Pediatric convulsive seizure is common and represents a source of major concern and anxiety for the parents. Seizures can have a broad spectrum of etiologies in children, including metabolic, traumatic, developmental, and infectious causes. Depending on the clinical presentation, laboratory testing and neuroimaging may be indicated in the workup of the first unprovoked afebrile seizure. We present a case of a six-year-old boy who was brought to the emergency department by his mother after an episode of convulsion. She reported that he had jerky repetitive movements of all extremities that lasted around two minutes with spontaneous termination. The child did not have a febrile illness. The mother reported no history of similar episodes. Upon examination, the child appeared alert and conscious. No dysmorphic features were evident. Initial laboratory investigations were within the normal limits. The child underwent magnetic resonance imaging for the brain, which demonstrated a large well-defined extra-axial cystic lesion occupying most of the left hemisphere that is connected to the ventricular system. The lesion had no grey-matter lining and it strictly followed the cerebrospinal fluid in all sequences. Such finding represented the diagnosis of a giant left porencephalic cyst. Porencephaly is an extremely rare neurological anomaly that may present with pediatric seizures. Magnetic resonance imaging is the gold standard modality for the diagnosis of porencephaly. The case demonstrated that porencephaly can have a massive size in a patient with normal psychoneurological development. Pediatric convulsive seizure is common and affects up to 10% of children . It reprWe present the case of a six-year-old boy who was brought to the emergency department by his mother after an episode of convulsion. She reported that he had jerky repetitive movements of all extremities that lasted around two minutes with spontaneous termination. He was not responding during the episode. The mother reported that his skin color turned blue. The mother reported that the movement was associated with urinary incontinence and frothy secretions from the mouth. There were no warning signs before the event. The mother reported that the child did not complain of any unpleasant sensation before the spell. The event occurred suddenly while the child was playing with his friend. He was not deprived of sleep before the event. The child appeared tired after the spell and he fell asleep. The child did not have a febrile illness. The mother reported no history of similar episodes.Regarding the medical history, the child was known to have asthma and eczema. His conditions were well-controlled. There was no history of previous surgeries. The perinatal history was uneventful. He was full-term with a birth weight of 3.8 kg. He was up-to-date with the vaccination schedule. He was not born of a consanguineous marriage. No family history of epilepsy was present. The social history was non-contributory.Upon examination, the child appeared alert and conscious. No dysmorphic features were evident. He was not pale, jaundiced, or cyanosed. His vital signs included a temperature of 36.5℃, a heart rate of 90 bpm, blood pressure of 80/58 mmHg, and respiratory rate of 23 bpm. His oxygen saturation was 99% on room air. The child had normal speech and comprehension appropriate for his age. His social and behavioral skills were normal. Upper and lower limb examination revealed normal tone and power. His gait was normal. The cardiorespiratory examination was unremarkable. Initial laboratory investigation revealed a hemoglobin of 14.2 g/dL, leukocytes count of 7,000 cells//µL, and platelet count of 390,000/µL. The random blood sugar was within the normal limits. Other biochemical findings, including electrolytes, hepatic, and renal profiles, were within the normal limits (Table Considering the aforementioned findings of unexplained first-time seizure with normal laboratory markers, the child underwent magnetic resonance imaging for the brain to rule out any structural abnormalities. The scan demonstrated a large well-defined extra-axial cystic lesion occupying most of the left hemisphere that is connected to the ventricular system. The lesion had no grey-matter lining and it strictly followed the cerebrospinal fluid in all sequences Figure . Such fiWe presented an interesting case of a child with a first-time seizure due to a giant porencephalic cyst occupying almost all the left hemisphere. Porencephaly is an extremely rare congenital disorder of the brain. Porencephaly can be congenital or acquired after infection, trauma, infarction, or hemorrhage . The sizPorencephaly can occur in any lobe. It is typically unilateral in most cases, but cases with bilateral porencephaly have been reported . The cliMagnetic resonance imaging is the gold standard for the diagnosis of porencephaly. As in the present case, it demonstrates an intracranial cystic lesion within the brain that follows the cerebrospinal fluid signal in all sequences and exhibits communication with the ventricular system or the subarachnoid space. The differential diagnoses of porencephaly include schizencephaly, neuroglial cyst, arachnoid cyst, and holoprosencephaly. In contrast to schizencephaly, a porencephalic cyst is not lined by grey matter. Antenatal diagnosis of porencephaly may be possible by third-trimester ultrasound . In the The surgical management for epilepsy caused by porencephaly can be challenging. It is difficult to choose the optimal surgical approach due to the widespread abnormality that can be detected by electroencephalography. Further, the functional cortical reserve may be limited in such patients. In a case series by Ichikawa et al. , they rePorencephaly is an extremely rare neurological anomaly. Despite its rarity, clinicians should be aware of this condition and consider it in the differential diagnoses of pediatric seizures. Magnetic resonance imaging is the gold standard modality for the diagnosis of porencephaly. The case demonstrated that porencephaly can have a massive size in a patient with normal psychoneurological development.


Endometriosis constitutes a benign condition, occurring in 10%–12% of menstruating women. Bowel involvement is estimated to occur in 5%–12% with the rectosigmoid region involved in up to 90% of these cases. We present the case of a 45‐year‐old Caucasian female patient with rectosigmoid endometriosis. While endometriosis is a difficult radiologic diagnosis to make, it must be considered in women being worked up for a colonic mass. Biopsy is usually necessary to confirm the diagnosis, as endometriosis can mimic colonic cancer during initial work‐up. Our presentation demonstrates the role of clinical suspicion in achieving a timely preoperative diagnosis and consequently ensuring better outcome for the patient.2A 45‐year‐old Caucasian female patient presented to the emergency department complaining of recurrent episodes of hematochezia. She had been also suffering from constipation and mild left‐lower quadrant abdominal pain for the last 6 months. Regarding her medical history, the patient was perimenopausal and on treatment with low dose ethinylestradiol/chlormadinone. Furthermore, she was treated with amlodipine because of arterial hypertension. The patient also reported a familial history of ulcerative colitis including her sister Figures , 4, 5, 6The patient had been recently hospitalized due to severe diarrhea, which shifted into rectal bleeding. Initial diagnosis was gastroenteritis, therefore she was treated conservatively with IV administration of ciprofloxacin and metronidazole. No colonoscopy was performed during her hospitalization. She was discharged after 5 days and was fully recovered.On physical examination, the patient presented with normal vital signs. Abdominal examination disclosed a soft, non‐distended abdomen with left‐lower quadrant tenderness. No palpable masses were present. Digital rectal examination revealed the presence of bright red blood. Laboratory evaluation demonstrated hemoglobin of 11.4 g/dl with normal WBC count. Electrolytes, renal function, and liver enzymes were within normal values. Initially, the patient was managed with intravenous fluid resuscitation. Nasogastric aspiration revealed no signs of active bleeding in the upper gastrointestinal tract. Subsequently, she was subjected to a colonoscopy. This disclosed a 5‐cm stricture of the sigmoid colon, located 25 cm above the anal ring.The patient was scheduled for an open surgical resection. Intraoperatively, a structuring lesion was distinguished in the distal sigmoid. Furthermore, an ovarian chocolate cyst was identified in the right ovary. The patient underwent a sigmoidectomy followed by an end‐to‐end anastomosis, combined with right salpingo‐oophorectomy.Gross examination of the resected specimen disclosed a fibrous transmural mass along with endometrial implants on the serosal surface.3Clinical presentation of intestinal endometriosis is characterized by non‐specific symptoms with considerable overlap with other clinical entities.Several imaging techniques are quite conducive to diagnosing intestinal endometriosis. Transvaginal ultrasonography is characterized by high sensitivity and specificity, but it may miss sigmoid lesions, since the latter remain outside of field of vision.Surgical resection and conservative treatment are the two major management strategies widely adopted, once bowel endometriosis is diagnosed.Surgical intervention is advisable in patients with symptomatic lesions refractory to medical treatment, obstructive disease, and exclusion of malignancy.Shave excision represents the least invasive technique, involving a layer‐by‐layer removal of the lesion. It may be performed either by ablation or resection of endometrial nodules, leaving muscularis and mucosa intact.Segmental resection, eventually, entails complete resection of the affected bowel with subsequent anastomosis. As a more invasive type of surgery, it is indicated mainly for patients with bowel stenosis, multifocal lesions, sigmoid involvement, and lesions larger than 3 cm or involving >50% of the circumference of the bowel wall.In conclusion, rectosigmoid endometriosis constitutes a rare cause of low gastrointestinal bleeding and also a major challenge for general surgeon, since the differential diagnosis from colorectal malignancy could be difficult. Representing a quite uncommon clinical entity, it should always be included in the differential diagnosis of hematochezia in women of childbearing age. Accurate and timely diagnosis remains crucial for an optimal therapeutic approach, highlighting the major role of a high clinical suspicion.None to declare.Athanasios Piachas reviewed the literature and the manuscript, made a contribution to drafting, and edited the images. Panagiotis Smyrnis reviewed the literature and wrote the manuscript. Andreas Tooulias reviewed the literature and the manuscript.The authors declare that the current manuscript is not published elsewhere. This paper does not appear online, either wholly or in part, as a thesis, working paper series, or preprint publication.A written consent was obtained from the patient for publication of the case report according to the ethical principles of Declaration of Helsinki.


Mixed neuroendocrine-non neuroendocrine neoplasm (MiNENs) is a rare gastrointestinal neoplasm that has been redefined by the World Health Organization (WHO) in 2017 as the association of two types of components, neuroendocrine and non-neuroendocrine, each of them present in at least 30% of the tumour mass. Small case reports and case series have demonstrated the occurrence of this neoplasm in the colon. We here report the case of a 47-year-old man undergoing colonscopy for anemia. This showed impassable polypoidal tumor budding in the right colic flexure. Computerized tomography (CT) scan and magnetic resonance imaging (MRI) showed the presence of liver metastases. As the tumor was hemorrhagic, right hemicolectomy with lymph node dissection was performed. The histological examination showed MiNEN of the ascending colon. The patient received adjuvant chemotherapy. MiNENs represent a rare diagnosis of the gastro-entero-pancreatic tract  that hasPatient information: a 47-year-old man, chronic smoker, with no medical history, presented with progressively worsening pain in the right lower abdominal quadrant in the last 2 months, which was associated with melena, postprandial vomiting, and weight loss of 5 kg for 3 months without anorexia or asthenia.Clinical finding: on examination, he was pale, and on abdominal examination, a palpable mass in the right lower abdominal quadrant that was painful, with dullness on percussion. On rectal examination, the finger pad was covered with blood.Diagnostic assessment: laboratory data showed microcytic hypochromic anemia with; hemoglobin (Hg) at 6.5g/dl, Mean Blood Volume (MBV) at 58.2 fl, and Mean Corpuscular Hemoglobin Content (MCHC) at 17.4 pg. Serum levels of tumor markers: Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) were normal. Colonoscopy for anemia examination showed an impassable polypoidal budding formation of the right colonic angle. The biopsy is in favor of a well-differentiated and invasive adenocarcinoma on a degenerated tubular villous polyp. The Computed tomography (CT) scan was performed, showed a large mass of polylobed appearance of the coecum extended to the colonic angle measuring 115x67x132mm  according to the prognosis and found that the grade was useful for determining treatment strategies [The prognosis of colorectal MiNEN is actually worse than that of pure adenocarcinoma, and most similar to that of PDNEC, especially at the metastatic stage ,12. The rategies . Low-grarategies . NETs carategies . If it irategies ,12,19-24et al. Adjuvant chemotherapy was considered, as a resection was already obtained since the tumor was symptomatic.In our case, the adenocarcinoma segment represented 15% of the total tumor tissue, infiltrating all tunics with perforation of the colonic wall, while the neuroendocrine component represented 85% of the total tumor tissue and developed around the colonic mucosa, so this case was diagnosed as a combined/biphasic type of MiNEN. The current tumor was histologically composed of G3 NET and adenocarcinoma, with the presence of distant metastases and classified as High-grade MiNEN according to the classification of Rosa MiNEN of ascending colon is very rare. Although our case was a high-grade lesion combining NEC with adenocarcinoma, which is considered the most aggressive component and the prognosis is expected to be bad. The treatment management should be based on the most aggressive component of neoplasia, which can be determined reliably only by analysis of a resected specimen, even if it is less than 30% of the neoplasm.


Myxedema coma and pituitary apoplexy are well-known life-threatening endocrine emergencies. The coincidence of these entities is exceedingly rare. Myxedema coma occurring as a result of pituitary lesion is a much less seen entity. A high index of suspicion is often required for early diagnosis as it is of particular importance in improving survival outcomes. We present a rare case of a patient with myxedema coma presenting as bradycardia and hypotension secondary to pituitary apoplexy, which was confirmed on magnetic resonance imaging (MRI). The patient was managed conservatively with levothyroxine and stress doses of steroid, with the resolution of hemodynamic changes and a decrease in the size of the suprasellar mass. Myxedema coma and pituitary apoplexy are well-known life-threatening endocrine emergencies. The coincidence of these entities is exceedingly rare. Myxedema coma occurring as a result of the pituitary lesion is much less seen and occurs as a result of severe hypothyroidism. The term “myxedema coma” is a misnomer as most of the patients present with an altered mental status more frequently rather than overt coma. Pituitary apoplexy generally presents with a sudden onset of excruciating headache, nausea, and visual disturbances such as diplopia, hypopituitarism, and neurological impairment  as a resThe abstract of this case report was presented at the Southern Regional Meeting, February 2019, New Orleans, LA.A 63-year-old male with a past medical history of hypertension, hyperlipidemia, and diabetes presented to our hospital with bradycardia, hypothermia, and hypotension. On presentation, his temperature was 85.4°C, blood pressure (BP) was 80/61 mm Hg, respiratory rate was 18 breaths/minute, heart rate (HR) was 40 beats minute, and saturation was 92% on 6 L nasal cannula. On physical examination, he was slow to respond, but arousable to voice, without clear orientation, and had a Glasgow coma scale of 12. An electrocardiogram (EKG) showed bradycardia, incomplete right bundle branch block, and prolonged QTc interval of 621 msec (corrected by Hodges method due to bradycardia), as shown in Figure Considering secondary hypothyroidism and hypocortisolism, further investigations for the possible central etiology were performed. Magnetic resonance imaging (MRI) revealed suprasellar mass measuring 2.5 x 2.2 x 2.0 cm with prominent T1 hyperintensity, abutting and uplifting the optic chiasma, findings compatible with hemorrhagic pituitary microadenoma Figure . FurtherOnce more arousable, the patient was further evaluated neurologically and did not have a visual impairment. Conservative management for pituitary apoplexy was considered with close neurological observation. Three months follow-up MRI revealed a reduction in the size of tumor and pituitary bleed, measuring as 2.1 x 1.9 x 1.8 cm Figure .Myxedema coma is more common in elderly females and occurs as a result of various precipitating events such as infection, gastrointestinal bleeding, cold exposure, stroke, surgery, and medications such as amiodarone or lithium . The preThyroid hormones act intracellularly by binding to thyroid hormone response elements modifying gene transcription . EffectsLow serum T4 results in low intracellular T3 hormone. The decreased thyroid hormone results in diastolic hypertension, decreased blood volume, peripheral vasoconstriction, and decreased contractility of the heart, resulting in impairment of cardiovascular hemodynamics eventually leading to overt heart failure ,9. ConseIn general, management involves protection of the airway in unconscious patients, external warming in cases of hypothermia, intravenous fluids in hypotensive patients, and antibiotics if the infection is suspected. It is important to look for an underlying precipitating cause. As gut edema may alter the absorption of oral thyroid hormone, intravenous replacement of thyroid hormone is considered the cornerstone of the treatment. Concomitant hypocortisolism is often present due to primary or secondary adrenal insufficiency, as seen in our patient. Also, thyroid replacement can cause increased cortisol clearance worsening the cortisol deficiency . TherefoMyxedema coma resulting from pituitary apoplexy is a rare entity. Life-threatening bradycardia and hypotension could be a part of the early syndromic presentation. Our case emphasized that early recognition of myxedema coma and its cardiac complication is important in improving survival outcomes.


Epitheliod trophoblastic tumor (ETT) account for only 1–2% of all the cases of gestational trophoblastic neoplasia (GTN), with a reported mortality rate of 10–24%. ETT is derived from chorionic type intermediate trophoblastic cells, which appears to be the reason for the only slightly elevated βhCG levels in these patients. We present a case of a 42-year-old patient who was admitted to the clinic eight months after Caesarean delivery, for irregular vaginal bleed with normal values of beta-human chorionic gonadotropin (βhCG). A 6 × 5 cm hematoma was evacuated from the isthmic uterine segment during the operation, and the histopathological exam of the tissue surrounding the hematoma revealed ETT. There were no metastatic lesions on the thoracal, abdominal, and pelvic CT. The second ultrasonographic exam revealed tumefaction of 5 cm at the site from the previous surgical procedure. Color Doppler imaging revealed no central nor peripheral blood flow. The patient underwent a total abdominal hysterectomy with bilateral adnexectomy without adjuvant chemotherapy. This appears to be one of the shortest intervals from the anteceded gestational event until the diagnosis of this tumor, along with the absence of the significant ultrasonographic feature of the ETT-peripheral Doppler signal pattern. We underline that, even with normal values of βhCG, irregular vaginal bleeding following the antecedent gestational event should always arouse suspicion of GTN. A little less than two decades ago, the World Health Organization (WHO) recognized epithelioid trophoblastic tumor (ETT) as a form of gestational trophoblastic neoplasia (GTN) . First dA 42-year-old patient, para 2, gravida 2, was admitted to the gynecology department for vaginal bleeding, eight months after Caesarean section delivery. She also complained about irregular bleeding that started two months after delivery. Her serum beta-human chorionic gonadotropin (βhCG) was not elevated. A gynecological exam revealed painful tumefaction around the lower uterine segment. A 5 cm tumefaction in the Caesarean scar region was observed on the ultrasonographic exam. During the explorative laparotomy, a 6 × 5 cm hematoma was evacuated from the isthmic uterine segment. The surrounding pelvic structures appeared to be morphologically intact. A small tissue sample around the hematoma was sent to the histopathological exam and the uterine wall was reconstructed in the two layers. Histopathological exam showed fragments of endocervical tissue with intermediate trophoblastic cells forming elongated structures and nests a,b. The As with all unfamiliar diseases, our knowledge about ETT is based on case reports, case series, and literature reviews. The variety of the presentation, patient’s age, and different medical histories make the diagnosis of this mysterious disease even more difficult. As of this moment, there are no universally accepted protocols for the diagnostic route(s), treatment regimens, and the duration of the treatment for patients diagnosed with ETT.We found only a few reports of ETT presenting as a mass in the Caesarean scar, with two being synchronous with choriocarcinoma ,7,8,9,10Most ETTs occur in reproductive-age women, but there are also reports of this disease in postmenopausal women . Based oWhat is remarkable in this case is that the patient’s mainly used tumor markers for gestational trophoblastic neoplasia returned negative. Serum βhCG, the most commonly used diagnostic tool for gestational trophoblastic neoplasia, is often only moderately elevated in the cases of ETT, with a range of 665–2500 mIU/mL . One of The main explanation for normal levels and moderate elevation in βhCG concentration in patients with ETTs is the origin of these tumors. They arise from intermediate-type chorionic trophoblasts, which produce little βhCG. Although these cell populations compose large quantities of hPL, experience from published case series determines that this is not a valuable tumor marker for ETT. On the other hand, hPL could be a useful marker for the diagnosis of the other rare form of GTN-placental site trophoblastic tumor (PSTT), even though its levels did not reflect disease activity and prognosis .In a retrospective series by Quin et al., all 12 cases of ETT presented as a well-circumscribed border with the hypoechogenic halo on the ultrasonographic exam, which appears the be the distinctive feature of these tumors . In the A histopathological exam is crucial for the definitive diagnosis of ETT. The exam should be performed by a pathologist with experience in GTN in order to minimize the risk of misdiagnosis, as it is often perplexing to differentiate ETT from other forms of GTN . ETT is The current opinion is that the primary treatment modality for patients with ETT confined to the uterus is surgical. Total abdominal hysterectomy with bilateral adnexectomy helped the definitive management of the disease in the reported case series. Even though there are some debates, most authors do not recommend adjuvant chemotherapy for these patients. One of the largest case series of patients with ETT underlined that stage I disease without adverse factors  should undergo surgery alone, and that adjuvant chemotherapy is advised if these factors are present. In their review, Gadducci et al. recommend hysterectomy with bilateral salpingectomy in stage I patients who wish to preserve fertility [Our knowledge regarding prognostic factors in patients with ETT relies on larger case series and literature reviews. Some authors believe that risk factors for an unfavorable prognosis are similar to those of PSTT, regardless of the rarity of this disease. So far, the period from the antecedent gestational event longer than 48 months and advanced-stage disease remain the only accepted factors for the poor prognosis in these patients.We presented the case of ETT diagnosed eight months following the Cesarean delivery, with what appears to be one of the shortest intervals from the anteceded gestational event until the diagnosis of this tumor. The other distinctive feature of this case was the absence of the significant ultrasonographic feature of the ETT-peripheral Doppler signal pattern. This second reported case of an accidental finding of ETT mimicking hematoma in Caesarean scar in the lower uterine segment further expands the spectrum of ETT’s clinical presentations. We underline that, even with normal values of βhCG, irregular vaginal bleeding following the antecedent gestational event should always arouse suspicion of GTN.


The urachus is the embryological remnant of the cloaca and allantois. Failure of its regression can cause diseases any time after birth. It is difficult to differentiate an abscess from urachal adenocarcinoma based on the clinical presentation and image findings. Cystitis glandularis reflects chronic irritation of the bladder urothelium, and tumor-like florid cystitis glandularis can be misdiagnosed as malignancy. We report a patient with concurrent urachal abscess and florid cystitis glandularis which increased the resemblance of malignancy.A 57-year-old female was incidentally found to have a heterogeneous pelvic mass abutting the urinary bladder. A cystoscopy examination revealed protruding tumors located in the bladder dome. Her blood test results were all normal, and urinalysis showed microscopic hematuria. Urachal cancer was diagnosed and en bloc excision of the umbilicus, tumor, and the involved bladder dome was performed. Pathology revealed urachal abscess with concurrent cystitis glandularis within the urinary bladder. No malignancy was identified in the resected specimen.It is challenging to distinguish urachal abscess from a malignant tumor based on the clinical presentation and imaging studies. As in our case, the coexistence of urachal abscess and tumor-like florid cystitis glandularis increased the resemblance to a malignancy. This is the first reported case of the concurrence of these two disease entities, and emphasizes that the detection of bladder tumors on cystoscopy is not sufficient to make the diagnosis of urachal cancer with bladder involvement. During embryogenesis, the allantois and cloaca give rise to the urachus, which then involutes and obliterates into the median umbilical ligament . FailureCystitis glandularis is a proliferative disorder of bladder epithelium, which may be caused by normal urothelium reacting to chronic irritation such as infection or malignancy .Herein, we report a patient who was initially diagnosed and treated for urachal cancer with bladder invasion. Pathology later revealed urachal abscess and cystitis glandularis. We also review the clinical presentations, imaging features, and management of urachal mass and cystitis glandularis.A 57-year-old female was incidentally diagnosed with an ovarian cyst during a clinic visit for occasional postmenopausal vaginal spotting, and was referred to our hospital. She denied fever, abdominal pain, lower urinary tract symptoms, hematuria, or any other symptoms. Transvaginal ultrasound showed a 6-cm heterogeneous pelvic mass with mixed echogenicity located anterior to the uterus. Her uterus, endometrium, and bilateral adnexa were unremarkable. Contrast-enhanced computed tomography (CT) showed an enhancing pelvic mass with solid and cystic components closely abutting the bladder dome and abdominal wall with adjacent fat stranding. No conspicuous local invasion, enlarged pelvic lymph nodes, or distant metastases were noted Fig. .Cystoscopy revealed protruding tumors in the bladder dome Fig. a. CompleAs a malignant tumor of the urachus was suspected, the patient underwent open surgical en bloc excision of the umbilicus, tumor, and involved bladder dome via a lower midline incision. A piece of thickened omentum adhered to the tumor was found intraoperatively, and was removed wholly due to the suspicion of omental cake. Pathology revealed a 6-cm necrotic mass with abscess formation and the focal presence of urachal remnants. Cystitis glandularis was identified in the resected bladder Fig. b. CytokeInfection of urachal remnants occurs most commonly in children and young adults . The rouMalignant urachal neoplasms comprise less than 0.5% of all bladder malignancies and are predominantly adenocarcinoma, even though the urachus is commonly lined by urothelium. Several studies have reported that chronic irritation-induced metaplasia followed by malignant transformation may explain the pathophysiology of urachal cancer , 7. UnliAbout 90% of urachal cancers develop in the juxtavesical portion of the urachus and may extend toward the umbilicus and bladder . Over 70As in our patient, urachal masses are often discovered incidentally in imaging studies. However, abscesses and malignancies are often indistinguishable in most imaging modalities , 4. UltrSome imaging features have been described that can be used to differentiate a urachal mass. For example, calcification occurs in 50–70% of malignancies but rarely in abscesses. In addition, bladder wall involvement or a lack of adjacent inflammation also suggests malignant disease .The management of urachal abscess in adults usually includes broad-spectrum antibiotics and drainage followed by surgical excision. A 30% reinfection rate of residual urachal remnants has been reported, and there is also a theoretical risk of malignant degeneration . RadicalCystitis glandularis is characterized by urothelium invaginating into the underlying lamina propria (Von Brunn’s nests) and foci of cuboidal or columnar epithelium with glandular metaplasia. Chronic inflammation of the bladder caused by infection, urolithiasis, outlet obstruction, and indwelling catheter has been implicated in the pathogenesis . CystitiPatients often complain of urgency, frequency, dysuria, and sometimes hematuria. The trigone and bladder neck are commonly affected, which may lead to obstructive symptoms or hydronephrosis . As mentA bladder infection may result in both urachal remnant infection with subsequent abscess formation and cystitis glandularis in chronic settings. To the best of our knowledge, our patient is the first reported case to have both of these diseases concurrently.In conclusion, urachal abscess is a rare condition in adults. It is challenging to distinguish urachal abscess from a malignant tumor based on clinical presentation and imaging studies. As in our case, the coexistence of urachal abscess and tumor-like florid cystitis glandularis is possible, which increases the difficulty in making a correct diagnosis. This combination of diseases should be taken into consideration as one of the differential diagnoses. This case also emphasizes that the detection of bladder tumors on cystoscopy is not sufficient to make the diagnosis of urachal cancer with bladder involvement.


Intestinal atresia is the result of fetal bowel maldevelopment which leads to congenital bowel obstruction. It is a common cause of ileus of the newborn and can occur at any site of the gastrointestinal tract. Prenatal diagnosis relies on the demonstration of dilated loops of the fetal bowel and the presence of polyhydramnios at the end of the second or more frequently the third trimester of pregnancy. This condition requires surgical correction soon after birth, with timely diagnosis improving the prognosis. Here, we present the case of a fetus diagnosed with jejunal atresia at 33weeks of pregnancy. Neonatal intestinal atresia is a rare condition with a reported incidence of 1.3 to 3.5 per 10,000 live births. Although the pathophysiology is not completely understood, bowel atresia is most probably the result of a vascular accident in the corresponding branches of the mesenteric arteries. Neonates with bowel atresia need appropriate medical care soon after birth. If these neonates remain undiagnosed without treatment, their condition may deteriorate rapidly ,3.Surgical correction is performed as soon as the general condition of the neonate is stabilized and other malformations or chromosomal abnormalities are excluded. The postoperative mortality in cases without other anomalies is low. However, the outcome depends on the gestational age at birth, the exact position, and the size of the defect in the bowel. These neonates are also at risk for complications such as sepsis and short bowel syndrome .Here, we present a case of jejunal atresia which was diagnosed at 33 weeks of gestation. Fetal chromosomal and structural anomalies were excluded before birth and the neonatologists were informed appropriately.A 35-year-old pregnant woman (G2P1), at 33 weeks of gestation, presented to the emergency department of our hospital reporting fluid leakage from the vagina. Her pregnancy so far was low risk. She was not on any regular medications, did not have any known allergies, and was a nonsmoker. Vaginal speculum examination revealed amniotic fluid leakage from the cervical os, and a diagnosis of preterm rupture of membranes was made.A transabdominal ultrasound examination revealed a normally grown fetus. Polyhydramnios was noted, with the deepest vertical pool measuring 10 cm. In addition, we noted small bowel dilatation, with a maximum diameter of 25 mm  were normal.At 34+5 weeks of gestation, she delivered a female neonate 2,680 g) by cesarean section because of initiation of labor with a history of a previous cesarean section. After birth, the neonate was examined by an expert neonatologist who found a mild abdominal distention with palpable distended loops of bowel. Appropriate medical treatment and parenteral nutrition were started the same day. The newborn underwent X-ray imaging according to the instructions of the neonatal team, and the following surgical management confirmed the diagnosis of jejunal atresia  and 25.9% (95% CI = 4.0-58.0%), respectively [In the current case, the diagnosis was made because of polyhydramnios and the presence of a small number of dilated loops of the bowel. Both findings are typical of proximal bowel obstruction. A detailed ultrasound scan was performed to exclude other malformations, mainly abnormalities of the gastrointestinal system. The parents were tested for cystic fibrosis, and, although this condition is not associated with increased risk for chromosomal abnormalities, amniocentesis was performed and array-based CGH was normal.In this case similar to other prenatally diagnosed cases, the diagnosis was confirmed with plain radiographs of the abdomen soon after birth, showing dilated loops of the small bowel with air-fluid levels. Contrast studies can also be performed to localize the defect prior to the surgical treatment.In neonates with bowel obstruction, a nasogastric tube is placed for suction of the gastric secretions, and parenteral nutrition must be initiated. Immediate surgery is recommended in cases complicated by malrotation and volvulus. In other cases, the procedure can be postponed until metabolic or other coexisting abnormalities are treated appropriately .A common problem in babies with jejunal atresia is that the segment of the bowel proximal to the obstruction becomes dilated because of the intense peristalsis and may cause problems with anastomosis. Additionally, it may lead to functional obstruction after the repair due to ineffective peristalsis. To avoid this complication and minimize dysfunction at the site of the anastomosis, some surgeons taper or resect the most dilated proximal bowel ,6.Primary repair is preferred if multiple atresias are present, and care should be taken to preserve intestinal length, ideally more than 75 cm, to avoid short bowel syndrome which is a lethal condition -8.Prenatal diagnosis of small bowel atresia has an overall sensitivity of approximately 50%, whereas two-thirds of the cases of jejunal atresia can be diagnosed. This case illustrates the potential of the diagnosis of proximal obstruction because of the presence of marked bowel dilatation and polyhydramnios. Prenatal diagnosis is crucial because parents can be counseled appropriately, detailed examinations can be performed to exclude other malformations or syndromes, and delivery can be arranged in a center with appropriate facilities.


Mucosal melanomas of the head and neck region are uncommon pathologies that can affect the oral cavity, and are characterized by a high rate of mortality. Considering the lack of knowledge regarding risk and prognostic factors, current best clinical practice is represented by a large surgical excision with disease-free margins, eventually associated with a reconstructive flap. Indeed, given the frequent necessity of postoperative radiotherapy and fast healing process, a reconstruction of the surgical gap is advisable. Even if several flaps have been most commonly used, the submental island flap represents a valid alternative thanks to local advantages and similar oncologic outcomes compared to free flaps. The evidence of early distant metastasis and the high rates of treatment failure are the reasons for dismal outcomes. Primary mucosal melanoma of the oral cavity (POMM) is considered as a head and neck tumor in National comprehensive Cancer Network (NCCN) guidelines and as a very rare disease with an incidence of 0.2 per million/year . Melanocant ones .As far as clinical signs and symptoms are concerned, POMM is usually diagnosed relatively early compared with other head and neck MMs thanks to the great accessibility of the oral cavity for inspection ,14,15,16When diagnosed, MMs need proper radiologic work-up to better define the dimension and potential infiltration of adjacent structures . MRI repTo reach a precise diagnosis, an incisional biopsy is usually necessary for histological examination and is based on immune histochemical biomarkers such as S-100, HMB-45, melan A, and vimentin; moreover, histologic analysis can add useful information, such as lymph vessel invasion and blood vessel invasion, which are associated with worse prognoses. All the above-mentioned information leads to the staging of the pathology based on the TNM system: however, due to the aggressiveness of the disease, involvement of epithelium/submucosa without nodal metastases is directly classified as stage III; deep infiltration of bone, nerves, skin, or nodal involvement is considered stage IV. As a consequence, stage I and II is not possible in the event of an MM.Once a diagnosis is made, surgery is considered the primary treatment for POMM, since radical tumor resection with disease-free surgical margins has an essential role in defining the prognosis . ElectivIn addition to surgery, two options are generally considered: radiotherapy, which is usually applied since it has been shown to increase loco-regional control, although with no increase in long-term survival; chemotherapy is not standardized due to the conflicting data available . FurtherThis article aims to report a case of MM of the oral cavity and to review the available literature on this topic, focusing on surgical treatment and reconstruction.S100+, SOX 10+), infiltrating and focally submucosal , radiological and clinical follow-up is negative. The patient has undergone a prosthodontist evaluation, which performed a mobile prosthesis to be anchored to the lateral teeth of the surgical defect .Both cutaneous and mucosal melanomas originate from neural crest cells, which migrate as melanocyte stem cells in human skin, dermal papillae, and hair follicles  where thIn the present case, the treatment of choice was tailored surgery based on the preoperative histologic mapping. However, given the extended type of surgery performed and the need for postoperative radiotherapy, we decided to reconstruct the surgical gap in order to guarantee proper and fast healing. Such a decision is not always standardized and falls on the SIF, which is a pedicled cutaneous flap with reconstructive outcomes similar to the widely used forearm free flap ,34,35,36In broad terms, after ablative surgery of the hard and/or soft palate, without its reconstruction, the patient will have unintelligible hypernasal speech, difficulty chewing and swallowing, nasal regurgitation, poor masticatory function, and facial disfigurement due to loss of support for the midfacial soft tissues . SurgicaMMs are uncommon lesions of the head and neck region with high mortality. Considering the lack of identified predictors of survival, best clinical practice is represented by radical tumor excision with disease-free surgical margins, eventually associated with postoperative radiotherapy. In some cases, given the large surgical gap and the need for rapid healing, surgical reconstruction is needed, and several flaps can be used. The SIF can be considered to be one of the most usable, thanks to reconstructive outcomes and local advantages.All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of San Raffaele Hospital (150920).


We present the peculiar case of an 11-year-old male patient of African descent, HLA B27+, with a previous history of minor ocular trauma and unilateral anterior uveitis a year before which was admitted to our department with total opacification of the crystalline lens in the right eye and lens neovascularization. During surgery, a vascular, white fibrotic mass measuring 0.1–0.2 cm was discovered inside the lens bag and was excised. (2) Methods: Retrospective case review. (3) Results: The histopathological exam of the excised mass revealed an abundant infiltrate consisting of CD68+ foamy macrophages and lymphoplasmacytic elements. CD68 is a pan-macrophage marker associated with an active inflammatory mechanism soliciting macrophages, and tissue activated macrophages are correlated to increased stromal and serum levels of vascular endothelial growth factor, providing an explanation for lens angiogenesis. (4) Conclusions: The diagnosis is of a “masquerade tumor” resulted from an abnormal inflammatory process in connection with previous ocular trauma and possibly the patient’s HLA B27+ status. Tumors concerning the lens  have been clinically described, however, the human crystalline cells are atypical since, according to Albert DM. et al.’s  study ofThe adult human lens is an avascular tissue under normal circumstances. The formation of the lens originates in a subset of placodal progenitor cells situated between the anterior neural plate and surface ectoderm that, having expressed the Pax6 transcription factor, differentiate into lens cells as opposed to olfactory and adenohypophysis cells . This prRetrospective case review including a search of our hospital records for previous presentations of the patient.An 11-year-old male patient of Central African descent, HLA B27+ positive and currently under treatment with methotrexate, was admitted to our department with progressively decreased visual acuity and leukocoria in the right eye.Anamnesis revealed a minor traumatic episode (fingernail scratch) a year before the current presentation involving the right eye. A detailed search of hospital records produced a previous presentation 3 months after the initial traumatism, where the patient was diagnosed with right eye anterior uveitis with hypopyon and posterior subcapsular cataract. The patient underwent local mydriatic and local and systemic anti-inflammatory and antibiotic treatment with a complete remission of the uveitis, and the patient was subsequently referred to rheumatology and infectious diseases specialists and was lost to follow-up until the current presentation.A complete ophthalmological exam and slit-lamp biomicroscopy revealed a completely opaque lens in the right eye A with fiSurgery was planned and performed. During the surgery , the antThe patient presented for the latest follow-up examination a year after the surgery and 10 months after cessation of the immunosuppressive treatment. Uncorrected visual acuity (UCVA) was 20/20  with a refraction of −0.5 spheric diopters and −0.25 cylinder at 23°. No signs of inflammation or neovascularization were observed, and no tumoral reoccurrence was observed.The macroscopic aspect is of a white, consistent tumor about 0.1–0.2 cm in length.Histopathological analysis of the excised specimen was performed using standard Hematoxylin and eosin stain (HE) and Van Gieson staining along with immunohistochemistry.A fibro-vascular tissue fragment was identified with resection limits, containing a stroma rich in immature and loose collagen fibers, stained with Van Gieson . An abunOur case presents the diagnostic difficulties of finding an intralenticular vascularized mass inside an opacified lens and, furthermore of pinpointing its etiology. The presumptive diagnosis after clinical examination was complicated cataract due to previous uveitis episodes. In light of the intraoperative findings and the subsequent histopathological analysis of the specimen, the following additional differential diagnoses were considered:A retrolental membrane, a congenital development abnormality with origin in the persistence of fetal vasculature (PFV) , with a Neoplastic syndromes are known to masquerade as uveitis and characteristically present as reoccurring unilateral uveitis with poor response to treatment . These iThe immunohistochemistry exam of the specimen highlighted the presence of CD68+ foamy macrophages. Microsialine (CD68) is a D-class scavenger receptor that consists of a glycosylated type I membrane protein from the lysosome-associated membrane protein family ,17. SeveHLA B27 associations with Ankylosing Spondylitis (AS) and other related pathologies are lower in African populations compared to European populations with the prevalence of HLA alleles being exceedingly rare (<1%) , especiaAll patients with multiple associated ocular complications undergoing cataract surgery should benefit from a thorough preoperative examination , keeping in mind that inflammation and trauma should be approached carefully. Although our case was unique, the therapeutic approach was standard: Initially, we treated the inflammation and investigated its possible etiologies, and we performed cataract surgery once the lens opacification impaired the patient’s vision. The intralenticular mass was an intraoperative finding; therefore, it was handled with care and sent for further investigation. Prior to surgery, the patient underwent treatment for chronic idiopathic uveitis. During the postoperative period, the medical therapy for the uveitis was ceased and no recurrence was noted.The most likely complete diagnosis is a “Masquerade tumor”, an inflammatory mass related to the previous minor trauma and possibly linked to the patient’s HLA B27+ status. The intraoperatively intact anterior lens-capsule does not exclude a traumatic origin of the process as there is the possibility of tissular repair of the breach from the moment of the trauma to the present moment of the patient’s examination, which is a whole year later. Considering the histopathological findings, the mass corresponds to an exaggerated inflammatory response possibly linked to the patient’s HLA B27+ status with the recruitment of inflammatory elements, including high amounts of CD68+ foamy macrophages and the local production of VEGF. We hypothesize that this inflammatory cascade repeated itself in a vicious circle where inflammatory elements promoted vascular growth that, in turn, brought more inflammatory elements to the scene, resulting in an abnormal tissue regeneration resembling an opaque, cataracted lens.Human lens cells are not known to malignly proliferate.“Masquerade tumors” are tumors that can mimic the appearance and clinical presentation of a tumor originating in the lens. Lens neovascularization can be present.Our case presents such a “masquerade tumor” in the context of a history of initial minor lens trauma and subsequent uveitis associating HLA B27+ status.Lens trauma can jump-start immune-mediated inflammatory ocular processes with the generation of neovascularization and abnormal granulation tissue.


The thrombophlebitis of the portal vein and or its hepatic branches accompanied with a positive blood culture is known as pylephlebitis, with the most common cause as sepsis. Liver abscess formation resulting from pylephlebitis is a rare but potentially lethal complication. We report a case of a 30-year-old male who presented with acute pain in the abdomen along with nausea and vomiting for two days with a history of alcohol dependence. Upon investigation, it was revealed to be a case of acute pancreatitis with hepatic abscess with superior mesenteric and portal vein thrombosis. The patient was managed conservatively with antibiotics and anticoagulants successfully. This case highlights the importance of keeping pylephlebitis with a hepatic abscess as a crucial potential complication of acute pancreatitis as its management promptly prevents mortality. Waller described pylephlebitis as the source of liver abscess in the year 1846. Pylephlebitis ) is rare to encounter but a dangerous complication arising out of intra-abdominal or pelvic infection and is often associated with significant morbidity as well as mortality . Most coAmongst the reported cases of pylephlebitis with liver abscess, pancreatitis is a rare cause, with only 5% of the reported cases having pancreatitis as the etiology . InitialThe major challenge in treating pylephlebitis remains non-specific presentation of the condition. Patients usually present with pain in the abdomen, malaise, fever and nausea .The imaging modality of choice in pylephlebitis is computed tomography which shows filling defects in the portal vein. While suspecting the diagnosis of pylephlebitis empirical antibiotic coverage should be initiated including metronidazole, gentamicin, piperacillin, ceftizoxime, imipenem, and ampicillin , which cA 30-year-old male presented to the emergency department with a history of pain in the abdomen, fever, nausea and vomiting for two days. The patient had a history of alcohol abuse with the last intake four days back. His CAGE score was calculated to be 2. There was no history of hypertension, diabetes mellitus, coronary artery disease, deep vein thrombosis, cerebrovascular episode or any other chronic medical conditions in the past. On general examination, the patient was stable with a pulse of 82 beats per minute, blood pressure of 120/70 mm of hg in right arm supine position and SpO2 of 97% on room air. On systemic examination, the abdomen was soft with tenderness present in the epigastrium and the right hypochondrium and spleen was palpable. Heart sounds were normal, the chest was bilaterally clear and the patient was conscious and oriented. The patient was admitted for further evaluation and blood investigations were suggestive of acute pancreatitis with sepsis (Table Pylephlebitis is the septic inflammation of the portal vein and or its hepatic branches. Initially, it starts as an infection of small veins dragging the territory of infection in the abdomen. The spread of this infection to larger veins ultimately leads to pylephlebitis, which can further lead to thrombosis of mesenteric veins Figure . PresentIn a study carried out by Baril et al., it was found that patients with pylephlebitis had associated hypercoagulability . A totalIn our case, the absence of any imaging feature of malignancy with a clinical picture of fever with pain in the abdomen confirmed on lab investigations as sepsis with acute pancreatitis was suggestive of an intraabdominal source of sepsis with pylephlebitis leading to hepatic abscess as the diagnosis rather than malignancy. Pylephlebitis results as hematogenous dissemination of intraabdominal sepsis from locations drained by the portal system or splanchnic system. The most common etiology of pylephlebitis are diverticulitis, acute appendicitis, pancreatitis, inflammatory bowel disease and gastroenteritis. In our case, pylephlebitis and liver abscess were a complication of acute pancreatitis. The common cause of mortality is sepsis or peritonitis or bowel ischemia and infarction.Pyogenic liver abscess occurring as a complication of pylephlebitis due to intra-abdominal infection from acute pancreatitis is a rare but potentially fatal phenomenon. The treating physicians, along with respective radiologists, should therefore be alert and aware of such important but rare complications presenting with nonspecific complaints and no significant physical findings in order to prevent mortality and morbidity.


Endodontic perforations are common accidents that occasionally happen as a result of misuse or difficult anatomy of some teeth; it may lead to teeth loss unless a good management is provided. Bioceramic (silicate-based) cements like mineral trioxide aggregate have a big role in management of such accidents. This case report aimed to evaluate the ability of five mineral oxides cement “5MO” in sealing two root canal perforations (furcation and postdrill perforations) and inducing clinical and radiographic healing in the periodontal tissues with/without the use of collagen sponge matrix. A 58-year-old healthy female was referred to our dental office complaining of severe pain in the upper left premolars' region. Periapical radiographic examination revealed unsatisfactory root canal treatment of the teeth #24 and #25 with a furcation perforation and a postdrill perforation, respectively. Cone-beam computed tomography “CBCT” scans confirmed the findings of the periapical radiography and revealed the presence of radiolucent lesions surrounding the apex of both teeth #24 and #25. The treatment plan was a nonsurgical root canal retreatment by endodontic access through the full-ceramic crowns. After three years of follow-up, CBCT scans revealed a complete healing and bone formation on both premolars. This case report indicates the use of 5MO cement for endodontic perforations management. Endodontic perforation is defined as the communication of the root canal system with the periodontium, it is considered as an accident of the root canal treatment “RCT,” and it may lead to tooth loss unless a good management is provided , 2. Conv2,” beside others, was the material of choice for tissue regeneration and repair [Regeneration in endodontics started in the last century, with some attempts by researchers, to induce regeneration and repair of exposed cavities , 5. Calcd repair , until td repair . MTA is d repair , 8, and d repair . Furtherd repair –12. Lated repair , 14.2  [Five mineral oxides “5MO” is a new repair silicate-based cement, derived from Portland cement, developed to treat all endodontic complications and accidents (patent). As a capping material, it is effective as Ca(OH)   and MTA    and as a  , 18.Collagen sponge is a biodegradable material, indicated as a surgical tampon . In someThe aim of this case report was to evaluate the ability of 5MO in sealing two root canal perforations (furcation and postdrill perforations) and inducing clinical and radiographic healing in the periodontal tissues with/without the use of collagen sponge.A 58-year-old healthy female was referred to our dental office complaining of severe pain in the upper left premolars' region with no history of trauma. However, the patient related a previous root canal treatment of most of her upper teeth, including the premolars, as a demand for “Hollywood smile,” according to the indication of the anterior professionals in the past six months, even without a pathological indication.The clinical investigation revealed severe pain (positive response) to vertical percussion and digital palpation in the periapical region of tooth #24. However, the neighboring teeth #23 and #25 presented negative responses for the same exams. There was no fistula nor swelling related to the evaluated teeth. The crowns were well-adapted without any infiltration, and the periodontal exploration revealed gingival pocket varied between 1 and 3 mm with various exploring locations and grade I mobility. Teeth #23–25 were tested by the pulp vitality test (the cold test) as detailed in a previous study . Teeth #Periapical radiographic examination revealed unsatisfactory root canal treatment of the tooth #24 presenting: (I) missed lingual canal; (II) furcation perforation (obturated and condensed with gutta-percha); (III) susceptible broken instrument in the furcation area; and (IV) broken instrument in the apical third of buccal canal. The remaining part of the buccal canal was obturated with gutta-percha, and a fiber post was inserted in the coronal part; then, the tooth was crowned.In addition to an unsatisfactory root canal treatment of the tooth #25 is associated with a lateral lesion because of postdrill perforation. Cone-beam computed tomography “CBCT” scans confirmed the findings of the periapical radiography and revealed the presence of radiolucent lesions surrounding the apex of both teeth #24 and #25 .The final diagnosis was acute periapical periodontitis of tooth #24 and chronic periapical periodontitis of tooth #25. The treatment plan was a nonsurgical root canal retreatment by endodontic access through the full-ceramic crowns with final composite resin restoration for teeth #24 and #25. An informed consent form was signed by the patient agreeing to undergo the treatment plan and authorizing the publication of the case report.After rubber dam isolation and under microscopic magnification by SmartOptic dental microscope , the access cavity was performed through the full-ceramic crown using a straight fissure diamond bur until 5 mm of depth and before reaching the furcation area . Then, S2 powder  was mixed with sterile saline solution and applied over the perforation site. The tooth was restored by temporary filing of Coltosol  and sealed by a layer of glass ionomer cement  for 14 days.After bleeding control and perforation site evaluation (3 × 3 mm), the lingual canal was detected and scouted using K-file #10  . Periapi2 dressing was washed away using sterile saline solution irrigation; then, the Zumax micro tweezer  was used to catch and remove the obturation material (gutta-percha) from the perforation site ion site . Then, uPeriapical radiography confirmed the removal of all foreign bodies from furcation perforation . Then, aThen, the fiber post in the buccal canal was removed by penetrating and enlarging the fiber post from inside using LN bur size 0.6  and Pesso reamers files sizes 1–3 ; then, the remaining part of the fiber post was drilled away using ultrasonic tip ET20  till the pink color of the gutta-percha appeared.The obturating material was removed using D3 retreatment rotary file  at a 300 rpm rotation speed associated with NaOCl 5.25% irrigation . The api2 dressing was also applied over the perforation site till the next session.Again, the same steps were followed, until reaching the fiber post ; howeverThe perforation site, measuring around 3 × 3 mm, was sealed using 5MO silicate-based cement , withoutOne month later, the patient had no postoperative complications, and an intraoral evaluation was performed to investigate any swelling, edema, or fistula. The patient related comfort and satisfaction with the treatment.Three years later, another follow-up session was performed. The clinical intraoral examination revealed a well-adapted full-ceramic crown, without signs of caries or marginal infiltration. Radiographically, healed periapical and lateral lesions were noticed, and a bone neoformation was observed . Last, t2 dressing will disinfect, dry the exudate, and elevate the pH at the perforation site before sealing with bioactive material [The adequate treatment planning demands an accurate diagnosis ; for thimaterial . MTA hasmaterial . TherefoThe silicate-based cement sealing should be associated with root canal disinfection to guarantee the success of the root canal treatment in perforated  or immatIt was stated in the literature that the adequate disinfection of the root canal system and the sealing site, associated with the sealing ability of 5MO bioceramic cement results in satisfactory clinical and radiographic healing . This diOther factors play a major role in healing, and preventing the lesion progression is the matrix metalloproteinases deactivation and endotoxins (LPS and LTA) detoxification, and this may be achieved by the irrigation of the root canal system by sodium hypochlorite , 32, besIn this case report, the furcation perforation was managed using collagen sponge to serve as a matrix to prevent 5MO silicate-based cement extrusion . Convers5MO was the material of choice in this case report because of its sealing ability stated previously , 17, 18;It was concluded that 5MO is considered as effective silicate-based cement in furcation and postdrill perforations closure with and without a collagen matrix.


EWSR1‐CREB1 fusion occurring in the ascending artery. A 42‐year‐old man exhibited an abnormal nodule on chest computed tomography (CT) during checkup. It revealed an intraluminal mass in the ascending artery with significant metabolic uptake in positron emission tomography (PET)/CT. Therefore, right upper lobectomy with wedge resection of the PA trunk was performed. Histologically, the tumor was multinodular and surrounded by a dense lymphoplasmacytic cuff. Each nodule was composed of myxoid stroma and comprised ovoid or spindle cell fascicles with mild atypia. Fluorescent in situ hybridization (FISH) analysis confirmed EWSR1‐CREB1 fusion. A diagnosed as AFH was made. This report widens the spectrum of differential diagnoses of primary tumors occurring in the PA.Angiomatoid fibrosis histiocytoma (AFH) is a rare neoplastic disease. Only one report has demonstrated an intraluminal tumor of the pulmonary artery (PA) corresponding to AFH to date. We describe the case of AFH with  Angiomatoid fibrosis histiocytoma (AFH) is a rare neoplastic disease. Only one report has demonstrated an intraluminal tumor of the pulmonary artery trunk corresponding to AFH with ESWR1‐ATF1 fusion to date. This is the first reported case of AFH occurring in the ascending artery with EWSR1‐CREB1 fusion. EWSR1‐ATF1 fusion.EWSR1‐CREB1 fusion occurring in the ascending artery.AFH is a rare neoplastic disease that usually occurs in the deep dermis or subcutis of the extremities in children and young adults. It was first reported as an angiomatoid malignant fibrous histiocytoma by Enzinger in 1979.18FDG uptake  during checkup. Enhanced chest CT showed an intraluminal mass in the ascending artery Figure . This lee Figure . Clinicay Figure . No recuEWSR1, CRBE1, and ATF1 gene FISH analysis . Recently, EMC has been reported to carry the translocation of the NR4A3 gene,EWSR1‐CREB‐family fusion tumors, especially carrying EWSR1‐ATF1 or EWSR1‐CREB1.Histological features of AFH are distinctive, such as multinodular growth, and up to 80% of cases are surrounded by a dense lymphoplasmacytic infiltrate cuff.EWSR‐CREB1 fusion. PPMS and AFH sometimes overlap histological and immunohistochemical features. Both can be nodular or multinodular and are composed of spindle or epithelioid cells with bland nuclei and sometimes the same features of immunostaining. However, the following features may help to distinguish PPMS and AFH. First, PPMS has abundant myxoid stroma but AFH is usually focal, <10% of the tumor size. Second, the salient feature of AFH that is not seen in PPMS is peritumoral lymphoid cuff.Primary pulmonary myxoid sarcomas (PPMS) also carry Due to the rarity, no standard guidelines have been established for the treatment. According to previous reports, its prognostic factor is the presence of metastatic lesions. If curative surgical treatment can be performed, long‐term prognosis could be expected. Local recurrence occurs in up to 11%EWSR1‐CREB1 fusion occurring in a very rare location.In conclusion, we describe a tumor with The authors report no conflicts of interest in this work.


Inflammatory pseudotumor (IP) is a rare pathologic condition that easily can be confounded with malignancy. The clinical presentation depends on the site of occurrence and the radiological or laboratory findings are not specific. Diagnosis can be established only with histology. We report a case of a 64-year-old woman with IP in an uncommon localization, the parapharyngeal space extending to skull base. Although the diagnosis was not certain after histopathological examination, broad diagnostic workup helped to exclude malignancy or bacterial infection and led to diagnosis of an IP by exclusion. We observed a good clinical and radiological regression of symptoms after administration of oral immunosuppressants, confirming the immunological mechanism of the disease. Inflammatory pseudotumor (IP) counts as a rare, benign entity and constitutes a diagnostic challenge in clinical practice. The various terms given for this condition and the different sites of occurrence are reflecting the disputable etiology and its heterogenous histopathogenesis ,2. InfecA rare case of IP deriving from the parapharyngeal space and affecting the adjacent skull base is presented with its corresponding clinical, serological, audiological, and radiological findings. The clinical presentation as Eustachian tube dysfunction and the unusual histopathological constellation is highlighted. Two years follow-up after effective treatment with immunosuppressants is also presented.We report a case of a 64-year-old female patient who presented in our outpatient clinic with gradually evolving, left aural fullness and hearing impairment accompanied by ipsilateral tinnitus over four months. Additionally, she complained about pressure over the left temporal region. She had no significant medical and family history. Upon examination, we noted a left middle ear effusion and a diffuse, bulging, mucosal erythema of the nasopharynx on the left side Figure , panel aSince a malignant tumor was suspected, a transoral nasopharyngeal biopsy was performed primarily. The mucosal probe was taken by a bended double-cup ended forceps. The histological examination revealed typical benign features of respiratory epithelium with submucosal lymphoid follicles. This result was interpreted as “sampling error” and therefore a second, transnasal, endoscopically guided, incisional re-biopsy was conducted. The histological evaluation delivered the same result as above, despite multiple and adequate probes from deep layers. The futile biopsies led to an extended diagnostic workup to rule out the differential diagnoses, such as tuberculosis, sarcoidosis, and antineutrophil cytoplasmic antibodies (ANCA)-associated diseases such as M. Wegener were excluded with appropriate serological tests and pulmonological consultation and imaging Table . The patAlthough IP can manifest in various sites and is depicted with different terminology, the lung and the orbit are most frequently affected  Table 22. With oOur patient presented with symptoms of obstructive Eustachian tube dysfunction. Initially, we suspected a malignant mass of the parapharyngeal space giving rise to middle ear effusion and ipsilateral dull pain of the temporal region. Furthermore, the lesion led to a combined hearing loss, affecting the sensorineural function of the inner ear. The pathophysiologic mechanism of the sensorineural hearing loss is unclear, toxic labyrinthitis due to persistent middle ear effusion could be an explanation. In contrast to the case report of Maruya et al., the infiltration of the foramen ovale and lacerum did not cause any cranial nerve palsies . Fever wThe radiologic characteristics of IP are various and not specific, they can mimic the appearance of inflammatory or malignant processes . In the The establishment of the correct diagnosis is crucial to administer proper therapy and avoid unnecessary morbidity through surgical procedures. We primarily started a trial, long-term antibiotic course; after two months of close clinical and radiological monitoring during antibiotic regime, we noted neither a progression nor a regression of the lesion. Since the pathology did not respond to the antibiotic treatment, we ruled out an infectious osteomyelitis. This fact was suggesting an autoimmune inflammatory process. The probatory immunosuppressive therapy with corticosteroids and methotrexate showed a tremendous response and led to almost complete resolution of symptoms and radiological signs of the tumor in four months. Other authors reported primarily surgical or combined therapeutic options with good level of control ,8.Despite the fact that the diagnosis of IP should rely on clinical-histopathological criteria, a high level of alertness of presence of this entity in uncommon sites could turn out advantageous for the clinician. It is crucial to rule out malignant and infectious disease at first glance. Even without a pathognomonic histopathological and serological constellation, IP should be considered as a differential diagnosis and be treated with antiinflammatory and immunosuppressive therapy.


Angioleiomyomas are relatively rare benign smooth muscle soft tissue tumors which often occur on the extremities. They are rarely diagnosed preoperatively as clinical and radiological examination is often nonspecific and inconclusive. An 80-year-old male presented with a 10-year history of a progressively growing and symptomatic lesion on his right dorsal foot within the first intermetatarsal space. The preoperative diagnosis was suspected to be a neurogenic schwannoma arising from the deep peroneal nerve. Simple excision and histopathology confirmed a diagnosis of angioleiomyoma with nil recurrence or complications. The size of the angioleiomyoma was the second largest reported in literature to date. Angioleiomyomas are often misdiagnosed, and a degree of suspicion should be maintained in patients presenting with lower extremity growing soft tissue tumors. Angioleiomyomas, or vascular leiomyomas, are benign smooth muscle soft tissue tumors which arise from the tunica media of subcutaneous blood vessels -3. They Due to their rare occurrence, lack of awareness from clinicians, and paucity of published literature, angioleiomyomas are rarely diagnosed preoperatively. This highlights the importance of better characterizing the diagnosis and treatment of angioleiomyomas in the clinical setting to expand the awareness of this pathology as a differential diagnosis for lower extremity soft tissue tumors. An accurate diagnosis prevents delay in treatment, improves patient outcomes, and excludes malignant involvement.The current literature of angioleiomyomas is predominantly limited to single case studies, with variance in reported clinical presentations and imaging findings. To enhance the general awareness of angioleiomyomas in clinical practice, further studies illustrating its unique presentation will improve our understanding of its pathogenesis, natural history, and treatment outcomes. This article details a case report of an exceptionally large, long-standing, and symptomatic angioleiomyoma of 4.6 cm diameter on the dorsal foot. A pedal angioleiomyoma of this size is second only to the reported case in 1994 by Habershaw et al. which measured 6 cm in diameter .An 80-year-old Caucasian male presented with a 10-year history of a progressively growing and symptomatic lesion on the dorsum of his right foot within the first intermetatarsal space  and fine needle aspiration (FNA) biopsy.MRI identified a nonspecific large dumbbell-shaped solid soft tissue tumor measuring 4 × 4 × 4 cm within the first intermetatarsal space Figure . The masFNA biopsy with histopathological testing was performed which confirmed a nonspecific benign spindle cell lesion with fibromyxoid stroma. Both MRI and FNA biopsy testing were inconclusive, suggestive of differential diagnoses of giant cell tumor, desmoid tumor, tophi, or a neuroma. Clinical and investigative testing suggested a provisional preoperative diagnosis of a deep peroneal nerve schwannoma.The large mass was excised under general anesthesia with a local anesthetic field block  without complication. The procedure was approached with a dorsal ellipse positioned at the lateral border of the mass Figure . The welThe large mass (46 × 36 × 30 mm) was sent for histopathology, where the sections demonstrated a circumscribed bland spindle cell proliferation with low cellularity (Figure The etiology of angioleiomyomas remains indefinite, with literature theorizing the involvement of vascular malformations, trauma, venous stasis, infection, and hormonal imbalances in females ,8,9. An Currently, the literature regarding MRI features of angioleiomyomas continue to be scarce, and thus distinguishing between various soft tissue tumors can be challenging . SimilarLiterature consensus reports histopathological testing to be the gold standard in definitively diagnosing angioleiomyomas ,14,15. DThis article highlights the diagnostic challenges of angioleiomyomas due to their relative rarity, paucity of radiological literature and nonspecific nature of clinical and diagnostic examinations. Despite preoperative clinical examination, radiological tests, and biopsies, the case study diagnosis of an angioleiomyoma was unsuspected. Angioleiomyomas should be considered as a potential differential when examining slow-growing soft tissue tumors of the lower extremity. A high index of suspicion is warranted to exclude malignant or aggressive tumors. Further research is justified to aid clinicians in obtaining an accurate preoperative diagnosis to ensure a suitable treatment plan.Angioleiomyomas are relatively rare benign soft tissue tumors which can occur in the extremities of middle-aged people. Preoperative diagnosis remains a diagnostic challenge, with clinical and radiological examination being ambiguous and nonspecific. Histopathology is the gold standard in obtaining a definitive diagnosis, and simple excision is highly curative. This article reports a case of the second largest angioleiomyoma of the dorsum foot where simple excision was successful with nil recurrence or complications. Angioleiomyomas are often misdiagnosed, and a degree of suspicion should be maintained in patients presenting with lower extremity growing soft tissue tumors.


Cases with intussusception caused by either intestinal hemangiomas or appendiceal mucinous neoplasms are extremely rare.In this study, we reported a 47-year-old male presented with paroxysmal abdominal pain and postprandial bloating for 3 days. CT results indicated a high possibility of secondary intussusception in ascending colon. Histopathology indicated a mixed type of cavernous and capillary hemangioma, combined with low-grade appendiceal mucinous neoplasms (LAMNs) and intestinal obstruction. The patient underwent laparotomy and right hemicolectomy. Finally, the patient was followed up for 4 months with no disease progression.Rare studies reported the intestine hemangiomas coincided with appendix low-grade mucinous tumor. Its manifestations are not specific, which is a challenge in the preoperative diagnosis. For cases with intussusception that was not observed in time, it may lead to intestinal necrosis and diffuse peritonitis. Additionally, the ruptured mucinous tumor in the appendix may lead to pathogenesis of pseudomyxoma peritonei. Therefore, accurate diagnosis and appropriate surgery-based treatment contribute to the improvement of prognosis and severe outcomes among these patients. Gastrointestinal (GI) hemangiomas are uncommon benign vascular tumors that may occur in any part of the GI tract. According to the size of the involved vessels, hemangiomas are histologically classified into cavernous, capillary, or mixed-type tumors. Cavernous type is the most common, while multiple hemangiomas are very rare. Mucinous neoplasm of the appendix is featured by mucinous epithelial proliferation combined with extracellular mucin and pushing tumor margins. According to the 2019 WHO classification of tumors of the digestive system , appendiA 47-year-old male patient was admitted to the Emergency Department in our hospital due to paroxysmal abdominal pain and postprandial bloating for 3 days. The pain was centered in the position around the umbilicus. The flatus and defecation were normal. He showed no fever, hematemesis, hematochezia, diarrhea, melena, or weight loss upon admission. CT performed in a local hospital showed intussusception, intestinal effusion, and pneumatosis. There was no remission in the symptoms after conservative treatment. Besides, the abdominal symptoms showed gradual deterioration.9/L, neutrophils, 73.1%; hemoglobin, 145.0 g/L; hematocrit, 46.80%; platelet, 356 × 109/L  was seen in the pelvic cavity. The distal ileum, appendix, cecum, and greater omentum were found to be intussuscepted into the ascending colon. The length of the intussuscepted ileum was about 15 cm. The root of appendix and cecal wall was hard, and there was purulent substance on the surface. The greater omentum showed adhesion to the cecal wall. There was slight enlargement in the lymph nodes of radix of mesentery. In addition, adhesion was seen in the lateral region of peritoneum.For the histopathological characteristics, the intestinal wall of ileum, cecum, and ascending colon were thickened in a diffuse manner and the thickest part was about 0.8 cm. The texture was hard and tough, with the serosal surface in a grayish color. Dilated lumen and blood clots were seen in the incisal surface. The mucosal surface of the ileum was erosive, and the colonic was smooth in a grayish-red color. The appendix showed a length of about 5 cm and a diameter of 1.5 cm. The wall of the appendix was hard. Mucoid substance was observed in the appendix cavity near the root. Microscopically, there were blood-filled lumens or cavities in the ileum, cecum, colon submucosa and serosa, which were lined with a single layer of endothelial cells, and the cells were not heteromorphic Fig. A–E. The CT results indicated a high possibility of secondary intussusception. Histopathology confirmed mixed type of cavernous and capillary hemangioma, combined with LAMNs and intestinal obstruction. For the treatment, the patient underwent laparotomy and right hemicolectomy. The postoperative recovery was good without any complications. The patient was followed up for 4 months, and no discomforts were reported by the patient until now.GI hemangiomas refer to a rare condition, with a prevalence of merely 0.05%  of all iThe disease was generally divided into three categories: (i) the capillary hemangioma, described as a small cluster of submucosal capillaries expanded intra-luminally, may develop into a stalk-like mass; (ii) a category represented by mixed capillary and cavernous hemangiomas; and (iii) the cavernous hemangioma, serving as the most common type. The histopathology of our case was mixed capillary and cavernous hemangiomas which involved small intestine, colorectal, and appendix.The majority of cases with GI hemangiomas presented occult or acute gastrointestinal bleeding signs, followed by bowel obstruction, abdominal pain, perforation, or intussusception. In partial patients, there might be small polypoid lesions incidentally after endoscopy screening. In this case, the patient showed no bleeding or concealed hemorrhage. On this basis, the lesion was not detected in a long time.Mucinous neoplasm of the appendix was an appendiceal neoplasm characterized by mucinous epithelial proliferation with extracellular mucin and pushing tumor margins. To date, little is known about the etiology of appendiceal mucinous neoplasms. In the 2019 WHO Classification of Tumors of the Digestive System , 6, the HAMNs show histological features similar to LAMNs, including subepithelial fibrosis, a broad pushing margin, broad-front pushing invasion, rupture, and peritoneal dissemination. The neoplastic epithelium has unequivocal high-grade features including enlarged, hyperchromatic, and pleomorphic nuclei, numerous atypical mitotic figures, single-cell necrosis, and sloughed necrotic epithelial cells in the lumen of the appendix. In cases of an infiltrative pattern, there would be stromal desmoplasia and mucin pools with atypical cells, as well as content of extracellular mucin > 50% in the lesions. Such condition was defined as mucinous adenocarcinoma.The clinical symptoms of patients with peritoneal dissemination included progressive abdominal distention, new onset of an umbilical hernia, or a palpable mass after abdominal or pelvic examinations. There might be a soft tissue mass in the appendix that was manifested as hydrops after CT or ultrasonography. To our best knowledge, curvilinear calcification of the wall was the specific lesions, but they were presented in only half of the cases. Our case showed features of hemangiomas of small intestine, cecum and appendix combined with LAMNs.The prognosis of LAMN is highly depending on the tumor stage . Those wIntussusception is primarily a disease in childhood and is relatively rare in adults. Unlike childhood intussusception, adult intussusception shows identifiable lesions such as malignant or benign neoplasms. However, intussusception caused by hemangioma is a very rare entity. In our literature search, we searched the articles on intestinal hemangioma and intussusceptions published between January 2000 and February 2021 using the following key words: “gastrointestinal hemangioma” and “intussusception”. Finally, 10 articles –15 in EnClinically, GI hemangiomas are symptomatic in 90% of cases, unlike other benign tumors of the GI tract that were symptom-free. The most frequent sign was chronic GI bleeding, which caused anemia of an unknown origin and massive bleeding under a rare condition. Occasionally, these tumors may cause intestinal obstructions, intussusception, intramural hematoma, perforation, and platelet sequestration. In a previous study, Fu et al.  reportedHistologically, our case was diagnosed with mixed capillary and cavernous hemangiomas. Indeed, rare adult cases showed intussusception caused by multiple hemangiomas. To our best knowledge, rare cases showed hemangiomas of small intestine, accompanied by large intestine and appendix.Appendiceal intussusception is a rare condition presenting as acute appendicitis. It is still a challenge in the clinical diagnosis. In a previous study by Collins et al., the authors conducted a 40-year prospective study involving 71,000 cases underwent appendectomy, which indicated an incidence of 0.01% for the appendiceal intussusception . As prevIn our case, there were a large amount of mucus in the lumen of appendix and abundant dilated capillaries in the mucinous interstitium and the wall of the appendix. Besides, neoplastic hyperplasia of capillaries was seen on the serous surface. The patient was finally diagnosed with mixed hemangioma of the appendix combined with low-grade mucinous tumor. Based on the literature search using the term “appendiceal mucinous tumor” and “intussusception” from the articles in the PubMed database between January 2000 and February 2021, 29 articles –47 were Appendiceal mucinous tumor and intestinal hemangioma were considered to lead to intussusception based on literature review. Intussusception caused by appendiceal mucinous tumor is more common than that caused by adult hemangioma. In our case, a large amount of mucus was observed in the appendix cavity, and there was more mucus in the residual mucosa interstitium of the appendix. Meanwhile, capillary proliferation was seen in the mucous background. A large number of new neovascularization was found in the submucosa, muscular layer and serosa surface of ileum, as well as cecum appendix and colon. We speculated that appendiceal mucinous tumor may lead to stiffness of intestinal wall, and disorder of peristalsis rhythm. On this basis, it may affect the blood circulation of local tissues, and then the congestion and telangiectasia would result in aggravation in the formation of new capillaries. In cases of hemangioma of colon and ileocecal region, hemangioma would greatly increase the load of intestinal peristalsis, which is likely to induce dysfunction of intestinal movement. Therefore, it may induce the accumulation of appendix mucus, which led to a possibility of occurrence and/or progression of low-grade mucinous tumors of the appendix. It has been well acknowledged that both appendiceal mucinous tumor and intestinal diffuse hemangioma are chronic processes. No matter which showed onset first or collision, the disorder of intestinal blood supplies and mucinous tumor all can lead to the disorder of intestinal movement rhythm. Mucinous tumor and hemangioma contributed to their mutual progression, which eventually resulted in intussusception. Pathological analysis indicated no necrosis in the colon wall. Besides, only erosion of the epithelium and the hemorrhage of the lamina propria were seen on the mucosal surface, which further confirmed that the occurrence of intussusception in our case was a chronic process. In the 4-month follow-up, the symptoms of gastrointestinal disorders showed attenuation with no significant postoperative complication.Multiple hemangiomas of small and large intestine are rare in adults. Rare studies reported the intestine hemangiomas coincided with appendix low-grade mucinous tumor. In clinical settings, the manifestations were not specific, which was a challenge in the preoperative diagnosis. For cases with intussusception that was not observed in time, it may lead to intestinal necrosis and diffuse peritonitis. In this study, we described a rare case with intussusception caused by either intestinal hemangiomas or appendiceal mucinous neoplasms. We described a possibility of intussusception. In addition, contrast-enhanced CT scan clearly showed hemangioma and mucous lesions. In this study, the patient underwent plain CT scan, which confirmed the presence of intussusception. On this basis, exploratory laparotomy and surgery were conducted. In the presence of confirmed diagnosis, the surgery should be given.


Osteoid osteomas are benign primary bone tumors that typically arise in posterior vertebrae of the spine. For patients with severe pain or those poorly controlled with non-steroidal anti-inflammatory drugs, surgical management is the mainstay of treatment. The recommended surgical treatment option is complete open excision, although minimally invasive CT-guided percutaneous excision and CT-guided radiofrequency ablation have been reported. Open resection can result in prolonged hospital stays, activity restrictions, and possible spinal destabilization. We sought to utilize a lateral minimally invasive approach. We highlight the importance of aggressive surgical resection and the utility of using fluoroscopy and O-arm guidance to optimize the extent of resection. We report a pediatric case of a 12-year-old male who presented with an S3 osteoid osteoma. The patient underwent a minimally invasive resection with complete resection and confirmation of the histopathologic diagnosis. Postoperative imaging showed complete resection of the tumor. The patient went home five hours after surgery with return to daily activities; his symptoms resolved completely. However, the patient had symptomatic recurrence and underwent a second more aggressive minimally invasive resection using O-arm guidance. At the current three-month follow-up, the patient is symptom- and tumor-free. The minimally invasive resection of a pediatric sacral osteoid osteoma is a valid alternative to standard open resection and is associated with a decreased blood loss, decreased length of stay in the hospital, and decreased time to full functional recovery. The pitfalls are learning curve and risk of incomplete resection that can be counterbalanced with an intraoperative O-arm to guide resection and confirm complete excision. Osteoid osteomas are benign osteoblastic tumors characterized by the formation of mature bone by the tumor cells . They arWe report the case of a 12-year-old boy presenting with an S3 osteoid osteoma. His tumor was located medially in the posterior aspect of the S3 vertebral body, adjacent to the spinal canal. Neither radiofrequency ablation nor open en bloc was considered safe options. A minimally invasive resection was performed and allowed for complete resection, and confirmation of the histopathological diagnosis. Although the postoperative scan confirmed complete resection of the lesion, the patient experienced recurrence, and underwent a subsequent resection using O-arm guidance. The patient is now asymptomatic and disease-free. We highlight the importance of aggressive surgical resection when periosteal reaction is present and the importance of an O-arm to achieve complete resection when carrying out MIS resection.A 12-year-old boy, previously healthy, presented with a two-month history of progressive, severe lower back pain worse at night. His physical examination revealed pain on palpation of the sacral region. A plain radiograph of the spine showed a small S3 osteolytic lesion with reactive sclerosis. A CT scan showed a sclerotic lesion medially in the posterior portion of the S3 vertebral body with compression of sacral nerve roots Figures , 1B. MagIn prone position, fluoroscopy was used to identify the midline and the S3 level Figures , 2B. A lThe postoperative course was uneventful and a complete symptom resolution was achieved. The patient was discharged home five hours after surgery, and quickly returned to his daily activities. Pathological analysis confirmed the initial diagnosis of osteoid osteoma. A complete resection was confirmed on the postoperative CT. However, at six-month follow-up, the patient had recurrence of low back pain. Repeat imaging with bone scan Figure , CT Fig, 3C, andOsteoid osteoma of the sacrum is a very rare occurrence. Traditionally, open resection by a posterior approach is used for the surgical treatment of spinal osteoid osteoma. However, open resection of spinal osteoid osteoma can be challenging, and typically requires significant healthy tissue resection and wide surgical resections of the bony structure to ensure removal of the nidus. This can increase morbidity for the patient in the forms of significant blood loss, postoperative pain, increased hospital stays, and perhaps even necessitating fusion to restore spinal stability . Our casAs of our case, the MIS technique was especially helpful in locating and removing the nidus safely. This technique allowed for the minimal dissection of the surrounding tissue; neuromonitoring was used to ensure the preservation of all nearby nervous structures. Intraoperative fluoroscopy combined with the expandable tube led to the great exposure of the lesion and greater confidence in complete resection. On the other hand, MIS offered a limited visual field, which increased the risk of incomplete resection of the tumor. This led to an additional procedure.Fluoroscopy has revolutionized spinal surgery instrumentations and increased accuracy. The C-arm was first used to render 2D images, and then O-arm fluoroscopy was introduced with 3D reconstruction of the surgical field. The latter has reduced operative time and minimized the surgeon’s exposure to radiation ,6.MIS techniques for tumors of the spine have sought to decrease paraspinal tissue damage while still treating the underlying pathology. Additionally, Regev et al. showed similar positive results with minimally invasive open resection of 14 benign osseous tumors, including five osteoid osteomas . Image-gWhile there are limitations to MIS, the risks and safety concerns of open sacral resection and RFA as outlined earlier made minimally open excision the only suitable technique to avoid major complications and functional impairment, as well as to offer a quick recovery. MIS with an O-arm should be considered as a valuable alternative for the treatment of osteoid osteoma and other benign osseous tumors of the spine.Osteoid osteoma of the sacrum adjacent to the spinal canal presents a technical challenge for resection that precludes the use of RFA or traditional en bloc resection due to safety concerns. Our case shows the utility of MIS techniques in a successful complete resection of a sacral osteoid osteoma while simultaneously preserving bladder/bowel function and lumbopelvic stability, and also decreasing blood loss and hospital stay compared to traditional methods. Minimally invasive techniques with an O-arm should be considered as a valuable alternative for the treatment of osteoid osteomas and other benign osseous tumors of the spine.


Epiblepharon is a condition characterized by the presence of a congenital horizontal fold of skin near the upper or lower eyelid margin and rarely requires intervention. In this communication, we present the case of a five-month-old child who had enlarged eyes, tearing, and intense photophobia; and was referred to as a case of congenital glaucoma. Congenital or infantile glaucoma can, indeed present with enlarged eyes, watering, and photophobia. However, in the absence of optic disc cupping and elevated intraocular pressures, a diagnosis of anterior megalophthalmos should be considered, especially in the presence of a very deep anterior chamber. Subsequent evaluation in our case established the diagnosis of anterior megalophthalmos along with concomitant bilateral epiblepharon. The child underwent surgery to correct the epiblepharon, following which, the tearing and photophobia resolved. The clinical characteristics of anterior megalophthalmos and the causality between an enlarged globe and epiblepharon are discussed in this article. The triad of enlarged eyes, watering, and photophobia in an infant is most often attributed to congenital glaucoma.  However,A five-month-old Indian boy presented to us with large eyes, photophobia, and tearing noticed since one month of age. The child’s birth and developmental histories were unremarkable. The child was suspected to have congenital glaucoma and was referred for glaucoma surgery. Although the child was photophobic; he was able to maintain steady, central fixation in both eyes. The lower eyelid lashes were found to be turned inwards with some excess skin appearing as a fold on both lower lids. The in-turned lashes were rubbing on the inferior part of the cornea in both eyes. No other systemic abnormalities were found in the child and a pedigree analysis showed a non-consanguineous marriage; the child had no other siblings. Family history was otherwise, non-contributory. On examination under anesthesia, the corneas were clear, but on fluorescein staining, superficial punctate erosions were observed on the inferior half of both corneas. In both eyes, a skin fold overlapping the lower lid margin was seen, confirming the diagnosis of epiblepharon Figure . The antThe child was treated with hourly instillation of carboxymethylcellulose sodium lubricant eye drops 0.5% w/v which improved the photophobia. Observation was advised at this time, in order to wait for spontaneous resolution of epiblepharon. However, this did not happen and at 18 months of age, the child underwent an eyelid surgery that involved resection of a strip of skin and orbicularis muscle along with anchoring of the lower lid retractors to the lower edge of the tarsus. This corrected the epiblepharon which in turn resulted in resolution of watering and photophobia Figures  and 2D.Anterior megalophthalmos is an uncommon, complex, congenital disorder with stationary enlargement of the anterior segment of the eye . The typThe closest differential diagnosis of this condition is infantile glaucoma which could be ruled out clinically based on the findings described. It must be noted that glaucoma has been reported in anterior megalophthalmos - but those are largely secondary to lens subluxation or ciliary body abnormalities. Other reported ocular associations include iris hypoplasia, zonular weakness, angle abnormalities, Descemet’s detachment, posterior dislocation of lens, vitreous degeneration, and retinal detachment ,9. CatarLid abnormalities like epiblepharon have not been reported in association with megalophthalmos. Epiblepharon is an eyelid anomaly commonly found in East-Asian children; a skin fold overlaps the lid margin resulting in cilia against the cornea, corneal irritation, and possibly astigmatism as well.  The enlaIn summary, anterior megalophthalmos must be considered as a differential diagnosis while assessing any infant who presents with enlarged eyes. Given the structural changes of the anterior segment observed in anterior megalophthalmos, ophthalmologists must be aware that resultant lower lid abnormalities could also be seen. Lid abnormalities due to enlarged globes should be carefully assessed and addressed in order to alleviate the symptoms of tearing and photophobia.