounted for less than 1% of all spinal canal space-occupying lesions . SSEH isAs it is a rapidly progressive space-occupying mass in the epidural space, it can produce devastating neurologic deficits within a short time frame of hours or days , 8. TherA 22-year-old female presented to our orthopaedic department with complaints of backache and bilateral lower limbs sensory and motor deficit since last five days. She was a known case of rheumatic heart disease and had undergone mitral valve replacement surgery nine years ago. She was on oral vitamin K antagonist anticoagulant (acenocoumarol) after the surgery.On neurological examination of bilateral upper limbs, sensory and motor functions were intact with normal deep tendon reflexes (DTRs). In the lower extremities, muscle tone was decreased with flaccidity. The motor power was assessed using Medical Research Council (MRC) grading, and it was zero (0/5) around the hips, knees, and ankles. DTRs were absent around the knees and ankles, the plantar reflexes were mute bilaterally, and the abdominal reflex was absent. There was complete involvement of the sacral segment of the spinal cord; perianal sensation, voluntary anal contraction, and sensation to deep anal pressure were absent. Sensory function was normal up to D11 dermatome, decreased from D12 to L2, and absent below L2 level. The bulbocavernosus reflex was absent.Laboratory parameters such as complete blood counts, liver and kidney function tests, and erythrocyte sedimentation rate were within the normal limit. C-reactive protein was markedly elevated with anemia. The prothrombin time and International Normalized Ratio (INR) were marginally raised with normal activated thromboplastin time. On further inquiry, she admitted that before coming to the present hospital, she quit taking the anticoagulants in consultation with a physician at the nearby place after the appearance of weakness in the limbs. Further, it was found that her value of INR of one week before the admission was highly elevated Table .On radiological evaluation, the X-rays of the lumbosacral spine were unremarkable except for a mild lateral curvature to the right side with some thoracolumbar kyphosis. MRI of the whole spine revealed an elongated dorsal epidural mass in the thoracolumbar region of the spine extending from D11 to L4 level in epidural space, showing slightly high signal intensity on T1 and T1 fat-suppressed sequences and hypo-intense signals on T2-weighted images. A definite signal change in the spinal cord was not seen Figure -1B. SpinBased on the clinical, laboratory, and radiological evaluation, she was diagnosed as a case of SSEH extending from D11 to L4 with complete paraplegia and bowel and bladder involvement. In addition, she had a picture of flaccid paralysis. Therefore, before taking her to the surgery, we consulted a hematologist to review her coagulation profile. Surgical managementSurgical decompression of the spinal cord was considered after due consultation with the hematology department. Laminectomy and posterior decompression were executed from D11 to L4 level under general anesthesia with the help of a BoneScalpel . On opening the epidural space, extensive clots were found in the thoracolumbar region. Meticulous removal of the clots with penfields of appropriate size was done, and complete decompression of the spinal cord was achieved Figure -2B.Post-operative managementSupportive care was provided in the post-surgical period. A hematologist reviewed the patient for regulating her coagulation profile. The doses of the anticoagulant "acenocoumarol" were reduced and adjusted. The INR test was done on a daily basis and was ensured in the range of 1.5 to 2.5 NA. She was discharged to home. The patient was counseled to get the INR report every week and advised to keep that in the prescribed bracket in consultation with a local physician. She was also counseled for taking care of bedsore prevention by doing respiratory and other exercises to prevent complications of recumbency.Follow-upThe patient was closely followed up every month after suture removal. A significant improvement in the neurological function was observed at every visit. At the last outpatient department (OPD) visit at one-year post-surgery, she gained complete bladder and bowel control with normalization of her sensory function. In addition, the muscle power in lower limbs improved significantly.Motor functions at one-year post-surgery: Hips 4/5, knees flexion 3/5, knees extension 4/5, flexor hallucis longus (FHL) 2/5, extensor hallucis longus (EHL) 3/5 (right side), EHL 1/5, and FHL 0/5 (left side). The power in plantar flexion improved to 4/5 on both sides Figure -3B, yet An MRI of her spine at one year revealed no residual compression of the neural structures. However, there were areas of hyperintensities in the cord at the level D11 to L1, suggesting a sequel of cord compression Figure .SSEH is a rare but significant neurological condition. Its incidence is most frequent after the fourth or fifth decade . Men havIn approximately 40% of cases, no exact etiology is found . Areas oPain in the back, which might radiate to one or more limbs, depends on the amount and location of the hematoma. In addition, the clinical picture may confuse the attending physician as similar symptoms may arise from other clinical entities such as cerebrovascular accidents, myocardial infarction, meningitis, etc. , 17.In most cases, the deficit is acute, with its onset ranging from hours to days. The quantum of neurological compromise varies in individuals, and it may range from a partial deficit to complete loss. For complete deficit, the scientific community is divided in its opinion as far as the treatment modality is concerned. Some authors have proposed an urgent surgical modality (within 36 hours) as the treatment of choice. The results of surgical decompression have been reported promising, even when the deficit is complete . HoweverIn our case, as the coagulation profile was reasonably in the normal range, we could do the surgical procedure within 48 hours of the admission. After surgical decompression, neurology improved gradually, and bladder and bowel function recovered completely. Just as in spinal cord injury, the amount of neurological recovery depends on the severity of the neurological compromise before the operative intervention, and it is the most crucial prognostic tool . As the Whenever a case having an atraumatic neurological deficit of sudden onset is seen, one should have a vigil on the coagulation profile. A thorough history can reveal the clinical diagnosis of SSEH. For cases with profound or progressive neurological compromise, early surgical intervention in the form of decompressive surgery can be hugely rewarding. In addition, patients on anticoagulant therapy should be counseled to monitor their coagulation profile at regular intervals. Any unacceptable derangement can lead to catastrophic consequences.


Background: Infantile myofibromatosis (IM) is a soft tissue disease with solitary or multiple benign tumors, and an etiology still unknown. IM is a mesenchymal disorder of early infancy and is more frequent in males. IM may present as a solitary lesion of the skin, bone, muscle, subcutaneous tissue, located at the head, neck, and trunk, with good prognosis; or, as a multicentric form, with or without visceral involvement , with a poor prognosis. The definitive diagnosis of IM is confirmed by pathology. Treatment may be conservative, surgical, or chemotherapeutical. Case presentation: A two months old female patient, prenatally diagnosed at 30 weeks, presenting with a tumor on the antero-internal aspect of the left thigh. She was admitted due to rapid postnatal evolution, and the patient required surgery for tumor resection. Previously, clinically, biological and imaging investigations were performed, but the final diagnosis was histological and by immunostaining. The patient had a favorable postoperative outcome. Conclusions: Despite its low frequency, IM should be considered in the differential diagnosis of soft tissue masses at an early age. The clinical form (solitary or multicentric), location, and visceral involvement will dictate the treatment and prognosis. Infantile myofibromatosis (IM) manifests as a single or multicentric lesion of benign nature . The incThis article describes a case of a 2 months old girl who was detected with a left thigh mass on the prenatal ultrasound at 30 weeks of gestation; she was presented for consultation due to the presence and rapid growth of the tumor. The aim of this article is to present the clinical case, its management and to review the literature on this disease.We report the case of a 2 months old female, presented for consultation due to the presence of a lump on her left thigh, with progressive and constant growth after birth. The lesion was first described on the prenatal ultrasound at 30 weeks of gestation as a pre-femoral soft tissue mass of 20/7 mm . The patThe initial X-ray and ultrasound (US) showed a pre-femoral soft tissue mass that measured approximately 30/13 mm, with nonhomogeneous structure, hypoechoic areas, calcifications, and weak Doppler signal, being located anteriorly to the vascular elements of the thigh A. AbdomiMagnetic resonance imaging (MRI) showed a mass of 19.33/15.19/34 mm, with a nonspecific vascular involvement B. In T1-Elective surgery was scheduled. An italic S-shaped incision on the antero-internal face of the left thigh was performed, from the crural arch distally extended for about 6 cm. A mass of approximately 4 cm × 1.5 cm × 1.5 cm was revealed, which included the entire thickness of the sartorius muscle A,B. In tHistologically, the mass in the sartorius muscle was noted as a proliferation of tapered cells arranged in an irregular spiral pattern and crossed by thin-walled vessels. In the central region, biphasic proliferation consisting of nodules with necrosis and central calcifications was observed, and between the nodules, fusiform cell proliferates arranged in small intersecting bundles A,B. OccaDiagnosis of IM of left sartorius muscle was made.Infantile myofibroma/myofibromatosis is a rare but well recognized spindle cell neoplasm, a mesenchymal disorder caused by the fibrous proliferation in the skin, bone, muscle, and viscera .Defined as a rare disease by the National Organization for Rare Disorders (NORD) and Orphanet, with an estimated incidence of 1/150,000 to 1/400,000, IM is the most common fibrous tumor in infancy and childhood [IM was first described in 1951 as “congenital fibrosarcoma” by Williams and Schrum. Then, in 1954, Stout called it “generalized congenital fibromatosis”, suggesting a multicentric benign fibroblastic process . Since tInfantile myofibromatosis (IM) has a male predominance of 1.7/1 and low incidence. As the lesions may not be clinically visible and involute spontaneously, the condition may be underdiagnosed and underreported. The lesions can appear over a wide age range, but generally manifest in infancy, half of them being diagnosed at birth; about 90% of cases are diagnosed before the age of 2 years ,5.The etiology of the disease is still unknown, the majority of the cases reported being sporadic and isolated; there seems to be a familial pattern suggesting an autosomal dominant or recessive trait ,12. In tPrenatal diagnosis of an IM was first reported in 1998 by Kubota et al., describing a lesion of the triceps detected at 36 weeks of gestation . As withClinically, a firm or hard nodule in the skin, subcutaneous tissue, muscle, or bone is defined as the solitary form, which is the most common (50–75% of cases), as noted by Chung and Muraoka, being the form of presentation in our patient ,20. The Multiple lesions define the multicentric form, with or without visceral involvement. The multicentric form usually presents at birth and the solitary form may present later, usually in the first 2 years of life ,21. WiswImaging is not pathognomonic but serves to assess the degree of disease , disease progression, and diagnosis of recurrences . The ultThe differential diagnoses for soft tissue masses includes neurofibroma, sarcoma, metastatic neuroblastoma, and other neoplasms , dermoid or epidermoid tumors. Histological examination of biopsies or resected tumors remains the gold standard method for diagnosis .Microscopically, both the solitary and multicentric forms have similar characteristic appearances with a distinct zoning pattern. There are spindle cells arranged in whorled or interlacing fascicles, giving a leiomyoma-like appearance in the peripheral areas of nodular lesions. The constitutive spindle cells demonstrate staining characteristics of both myoblasts and fibroblasts, and frequently contain a large quantity of collagen within the surrounding matrix. In the central areas, a hemangiopericytoma-like pattern consisting of cells with less differentiation is usually found. A high mitotic rate with the presence of up to as many as 3 mitotic figures per 10 high-power field and infiltration of adjacent adipose tissue and skeletal muscle are not unusual, but have no adverse prognostic significance ,22,25,26The prognosis and natural evolution depend on the type of IM. Spontaneous regression may occur in solitary cases and also may be observed in most of the multicentric cases, within 18 to 24 months. In this scenario, careful follow-up must be done, as recurrences after regressions may occur . Chung eThe treatment should be individualized, as there are no standard protocols or guidelines because of the rarity of the disease. The interventions, procedures and therapeutics are variable according to the number, size, location, symptoms, and evolutive pattern of IM.Solitary lesions or multiple lesions in infants, in the absence of visceral involvement, usually have a benign and self-limited course that ends with spontaneous regression. If the tumor size increases significantly in a short time or if it produces compression to surrounding structures, surgical removal may be considered. The recurrence rate after excision in the solitary form is less than 10% ,27. In t2 daily) for 2 months was the treatment in a Turner’s syndrome patient with IM, which resulted in a decrease in size and apoptosis on histological examination [In cases of persistent nodules or recurrence and in forms with visceral involvement when surgery was not possible, chemotherapy, radiation, and steroid therapy have been tried for treatment of IM ,29. In amination .A connection between the p.R561C mutation in gene encoding platelet-derived growth factor receptor beta (PDGFR-beta) and the development of infantile myofibromatosis, was confirmed by recent studies, raising the idea that PDGFR-beta phosphorylation in tumor cells may be reduced by the receptor tyrosine kinase inhibitor sunitinib, a very promising agent that affects the proliferation of tumor cells with a p.R561C mutation in PDGFR-beta .The case reported was particular because it associates some rare features: prenatally diagnosed solitary lesion in a female patient, with localization in the lower part of the body. We have systematized the cases identified in the literature by prenatal diagnosis, their features, treatment, and outcomes .IM is a differential diagnosis of soft tissue masses in early infancy and should be considered despite its low frequency and even if the typical characteristics are not met, like in the case presented. For diagnosis, the biopsy is mandatory, as treatment and prognosis depend on lesion characteristics such as clinical form (solitary or multicentric), location, and visceral involvement.


The paranasal sinuses in pediatrics can harbor a wide variety of pathologies. With the present literature being composed of case studies only, this entity is quite understudied.  This article aims to study the clinical presentation, diagnosis, and endoscopic management of six different rare frontal sinus pathologies in pediatrics, which include extensive allergic fungal sinusitis, mucoceles, osteoma, superior sagittal sinus thrombosis, CSF leak, and subdural empyema.  We retrospectively studied all pediatric patients with frontal sinus pathologies presenting to our center, King Fahad Specialist Hospital, Dammam, Saudi Arabia, from the period of 2006 to 2020.  A total of 8 patients presented to our hospital with different frontal sinus pathologies. 5 of them were males, and 3 were females with an age of presentation ranging from 7 to 17 years. The diagnosis and localization were performed through computerized tomography without contrast and magnetic resonance imaging, when indicated. All cases were primarily managed with endonasal endoscopic approaches successfully without complications and with no recurrence evident upon follow-up.  In this case series, six different frontal sinus pathologies were managed by an endoscopic approach, with excellent recovery and no recurrence upon follow-up demonstrated. This approach enabled excellent visualization of the pathologies, accurate localization, adequate drainage, and repair or grafting when needed. Although paranasal sinus disease has been extensively studied in literature, it has yet to be comprehensively studied in the pediatric population. The difficulty arises as a result of the variability in the size, shape, and pattern of development of each of the sinuses, along with a wide spectrum of pathologies that can affect them . These pAmong all the paranasal sinuses, the frontal sinus is of particular significance due to its close anatomical relationship to the orbit and anterior skull base, which makes it vulnerable to complications, caused by either the disease or surgery .The aim of this article is to showcase our experience and study the outcome of a set of six different frontal sinus pathologies in pediatrics. All were managed with an image-guided endoscopic surgical approach in King Fahad Specialist Hospital, a tertiary referral hospital in Dammam, Saudi Arabia.During the period from 2006 to 2020, all pediatric patients presenting to our Otorhinolaryngology Head and Neck Surgery department in King Fahad Specialist Hospital, Dammam with frontal sinus pathologies were enrolled in this study. Inclusion criteria included patients who were 18 years of age and younger at the time of presentation, with diagnosed frontal sinus disease, and managed solely by an endoscopic approach.All patients were evaluated and diagnosed by CT scans and/or MRIs, when indicated, prior to surgical management. All patients were followed up postoperatively to assess resolution of symptoms and disease recurrence.Ethical clearance was obtained from the Institutional Review Board (IRB) at King Fahad Specialist Hospital, Dammam. Written consent was obtained from all patients prior to the involvement of the study.A 15-year-old male presented to our ENT clinic complaining of nasal discharge, obstruction, and occasional headache. A detailed history of the present illness also revealed the presence of associated allergic symptoms. Past medical and surgical histories were unremarkable.Noncontrast enhanced computed tomography of the paranasal sinuses revealed the presence of extensive disease with a marked expansion of the sinuses, more pronounced in the right frontal sinus, with dehiscence of the posterior wall and intracranial extension . MagnetiFor the management, the patient underwent navigated endoscopic sinus surgery, in which the following were performed: cleaning of the sinuses and the dehiscent pulsating dura from mucin with no CSF leak observed intraoperatively. After one year of following up with the patient, recurrent polyps have been noticed and managed with a short course of oral steroids. No recurrence has been noted after 3 years of follow-up.A 14-year-old female presented complaining of a one-month history of right frontal bone depression, associated with a headache. The patient denied the presence of nasal obstruction, discharge, and epistaxis. Detailed past medical and surgical history were unremarkable. Clinical examination in the form of nasal endoscopy and ophthalmic examination was unremarkable.Noncontract enhanced computed tomography of the paranasal sinuses revealed the presence of the following: a low attenuation lesion filling the lateral aspect of the right frontal sinus, associated with thinning and resorption of the anterior, lateral, and posterior walls. The anterior wall showed posterior depression suggestive of a fracture . MagnetiFor the management, the patient underwent an image-guided endoscopic marsupialization of the right frontal mucocele, in which the following was performed: frontal sinusotomy , mucocelA 14-year-old male presented complaining of long-standing left-sided nasal obstruction, associated with a left-sided headache. Past histories of diagnosed sinusitis, allergic rhinitis, or epistaxis were denied by the patient. Clinical examination in the form of nasal endoscopy revealed the presence of a mass lateral to the middle turbinate on the left nasal cavity.Noncontrast enhanced computed tomography of the paranasal sinuses showed a left ethmoid calcified soft tissue mass with the following characteristics: an inferior extension into the superior aspect of the left maxillary antrum, heterogenous density with a ground glass appearance, calcified density at the periphery, and remodeling of the left medial orbital wall .For the management, the patient underwent image-guided endoscopic sinus surgery to remove the lesion from the left ethmoid. The skull base and the orbital wall were preserved with no complications noted postoperatively. The patient demonstrated excellent recovery with no recurrence after 2 years of follow-up.A 17-year-old male presented to our ENT clinic complaining of long-standing facial heaviness, left-sided headache, bilateral nasal obstruction, anosmia, and recurrent episodes of epistaxis. A detailed past medical and surgical history revealed that the patient has diabetes mellitus type II, on insulin, and a surgical history of functional endoscopic sinus surgery, performed one year prior to presentation. Clinical examination revealed the presence of a displaced left eye downward and outward as well as bilateral nasal pale polyps grade 3-4 with white discharge.A noncontrast enhanced computed tomography of the brain and paranasal sinuses was performed preoperatively, in which the following was revealed: a marked enlargement of the frontal sinuses with the largest being on the left side, dehiscence of the posterior wall of the sinus, and intracranial extension of soft tissues within epidural space measuring 5.3 × 4.1 cm on the axial image. Magnetic resonance imaging of the brain and sinuses  confirmeFor the management, the patient underwent image-guided endoscopic sinus surgery, in which the following was performed: removal of the bilateral extensive nasal polyposis, grade 4, by a microdebrider with drainage of frank pus, removal of the obstructing polyps from the ethmoidal cavities, and removal and drainage of obstructing infected polyps in the frontal recess . DrainagA 7-year-old female patient presented complaining of a two weeks' history of unresolving sinusitis with accompanying fever, headache, vomiting, and drowsiness. The patient was subsequently diagnosed as a case of bacterial meningitis secondary to acute frontal sinusitis.The findings of the preoperative magnetic resonance imaging of the paranasal sinuses confirmed the presence of left frontal sinusitis, meningitis, and sagittal sinus thrombosis.For the management, the patient underwent image-guided endoscopic drainage of the sinuses accompanied by a course of intravenous antibiotics administered postoperatively. An excellent recovery with no complications has been confirmed by the posttreatment MRI, performed upon follow-up.An 11-year-old female presented to our clinic complaining of fever, headache, vomiting, and drowsiness. History taking revealed that the patient was diagnosed prior to presentation with acute sinusitis, unresolved with conservative management.Noncontract enhanced computed tomography of the brain confirmed the diagnosis of a subdural empyema secondary to acute frontal sinusitis .For the management, the patient underwent an image-guided endoscopic frontal sinusotomy and a frontal minicraniotomy, performed by the neurosurgery team, to drain the empyema. Surgical management was accompanied by a course of intravenous antibiotics. An excellent recovery with no complications has been confirmed by the posttreatment CT scan, performed upon follow-up.A 10-year-old male referred to our ENT clinic with a history of two previous attacks of bacterial meningitis. Detailed history taking revealed a trauma to the head acquired while playing that preceded the attacks.Noncontract enhanced computed tomography of the paranasal sinuses showed a suspicious frontal sinus defect. MRI and CT cisternography confirmed the site of the defect and excluded the presence of an associated meningocele.For the management, an endonasal endoscopic localization of the CSF leak situated in the posterior wall of the frontal sinus was performed  and manaA 15-year-old male presented to our ENT clinic complaining of watery nasal discharge. A detailed history revealed that the patient was diagnosed with bacterial meningitis prior to presentation and had a trauma history of a recent motor vehicle accident.Noncontract enhanced computed tomography of the sinuses revealed the presence of a frontal meningocele protruding through a frontal sinus defect in the coronal plane  and confFor the management, two layers of free graft and a middle turbinate flap were placed for skull base reconstruction . The intJust like in adults, paranasal sinuses in pediatrics can harbor a large variety of pathologies. These pathologies range from self-limiting diseases to life-threatening conditions. In this case series, we present to you eight different cases of frontal sinus disease in pediatrics, which represent a fairly rare entity reported in the literature.Acute sinusitis is highly prevalent in pediatrics –5. The sDiagnosis of acute sinusitis is especially challenging in pediatrics because patients often lack the typical nasal symptoms of the disease –12; thusSubdural empyema is recognized in the literature as the most common sinogenic intracranial complication, making up to 85% of all complicated cases of sinusitis –23. In aManagement of such cases generally includes the administration of broad spectrum antibiotics and surgical drainage , 16. BotA mucocele is a mucous sac lined with an epithelial lining . FrontalAnother pathology demonstrated in two of our cases is traumatic cerebrospinal fluid (CSF) leak. Underlying causes can be broadly divided into nontraumatic and traumatic, with the latter one being the most prevalent (80% of cases) , 39. TraFrontal sinus cerebrospinal fluid leaks are rare, and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach are now used. Nevertheless, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency .In a case series of 10 pediatric patients with CSF leak, all cases were managed successfully using an endonasal approach . Both ofParanasal sinus osteogenic tumors are an uncommon finding in pediatrics . Out of In this case series, six different frontal sinus pathologies were managed by an endoscopic approach, with excellent recovery and no recurrence upon follow-up demonstrated. This approach enabled excellent visualization of the pathologies, accurate localization, adequate drainage, and repair or grafting when needed. We recommend the use of this approach to be the rule, especially when the disease is confined to the frontal sinus, as it provides superior cosmetic outcomes along with minimal postoperative morbidity as opposed to open approaches.


We are presenting a case of a 50-year-old female, a farmer by profession and often exposed to sunlight. She came with complaints of lesions on her face along with pain over the lesions for the past year, which was left unmanaged since then. No one in their family has similar complaints as per her knowledge. On thorough inspection of lesions, there was neither sensory loss nor oozing of any fluid. On evaluation, there were lesions over the nose and medial aspects of eyes looked like a hemorrhagic crusted plaque with hyperpigmented border initially started as hyperpigmented papules which progressed to present size gradually in one year. Skin biopsy was sent for histopathological examination which confirmed it as basal cell carcinoma, on the confirmation the patient was referred to the oncology department for further management.


Concurrent platinum-based chemoradiation (CCRT) is the established treatment for locally advanced cervical cancer and has an acceptable toxicity. Radiation-induced necrosis of the uterus and pelvic tissue is a rare and usually late potential complication. Limited data are available about its management. Here, we describe a case of a patient affected by a locally advanced cervical cancer (stage IVA) who received CCRT, obtaining a partial response with persistence of bladder and rectal infiltration. Unfortunately, after the first brachytherapy dose, the patient developed a worsening clinical picture with fever and altered laboratory data indicative of sepsis; the computed tomography revealed a massive necrosis of the uterus with pelvic abscess and peritonitis. We performed a laparoscopic emergency surgery with removal of the necrotic tissue, supracervical hysterectomy, bilateral-oophorectomy, and abscess drainage. Thereafter, once the severe inflammatory condition was resolved, the patient underwent pelvic exenteration with palliative/curative intent. The postoperative PET/CT was negative for residual disease. However, the patient needed further hospitalization for re-occurrence of peritonitis with multiple abscesses. A careful diagnosis is crucial in locally advanced cervical cancer patients who, after CCRT, present persistent pain and problematic findings at imaging and laboratory parameters. In these cases, radiation-induced necrosis of the pelvis should be suspected. This case helps to clarify the central role of surgery, especially when actinic necrosis leads to complications such as abscess, fistulae, and extensive tissue destruction that cannot be conservatively medically handled. Laparoscopy represents an ideal approach to realizing the correct diagnosis, as well as enabling the performance of important therapeutic surgical procedures. Concurrent platinum-based chemoradiation (CCRT) is the standard treatment for locally advanced cervical cancer and can be performed with acceptable toxicity ,2. Howev2) for five cycles, whole pelvic radiation 45 Gy in 25 fractions over 5 weeks, boost 12.6 Gy in seven fractions, and brachytherapy 7 Gy. Following the first brachytherapy administration, the patient presented with a fever (>39 °C) and was admitted to our Unit of Gynecologic Oncology at Businco Hospital, ARNAS G. Brotzu, Cagliari. Laboratory tests showed an increase in white blood cells (WBC) , platelets , C-reactive protein (CRP) (23.1 mg/dL), and fibrinogen (844 mg/dL), and decreased hemoglobin level (9.6 g/dL). A computed tomography (CT) scan was performed, which showed the presence of a cervical tumor with extensive necrosis (78 × 43 mm), infiltrating the bladder and without cleavage plan with the rectum. Adjacent to the tumoral mass, a large (multichambered) abscess measuring 124 × 85 × 125 mm was observed which extended to the right parietocolic wall  was necrotic with inflammation, without presence of tumoral cells; the fundic uterine margin showed active inflammation without tumoral localization; the tubaric surgical margin was involved by active inflammation without evidence of neoplastic cells. Actinic necrosis was observed in the pelvic abscess .After 30 days, once the severe inflammatory picture was solved, the patient underwent radical laparotomic surgery with palliative/therapeutic intent. The surgery was performed with radical cystectomy en bloc with the cervix. The small intestine with the results of actinic necrosis showed a sub-occlusive pattern, necessitating a large ileal resection. Rectal resection and termino-terminal sigmorectal anastomosis and a preventive colostomy were performed due to the suspected rectal infiltration and absence of surgical cleavage plane from the cervix. Because of the ileal resection, ileal conduit urinary diversion according to the Bricker technique was contraindicated; therefore, we opted for a left ureterocutaneostomy ,5. In adThe study was carried out according to the guidelines of the Declaration of Helsinki. According to the Italian Regulatory Agency for observational trials not involving drugs, the protocol was disclosed to the Institutional Ethics Committee of “Azienda Ospedaliero Universitaria di Cagliari”, Cagliari, Italy. The patient signed an informed consent form for the surgical and medical treatment. Written informed consent has been obtained from the patient to publish this paper.The efficacy of concurrent chemoradiation for treating advanced cervical cancer has been widely reported ,7.Acute and late toxicity have been described as radiation enteritis, genito-intestinal, genito-vesical, and vesico-intestinal fistula, urinary tract obstruction/stenosis, fibrosis, and necrosis ,8.Nakano et al. examined 1148 patients treated with radiotherapy alone. They reported an incidence of late complications in the rectum, small intestine, and urinary tract at 10 years as 22%, 9%, and 18%, respectively, with significant complications occurring in 4.4%, 3.3%, and 0.9% of cases, respectively [Toxicity may depend on the radiation dose, treatment volume, and tissue health within the target area. Additionally, different tissue types may develop sequelae following RT at varying rates and timing of onset . Pelvic Moreover, of note, tumor extension at diagnosis has been correlated with increased incidence of complications, such as fistulae , which represent a therapeutic challenge in very locally advanced cervical cancers ,14,15. TNecrosis of pelvic tissues represents a rare, usually late, complication of CCRT. Risk factors include total dose of radiation therapy, the radiation therapy field size (likely as a function of disease extension), advanced stage disease, history of abdominal surgery (with compromised vascular supply), and diabetes . The patPelvic necrosis following CCRT for cervical cancer has been described by few authors. In 1986, DeMuylder et al.  describeTo date, Fawez et al.  have perIn our case, conservative medical management was not feasible because of the acute and progressive increase of inflammatory indexes, the presence of sepsis, and the worsening clinical picture. Indeed, the first surgical intervention was finalized to the resolution of the emergency, and yet, as described above, consisted of removal of the necrotic tissue including the body of the uterus and adnexa, then carrying out supracervical-hysterectomy, bilateral salpingo-oophorectomy, and abscess drainage. On the other hand, the second surgery had a palliative therapeutic intent.Radical hysterectomy after CCRT in LACC continues to fuel debate, since the instrumental evaluation of residual disease before surgery is uncertain. In fact, both MRI and PET/TC remain suboptimal in the evaluation of response to initial treatment because of poor specificity and high risk of false negative . Of noteNecrosis of pelvic tissues is a rare complication of CCRT in patients treated for locally advanced cervical cancer. Surgical management is recommended when laboratory tests, radiologic imaging, and clinical symptoms are not reassuring.Thus, in patients that come to our attention after CCRT with persistent abdominal-pelvic pain, who have questionable findings in their imaging results, elevated inflammation parameters, or both, the differential diagnosis should include the suspicion of radiogenic necrosis of the uterus and other pelvic organs. Laparoscopy is an ideal technique to confirm or reject this diagnosis, in addition to allowing the performance of important therapeutic surgical steps. The present paper contributes to clarifying the central role of surgery, in particular when actinic necrosis determines complications such as abscess, fistulae, and extensive tissue destruction that cannot be medically conservatively managed.


Herpes zoster involving all three divisions of the trigeminal nerve is extremely rare and may pose a diagnostic challenge, especially in young and immunocompetent patients. We present a unique case of herpes zoster involving all three divisions of the trigeminal nerve and illustrate that this uncommon eruption can be a presenting sign of varicella zoster aseptic meningitis. This case emphasizes the importance of fundamental morphology recognition, particularly its ability to aid in clinical diagnosis and its potential to decrease patient morbidity and mortality by expediting the initiation of appropriate treatment. Herpes zoster is a dermatomal, painful, vesicular rash caused by the reactivation of the varicella zoster virus (VZV) . It is mHerein, we describe the first known presentation of multi-dermatomal herpes zoster involving all three branches of the trigeminal nerve with unilateral oral vesicles and aseptic viral meningitis in a young, immunocompetent adult. This case highlights the importance of analyzing the morphology and distribution of a dermatologic process to not miss an atypical aggressive case of VZV in an otherwise healthy individual and prevent the possible morbidity and mortality associated with delayed diagnosis.A 33-year-old previously healthy male presented with oral pain and a painful left-sided facial rash of two days duration. The patient reported a left-sided headache with subjective fevers, body aches, night sweats, and odynophagia. He had an uncomplicated left upper molar extraction one month prior. Upon presentation, skin examination revealed erythematous, edematous, well-demarcated plaques to the left jawline, cheek, eyebrow, and nose Figure .Oral examination showed multiple coalescing vesicles to the left buccal mucosa and soft and hard palate, all strictly obeying the midline Figure . A lumbaGiven its rarity, a multi-dermatomal vesicular rash may pose a diagnostic challenge, especially in young and immunocompetent patients. The patient in this case report was found to have multi-dermatomal herpes zoster of the trigeminal nerve with disseminated disease to the central nervous system, which has not previously been reported in an immunocompetent individual. However, aseptic meningitis with an associated abdominal herpes zoster eruption has been observed, highlighting the ability of herpes zoster to present with concomitant central nervous system invasion . The iniThere have been only a few published cases of herpes zoster affecting all three branches of the trigeminal nerve, although none were associated with disseminated central nervous system infections ,5,6. SimThis case reemphasizes the importance of analyzing distribution, morphology, and arrangement in addition to conducting a thorough examination, including mucous membranes, when evaluating a patient with a new eruption. Clinicians should maintain high clinical suspicion of central nervous system dissemination in all patients with systemic symptoms, especially in the setting of multi-dermatomal eruptions, as such aggressive presentations will require prompt treatment with intravenous acyclovir. Viral PCR from either cutaneous lesions or CSF can take several days to result. Clinical diagnosis made on the basis of morphology, even in rare or atypical cases, has the ability to decrease the morbidity associated with delayed diagnosis of VZV.


Richter’s hernia, also called a partial enterocele, involves a protrusion of peritoneum with subsequent strangulation or incarceration of only part of the lumen of the anti-mesenteric portion of the small bowel through a fascial defect. We report a rare presentation of incarcerated incisional Richter’s hernia of the cecum in a 39-year-old female. The patient presented with acute abdominal pain that gradually improved. Physical examination revealed right lower quadrant tenderness and nodularity just above an abdominoplasty scar. Subsequent computed tomography scan demonstrated a 1 cm by 1 cm hypovascular pocket arising from the cecum with protrusion into the anterior abdominal wall. The hernia was successfully repaired surgically with resolution of symptoms. It is essential for clinicians to be mindful of the diagnosis of Richter’s hernia on the differential for abdominal pain as the risk of detrimental outcomes increases with delayed surgical intervention. Richter’s hernia involves a protrusion of peritoneum with subsequent strangulation or incarceration of only part of the lumen of the anti-mesenteric portion of the small bowel through a fascial defect. As a result, the lumen is incompletely contained in the defect. Timely repair of a Richter’s hernia is instrumental as mortality increases with delays in surgical intervention due to the high risk of strangulation and necrosis. The insidious nature and late presentation of a Richter’s hernia, as well as its relative rarity, may lead to late diagnosis or misdiagnosis ,2.A 39-year-old female patient initially presented to the emergency department after a fall at home. Computed tomography (CT) imaging of the abdomen and pelvis at the emergency department did not reveal any major pathology. She visited the clinic a month later for persistent tenderness at the right lower quadrant of the abdomen. She denied any exacerbating or relieving factors. The patient additionally denied any associated symptoms, including fever, chest pain, shortness of breath, palpitations, dysuria, or known exposure to coronavirus disease 2019 (COVID-19). The patient has a past surgical history of an appendectomy, three cesarean sections with bilateral salpingo-oophorectomy, and abdominoplasty. Her family history was only remarkable for unspecified heart disease.At the clinic, physical examination revealed right lower quadrant tenderness and nodularity 2 cm above her abdominoplasty scar that was potentially overlapping the site of a previous appendectomy incision. The nodularity could not be easily reduced into the abdominal cavity. On closer review of the previous CT scan from her emergency room visit, there was a newly appreciated area of hypervascularity near the palpable nodularity Figure .Given the likelihood of a hematoma or a fascial defect at the site of the incision along with the concern that this suspected hernia was not reducible, urgent imaging was warranted to rule out incarceration or strangulation. Subsequent preoperative CT imaging revealed a 1 cm by 1 cm hypovascular pocket arising from the cecum and protruding into the anterior abdominal wall without any inflammatory changes Figure . Such fiShortly after, the patient appropriately underwent an exploratory laparoscopy. The abdomen was entered in the left upper quadrant and left lower quadrant with three optical trocars Figure . It was The patient did well postoperatively and was discharged home from the recovery unit. The pathology laboratory reported the patient’s specimen as demonstrating benign disease with nonspecific chronic inflammation. A repeat CT of the abdomen and pelvis demonstrated full resolution of the incisional Richter’s hernia with lack of pathology at the surgical sites Figure .The initial differential for abdominal pain is very broad, and thus a careful attention to patient’s history, particularly those of symptoms as well as prior operations, physical examination, laboratory studies, and imaging is required. This tailors the differential based on the likelihood of diagnosis in that patient .It is important to note that the patient’s physical findings of tenderness and nodularity at the right lower quadrant was near the same site as a prior appendectomy, even though her cutaneous scar was excised during the subsequent abdominoplasty. This context is highly suggestive of herniation given the inherent weakness to the fascia from a past incision. A diagnosis of hematoma would have been sufficient if there was no history of surgery at the site.Additionally, the inability to reduce the mass was highly suggestive of incarceration or strangulation. At this stage, CT imaging was able to demonstrate the likely diagnosis of a hernia given the protrusion of the cecum through the anterior abdominal wall. It is for this reason that imaging can be essential to confirming a diagnosis that requires prompt management. Given the clinical urgency of incarceration or strangulation of abdominal hernias, CT imaging is considered superior for both its accuracy in diagnosing the condition as well as its fast turnaround . In contIn a Richter’s hernia, the portion of the bowel that is herniated may have subsequent compromise of the vasculature, leading to infarction and potential peritonitis secondary to perforation . This tyThe symptoms of a Richter’s hernia include nausea, vomiting, and crampy abdominal pain. Symptoms are often subclinical with consequent late presentation. CT imaging is typically diagnostic, as in this case. It is instrumental to repair Richter’s hernias as they are at higher risk of progression to gangrene in comparison to other hernia types, consequently with increased risk of mortality. Repair typically involves a preperitoneal approach with laparotomy and potential bowel resection, in addition to repair of the fascial defect ,8. The dOur patient is a female who presents with a history of multiple abdominal or pelvic surgeries, increasing the index of suspicion for a hernia as the source of her prolonged abdominal discomfort on presentation to the clinic. The insidious nature and late presentation of a Richter’s hernia may lead to late diagnosis or misdiagnosis ,2. EvaluThe operative management of a Richter’s hernia depends on bowel viability. With viable bowel, no bowel resection would be needed, but ischemic bowel may require a resection in addition to repair of the defect in the fascia . If a RiThe patient did not report any concerns regarding this case at the time of writing this report. Despite its rarity, a Richter’s hernia is a more dangerous type of hernia with high risk of strangulation and necrosis. The authors urge clinicians to be mindful of this rare type of hernia for its high risk of mortality in patients.