A 40-year-old woman was admitted to the hospital because she complained of lower abdominal pain. An ultrasound performed by the gynecologist Figure  showed aThe cyst was surgically resected, and histopathology revealed a paratubal borderline serous tumor  originating from the vesicular appendage of the right epoöphoron.Tubal and paratubal serous borderline tumors (SBT) are of Müllerian origin. Though they are not limited to a specific part of the fallopian tube, ovarian SBT are common, whereas their fallopian tubal and paratubal counterparts are rare. To our knowledge, only two cases of paratubal SBT have been described in the literature. We add a third case and describe its appearances on MR for the first time. These characteristics are similar to that of their ovarian counterparts. In our case, some tiny enhancing micropapillary protrusions could be distinguished. This is compatible with the peroperative finding of papillary excrescences in the wall of the cyst, as described by Seamon et al. . HistopaMicroscopically, all Müllerian SBT are identical , althoug


Uterine rupture due to a morbidly adherent placenta is a rare obstetrical cause of acute abdominal pain in the pregnant patient. We present a case to add to the small body of published literature describing this diagnosis.+3 weeks' gestation with abdominal pain and presyncope. Ultrasound showed a large volume of complex intraabdominal free fluid and a heterogenous placenta with irregular lacunae and increased vascularity extending to the posterior bladder wall. Exploratory laparotomy identified a uterine defect and a hysterectomy was performed due to significant bleeding. Pathology confirmed a diagnosis of placenta percreta. A 32-year-old G5T2P1A1L2 with multiple prior cesarean sections presented at 21 Early recognition and management of uterine rupture due to a morbidly adherent placenta are essential to prevent catastrophic hemorrhage. Pregnant patients commonly present with abdominal pain. Diagnosis can be challenging as the differential for both obstetric and nonobstetric causes can be extensive, and the physical examination can be altered when a gravid uterus is present. Two rare obstetric causes of acute abdominal pain include uterine rupture and intra-abdominal hemorrhage due to a morbidly adherent placenta. As the rate of cesarean sections increases, these severe complications may become more frequent and should be included in the differential diagnosis for abdominal pain in pregnancy. This case report aims to contribute to the small body of published literature describing these rare complications of pregnancy.A 32-year-old G5T2P1A1L2, at 21 weeks and 3 days of gestation, was brought to Labour and Delivery Triage at a tertiary care centre by ambulance. The patient had noted abdominal pain that she felt may be bowel related. After attempting to have a bowel movement, she experienced a presyncopal episode that prompted her to call for an ambulance.Upon arrival, the maternal heart rate was 71, respiratory rate was 18, oxygen saturation was 98% on room air, and blood pressure was 80/40 mmHg. The fetal heart rate was auscultated to be normal at 145 beats per minute. The patient arrived with an intravenous line in situ and was receiving a fluid bolus. She appeared to be in pain but was awake and oriented. On history, the patient did not endorse any change to her bowel habits, fever, nausea, or vomiting. She did not have any vaginal bleeding, contraction-like pain, rupture of membranes, or abnormal vaginal discharge. Her past obstetrical history was significant for a therapeutic abortion, a classical cesarean section for a stillborn infant after preterm premature rupture of membranes and cord prolapse, an elective cesarean section at term, and a subsequent elective cesarean section at term with an incidental finding of uterine dehiscence at the time of surgery. She was otherwise healthy.In her current pregnancy, she had been referred to the Maternal Fetal Medicine service for investigation of a suspected abnormally adherent placenta, possibly placenta increta or placenta percreta. This was identified at the time of her anatomy ultrasound, when a complete anterior placenta previa was noted, along with concerning findings including loss of the placental-myometrial interface, multiple large and irregularly shaped lacunae, significant vascularity within the myometrium abutting the bladder wall, and a marginal placental abruption measuring 37.5 x 57.6 x 9.5mm. The fetus was appropriately grown and anatomic survey was normal.Repeat vital signs continued to be stable. Blood pressure improved to 92/51 with an ongoing fluid bolus. The abdomen was soft and tender throughout, with most pain in the right lower quadrant; however, the uterus itself was nontender. In addition, there was rebound tenderness and voluntary guarding.9 per liter, and platelets of 154 x 10∧9/L. AST was 13 U/L ALT 7 U/L and Kleihauer-Betke was negative. The patient was known to be anemic, with a hemoglobin of 92 g/L approximately one month prior. An abdominal ultrasound done emergently identified a normal liver, biliary tree, common bile duct, spleen, aorta, kidneys, and gallbladder. There was no evidence of hydronephrosis or renal stone. The appendix was not visualized. There was no evidence of ovarian torsion. There was free fluid throughout the abdomen with low-level echoes concerning for blood. In the left flank there was a large heterogeneous mass-like echogenic area without internal vascularity, measuring 14 x 10 cm, concerning an intra-abdominal hematoma. An obstetrical ultrasound identified a single live intrauterine gestation. The placenta was again noted to be heterogeneous with multiple irregularly shaped lacunae, and the border between the myometrium and placenta was difficult to identify along the anterior wall, as shown in Laboratory investigations initially revealed a hemoglobin of 87 g/L, leukocytes of 12.0 x 10∧9/L. Coagulation studies showed a normal INR and PTT of 0.9 and 30 s, respectively, but fibrinogen was relatively low for the pregnancy state at 2.7 g/L. There was no further deterioration of clotting factors throughout the intraoperative course. The patient's vital signs remained stable, with continued slightly low blood pressure. Despite the stable hemoglobin, given the ultrasound findings suggestive of intra-abdominal hemorrhage and hematoma, along with the clinical finding of an acute surgical abdomen, the patient was taken to the operating room for an exploratory laparotomy via Pfannenstiel incision. The main concern was for bleeding due to either uterine rupture and/or bleeding from placenta percreta. The patient was counseled extensively regarding this possibility and the current previable gestation. Consent was obtained to proceed with hysterectomy if these concerns were confirmed intraoperatively.Blood work was repeated several hours after the initial measurements, once the suspicion of intra-abdominal hemorrhage was reported on ultrasound. Repeat hemoglobin was stable at 87 g/L, leukocytes rose to 15.6 g/L and platelets were relatively stable at 144 x 10Upon entry into the peritoneal cavity there was a significant amount of old and new blood, which was immediately evacuated. A small defect on the anterior surface of the uteruswas actively bleeding; it was felt to be the source of the hemoperitoneum. This focal area of the uterine wall was very thin, revealing placenta extending through the level of the serosa. Internal iliac ligation and hysterectomy were performed with the fetus in situ, due to the active bleeding. The estimated blood loss was 2.5 liters, most of which was noted in the abdomen at the beginning of the surgical procedure from prior blood loss. The patient received 3 units of packed red blood cells, 2 units of fresh frozen plasma, and 10 units of cryoprecipitate and 1L of Ringer's Lactate intraoperatively.Fresh surgical specimens were forwarded to pathology, including bilateral fallopian tubes, the cervix, and the uterus containing the fetus and placenta. The uterine cornua and fallopian tubes, as well as peritoneal reflections, were anatomically normally in position. The serosal surface was intact, except for a 1.0 x 0.6 cm variegated, slightly ragged area, at the midline of the anterior wall, approximately equidistant from the fundus and cervix .A subchorionic blood clot, continuous with a retroplacental hemorrhage, was noted. A brick-like color indicated that bleeding was remote. Cross-sections of the uterus demonstrated placental infiltration directly under the serosa, with a variegated appearance of the clotted blood admixed with infarcted tissue. Representative sections from the deepest point of placental invasion demonstrated retroplacental hematoma directly abutting serosal uterine surface with adjacent nonviable villi. Overall gross and microscopic findings confirmed the clinical diagnosis of placenta percreta with retroplacental hematoma.Placenta accreta is defined as an abnormally adherent placenta that invades and is inseparable, from the uterine wall. The term placenta increta is used when the chorionic villi invade only the myometrium, whereas placenta percreta describes invasion through the myometrium and serosa and occasionally into adjacent organs . The incAccurate prenatal diagnosis of placental accreta is vital in order to facilitate appropriate antenatal management, delivery planning, and appropriate patient counseling. Ultrasound is the standard modality for assessing the placenta, but MRI has also proven useful . The norUterine rupture or intra-abdominal hemorrhage prior to delivery is a rare complication of placenta accreta. This is the first Canadian case report describing uterine rupture associated with a morbidly adherent placenta in the second trimester. This is also the first reported case of a hysterectomy being performed with fetus in situ for uterine rupture. Unfortunately, our patient presented at a gestational age remote from viability. Prior to surgery, a long discussion with the patient revealed that she did not wish conservative treatment, but rather she preferred definitive management in the case of intra-abdominal hemorrhage due to either uterine rupture or placenta percreta. Due to active hemorrhage intraoperatively, in order to preserve maternal health and well-being and in accordance with the patient's wishes, we felt it was most prudent not to attempt conservative management to prolong the pregnancy. Conservative measures could be considered with guarded optimism in patients wishing to attempt pregnancy preservation.There is only one case reported by Aboulafia et al. that describes successful conservative management of a patient with a similar presentation . This paIn terms of definitive management, a hysterectomy is most commonly performed. Given that significant hemorrhage can occur during this procedure, adjunct procedures can be used to minimize blood loss including internal iliac balloon occlusion and internal iliac ligation. Internal iliac artery occlusion with a balloon has been shown to significantly reduce the blood loss and risk of hysterectomy in patients undergoing nonemergency cesarean section for morbidly adherent placenta . In an eIn summary, there have been case reports describing pregnant patients presenting with acute onset of abdominal pain and a surgical abdomen found to have uterine rupture due to morbidly adherent placenta. This is the first Canadian case report, and the first report to describe a hysterectomy performed with fetus in situ where the diagnosis of hemorrhage due to uterine rupture and morbidly adherent placenta was suspected preoperatively. It is important to consider this rare but morbid and severe diagnosis when seeing an obstetrical patient with acute abdominal pain.


Metastatic liver tumors from primary gastric cancer are rarely resected because of the high rate of metastasis and recurrence of gastric cancer, and there is little information regarding the pathological assessment of these tumors. We present a case of a single metastatic liver tumor from gastric cancer with invasion of the interlobular bile duct for which we achieved margin-free resection with good clinical outcomes.An 80-year-old patient presented with a tumor in segment V of the liver, with invasion of Glisson’s pedicle confirmed on preoperative magnetic resonance and positron emission tomography imaging. On the basis of the preoperative assessment, we proceeded with partial hepatectomy, with transection of one of the roots of Glisson’s pedicle performed under echography guidance. Pathological examination confirmed gastric cancer as the primary source of the metastatic tumor. R0 resection was achieved, with no evidence of cancer recurrence at one year after surgery.Our experience supports partial hepatectomy with R0 margin tumor resection as an oncologically feasible treatment for metastatic liver tumor arising from primary gastric cancer (in the absence of other metastatic lesions) and shows that a good prognosis can be achieved. Of note, intraoperative echography did not detect tumor invasion of Glisson’s pedicle, which was evident only on preoperative imaging.This case suggests that magnetic resonance and positron emission tomography imaging findings are important for surgical planning of hepatectomy. Further follow-up data and more cases are needed to completely define the clinical significance of tumor invasion of Glisson’s pedicle. Partial2th classification] and colectomy for transverse colon cancer  four years previously. Eight months after these surgeries, the patient underwent partial hepatectomy for a metastatic liver tumor arising from primary gastric cancer, which was pathologically confirmed. The patient refused to undergo adjuvant chemotherapy. Periodic assessment of tumor marker levels (carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9)) and enhanced computed tomography (CT) were performed during follow-up. Enhanced CT performed 4 years after the gastric/colon surgeries revealed a new low-intensity mass, 16 mm in diameter, located in segment Ⅴ of the liver; the location of this lesion was different from that of the lesion identified during the first liver surgery. There was no evidence of other local, peritoneal, or lung metastases. On PET–CT, the mass presented as a hot, linear-like lesion, that almost appeared as two separate lesions  staging, 7 lesions a. Consis lesions b/c. The Although the mass and Glisson’s pedicle in segment V of the liver were visible on intraoperative echography, invasion of Glisson’s pedicle, identified on MR imaging and PET examinations, was unclear. Accordingly, following cholecystectomy, we proceeded with partial hepatectomy and transection of the root of Glisson’s pedicle in segment V, under intraoperative echography guidance.On gross appearance, the surgical margin of the tumor was within the cut surface . On the 3This is, to our knowledge, the first case report of invasion of Glisson’s pedicle by a metastatic liver tumor arising from primary gastric cancer, although cases of intrabiliary metastases from colorectal cancer have been reported ,6. MetacAnatomical hepatectomy is the treatment of choice for primary liver tumors and hepatocellular carcinomas, which often infiltrate the portal vein. Partial hepatectomy is typically sufficient for the treatment of metastatic liver tumors; Glisson’s pedicle invasion is generally not observed in metastatic liver tumors, particularly small tumors . In our Metastatic cancer cells may migrate with the bile flow to the distal bile duct, and recurrence in the hepatoduodenal ligament, peritoneal dissemination, or lymph node metastasis may occur. The clinical significance of Glisson’s pedicle invasion (particularly of the interlobular bile duct) with metastatic gastric tumor is, however, largely unknown because of the rarity of this condition. Considering the absence of recurrence in the remnant liver one year after surgery, including the remnant segment V, partial hepatectomy with R0 resection may be an oncologically acceptable option if invasion of Glisson’s pedicle is detected on preoperative imaging. Further postoperative follow-up would clarify the clinical significance of this type of cancer, considering the relatively short-term follow-up  in the current case.4We treated a patient with a metastatic liver tumor arising from gastric cancer, with infiltration of Glisson’s pedicle, including the interlobular bile duct. (Gd-EOB-DTPA)-MR (T2- and diffusion-weighted images) and PET-CT imaging were useful modalities for detecting the invasion of Glisson’s pedicle and for surgical planning. Considering the one-year survival of our patient with no cancer recurrence, partial resection with an R0 margin may be appropriate for oncologic treatment of metastatic liver tumors from gastric cancer with Glisson’s pedicle invasion in the absence of other metastatic lesions.There are no conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Ethical approval was not obtained for this case report.Written informed consent was obtained from the patients for publication of this case report and accompanying figures. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Study concept, design, and writing of this case report were by author: Yusuke Takahashi. Hitoshi Seki participated in the treatment of the patient and drafted the manuscript. Hitoshi Seki critically revised the manuscript. All authors read and approved the final manuscript.This case report was not registered in a publicly accessible database.Yusuke Takahashi accepts full responsibility for the work and the conduct of the case report, had access to the data, and controlled the decision to publish.Not commissioned, externally peer-reviewed.


Endometriosis is the presence of endometrial tissue outside of the uterine cavity. Scar endometriosis (SE), a rare occurrence, results from inadvertent extrapelvic transplantation of endometrial tissue to an incision site, such as from a low transverse cesarean section (LTCS). The reported incidence of abdominal wall scar endometriosis status-post cesarean section is 0.03 - 0.6%. We present a case of rectus abdominis scar endometriosis diagnosed four years following an LTCS. Our case report discusses the history/presentation, imaging findings, histopathology, and pertinent literature concerning abdominal wall scar endometriosis. While endometriosis is a common disease, ectopic endometrial implants involving the abdominal wall, pleura, surgical scars, and extremities are much less common . Given tWe report the case of a 34-year-old, multigravid female who presented to the Obstetrics/Gynecology Clinic with complaints of right-sided pelvic pain and a palpable “knot” within the right anterior pelvic wall region. She reported first noticing this mass four years prior, following her cesarean section, and attributed this to scar tissue from her LTCS incision. The patient reported a two-month history of focal increased tenderness at the site, particularly with menstruation, and described the discomfort as constant, dull, and aching. Her pain started around the mass and radiated towards her back.Physical examination revealed normal vital signs and an abdominal right lower quadrant hard, non-mobile, tender-to-touch, 1.6 cm mass palpated 3 - 4 cm cranial to her LTCS cutaneous scar.The palpable mass was further evaluated with an ultrasound (US) which revealed a 1.6 cm complex, predominantly hypoechoic, intramuscular mass exhibiting foci of internal vascularity and punctate echogenic foci  of the pelvis with and without intravenous gadolinium contrast was performed to better characterize the abnormality. The MRI revealed a 4 cm area of mildly heterogenous T1 and T2 signals with enhancement after the administration of gadolinium contrast. The mass was located in the medial aspect of the right rectus abdominis muscle, immediately adjacent to a curvilinear area of magnetic susceptibility artifact, which corresponded to the LTCS incision (Figure As a result, a US-guided percutaneous core biopsy of the right rectus abdominis soft tissue mass was performed using an 18-gauge spring-loaded coaxial biopsy system. The histopathology demonstrated the presence of endometrioid glands surrounded by endometrial stroma Figure . The glaSurgery to resect the ectopic endometrial tissue and to perform lysis of the adhesions of the LTCS incision area was subsequently performed.Scar endometriosis is described in the literature but remains an extremely rare diagnosis with its incidence in post-cesarean scar tissue estimated at 0.03% - 0.4% . The etiDiagnosing SE can be challenging. As described in published case reports, often there is a history of pain that corresponds to the patient’s menstrual cycles . Other dThe imaging appearance of scar endometriosis depends on the menstrual cycle phase and duration of the process . UltrasoSE can be treated medically and surgically -10. MediGiven the failure of medical therapy, surgical excision remains the treatment of choice and is curative for extrapelvic endometriosis in the vast majority of cases. For example, in a series of 21 patients with an average complaint duration lasting 25.3 months, recurrence was not observed in any patient during an average follow-up of 31.3 months after total excision . The mosWhile SE remains a rare disease, the diagnosis can be suggested when there is a focal mass in close proximity to a cesarean section scar exhibiting catamenial symptomatology. Appropriately tailored imaging can help to narrow the differential diagnoses in postoperative patients experiencing unusual postoperative abdominal wall pain.


Gastric neuroendocrine tumors (GNET) are rare gastric neoplasms accounting for <1% of all gastric neoplasms. The World Health Organization (WHO) categorized these neoplasms as types 1-3 to help predict malignant potential and long-term survival and guide management. Improved outcomes have been shown with endoscopic resections, but further studies are needed to confirm the best approach. We present a case of a 56-year-old woman who demonstrated the classic features of type one GNET with mucosal and submucosal involvement in the setting of primary atrophic gastritis, secondary hypergastrinemia, and underlying pernicious anemia. In general, standardizing treatment has been difficult due to a variable presentation. Gastric neuroendocrine tumors (GNET) are exceedingly rare, accounting for <1% of gastric neoplasms and 8.7% of gastrointestinal neuroendocrine tumors . Of the A 56-year-old woman with a history of cholelithiasis and irritable bowel syndrome presented to the office for postprandial, colicky left upper quadrant pain radiating to the right shoulder lasting approximately 45 minutes. The pain was associated with three to four episodes of diarrhea and dyspepsia. Lab studies showed gastrin level off PPI of 2100 pg/mL. Ultrasound of abdomen showed diffusely increased hepatic echogenicity suggesting fatty change and cholelithiasis. The patient was sent for a hepatobiliary iminodiacetic acid (HIDA) scan that was performed, showing an ejection fraction of 90%. Elective cholecystectomy was scheduled and performed without resolution of the symptoms. The patient was sent for colonoscopy that was negative. Esophagogastroduodenoscopy (EGD) with biopsy and snare polypectomy showed erythematous “carpet-like” atrophic mucosa in the antrum, five to six sessile polyps (the largest being 10mm) with nodular mucosa in the body of stomach and fundus  and/or less than 3% Ki-67 labeling index, which is expressed during the active phases of the cell cycle. Grade 2 has a mitotic count of two to 20 per 10 HPFs and/or 3% to 20% Ki-67 labeling index. Grade 3 tumors are high-grade neuroendocrine carcinomas . If therBoth anatomic and functional imaging can be helpful when diagnosing neuroendocrine tumors of unknown primary location or unknown metastatic disease. Computed tomography (CT) scan is a good imaging modality for the lungs and CT enterography can detect neuroendocrine tumors (NET) as small as 0.5 cm . MagnetiOur case demonstrated type one GNET with submucosal involvement in a patient with primary atrophic gastritis and underlying pernicious anemia. About 65% of patients with type one GNET will present with pernicious anemia such as the case with this presentation . It has Treatment of gastric neuroendocrine tumors is stratified by type, as the prognosis varies greatly from types one to three tumors. The standardization of treatment of type one GNET has been difficult due to the lack of consensus on diagnostic histological classification and a typically benign disease course. Treatment modalities include endoscopic lesion resection, antrectomy, and pharmacological therapy -14. TypiThis case highlights the rise in type one GNETs found incidentally on endoscopy. Our case is atypical in the presentation as the patient initially complained of right upper quadrant postprandial, colicky pain. Post-cholecystectomy, the patient had persistent symptoms prompting endoscopy in the setting of pernicious anemia. Treatment modalities are not well delineated, but endoscopic resection in small polyps have shown to be associated with low risk of recurrence. Given this, our patient had the recurrence of polyps at six months. More comprehensive studies on treatment modalities will be needed to ensure optimal curative intervention.


Perforation of low-grade appendiceal mucinous neoplasms (LAMN) is characterized by its potential to spread mucin into peritoneal cavity, giving rise to pseudomyxoma peritonei, commonly treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.Symptoms of intestinal obstruction and appendiceal infection are rare at early stages of the disease, while abdominal distension are observed in the later stages due to mucin spread.We report herein a case of LAMN with atypical symptoms in a 35-year-old woman with abdominal symptoms evoking an intestinal obstruction.An abdominal CT scan revealed an ileo-caecal intussusception. An exploratory laparotomy and examination of the peritoneal cavity ruled out an exteriorization of mucin and the bowel was resected.The pathology analysis confirmed the diagnostic of LAMN. This report aims to raise awareness among surgeons, of rare clinical presentations that LAMN may show, to adapt the surgical treatment to these patients and assign them to referral centers. We report a case of 35-year-old female patient with no medical history presented to the emergency department with acute vomiting and abdominal pain. The abdomen was distended with significant guarding in the left upper quadrant. An abdominal CT scan revealed an ileo-caecal intussusception through the left transverse colon (


Scrotal masses are common findings in primary care and can develop from all anatomical structures of the scrotum. They are usually painless, although pain may be present occasionally. In this report, we present the case of an unusual testicular mass caused by the migration in the scrotum of a mesh used for inguinal hernia repair. The patient was treated conservatively owing to the spontaneous resolution of symptoms. The most frequent are cysts of the epididymis that occur in up to 40% of men. Primary malignancies of the epididymis or paratesticular structures are extremely rare in adults.2 Metastases could also be found occasionally.3Scrotal masses are common findings in primary care and can develop from all anatomical structures of the scrotum such as testes, epididymis, appendix of the epididymis, appendix of the testes, gubernaculum testis, vas deferens, pampiniform plexus and spermatic cord.Patients presenting with acute scrotal pain to the emergency department represent less than 1% of all the cases and require a timely diagnosis.In this report, we present the case of an unusual testicular mass seen at the emergency department of our institution in a patient with previous scrotal pain.A 60-year-old male was admitted to the emergency department of our hospital for a palpable mass in the scrotum. The patient was sent by the general practitioner for suspected testicular torsion, as he reported an onset of sudden intense pain over the left side of the scrotum.On admission to the hospital, a few hours after having been seen by the general practitioner, the patient reported a complete resolution of pain. He denied symptoms of the urinary tract. He reported a clinical history of left inguinal hernia repair about 30 years ago, with the implantation of a mesh. However, no clinical documents were brought for reference. He recently underwent mitral valvuloplasty and was on oral anticoagulant therapy.–1, blood pressure was 120/75 mmHg and oxygen saturation was 100%.On physical examination, a tender palpable mass cranial/superficial to the epididymis was found. There were no signs of acute inflammation and no pain was elicited on local or abdominal palpation. Vital signs were good: heart rate was 80 beats minThe patient was sent to the radiology department for a testicular ultrasound . Ultrasound scan revealed that the left testicle was unremarkable . The epiAs the patient was asymptomatic on admission to the hospital, no surgery was performed. The patient was discharged from the hospital with indication of abstention from physical exertion and follow-up in case symptoms recur.4 The technique has continued to evolve and the use of meshes as patches and plugs represents the standard practice.5Hernia repair is one of the most frequent operative procedures performed throughout the world.6 considered mesh plug migration into the scrotum a new complication of hernia repair owing to the change in surgical technique. He reported two cases of migration, both also complicated by the presence of an incarcerated scrotal hernia, in which correction of the hernia and resection of the migrated mesh plug from the scrotum were carried out concurrently.In 1999, Dieter7 reported a case of a mesh plug positioned to treat an inguinal hernia via transabdominal approach during laparotomy performed in a patient operated on in emergency. Several months after surgery, the patient came back with the scrotum remarkably tender to palpation and a palpable mass at the apex of the right scrotum. At surgery, he had an incarcerated right scrotal hernia and the mesh plug represented the scrotal mass felt on pre-operative examination. The authors concluded that the indication to treat an asymptomatic scrotal hernia during emergency surgery was incorrect.8Nowak et al8 found six cases of reported mesh plug migration in males ranging from 30 to 83 years of age. He found that three cases were due to poor surgical technique, one case was not a real migration, another was a case of wrong surgical indication, and in the last case, the patient was in overall very poor health. Only two of these cases concerned a migration of the mesh into the scrotum, both requiring surgical treatment. Jeans et al8 concluded that mesh plug migration after open inguinal hernia repair can be avoided if proper attention to detail is paid at the time of the initial repair.9Mesh migration into the scrotum is a rare complication of inguinal hernia repair. In a literature review, which included papers published from 1995 to 2006, Jeans et alOur case seems to be different from those reported in the literature. First, the patient reported the occurrence of severe scrotal pain that spontaneously resolved. Also, no signs of inflammation were seen, neither on physical examination nor on blood test and ultrasound examination. Thus, we can hypothesize that the pain was unrelated to the scrotal mass, which was therefore discovered incidentally. Also, no clinical or ultrasound signs of recurrent hernia were seen.10 in 2004 reported the use of ultrasound and CT scan in the evaluation of post-operative complications of inguinal hernioplasty using prosthetic polypropylene mesh in 31 patients. They also performed an invitro evaluation of the mesh to show the ultrasound appearance. They report that invitro the prosthetic mesh appeared as a linear hyperechoic image measuring about 2 mm in thickness, with a posterior acoustic shadow and a finely irregular surface. Invivo, they reported a similar appearance, occasionally without the presence of the posterior acoustic shadow. In a pictorial review, Parra et al9 reported that ultrasound appearance is related to the composition of the mesh itself and an acoustic shadow is not always visible.We were not able to find in the literature any paper dealing with ultrasound evaluation of migrated mesh used for hernia repair. A few papers in the literature report the appearance of a mesh used for hernia repair, but only when evaluating complications of surgery. Crespi et ale.g. the mesh). No other cause of paratesticular mass may present with that appearance. The absence of signs of inflammation on ultrasound  suggested that the migration was not a recent event and that probably the pain reported by the patient was not related to the mesh itself.In our case, we do not have any clinical information regarding the type of surgery and the composition of the implanted mesh. The elongated tubular structure with regular geometric echotexture seen on our images may recall a rolled up thin structure (e.g. CT scan) may have been useful to confirm the diagnosis. However, it was not considered clinically adequate as the patient was asymptomatic at that moment.One remarkable limitation of our report is that the patient did not undergo surgery. Thus, the only confirmation of our hypothesis is based on both the affirmation of the patient of having been implanted with an inguinal mesh and the fact that the mesh was not seen on ultrasound scan of the groin. Also, another imaging modality (We reported an unusual case of scrotal mass, which on ultrasound evaluation resembled a migrated mesh used for inguinal hernia repair. Ultrasound scan was able to depict clearly the appearance of the migrated mesh, thus avoiding surgical exploration.A mesh used for inguinal hernia repair can migrate into the scrotum, mimicking a scrotal/testicular mass.Ultrasound scan may help in detecting the mass and highlighting the typical echotexture.Ultrasound scan of the inguinal canal demonstrating the absence of the mesh may help in orienting the diagnosis.Consent to publish was obtained.


Abdominal pain is a frequent problem encountered in the emergency department, and acute appendicitis is a well-recognized diagnosis. Laparoscopic appendectomy has become one of the most common surgical procedures in the United States. Patients with a history of appendectomy may experience recurrent right lower quadrant abdominal pain from an infrequently encountered complication that may occur when the residual appendix becomes obstructed and inflamed. We describe two cases of stump appendicitis in pediatric patients with a review of clinical and imaging findings and surgical management. Abdominal pain is a common complaint in pediatric emergency visits, accounting for about 460,000 yearly visits for females under 15 years old and 314,000 for males under 15. Common entities such as appendicitis are diagnoses entertained early in the evaluation by emergency physicians; however, this diagnosis is often quickly ruled out in patients with a prior history of appendectomy. The provider must be familiar with complications of appendectomy such as retained stones and, as illustrated, stump appendicitis. Although rare, with a reported incidence of 1 in 50,000 appendectomies,An 11-year-old male presented to the emergency department (ED) with abdominal pain of one night duration causing difficulty with sleeping and ambulation. Of note, the patient denied loss of appetite, vomiting, and fever. Past surgical history was significant for appendectomy 19 months prior after presenting with similar symptoms and being diagnosed with appendicitis sonographically. There were no reported operative or postoperative complications.Upon presentation the patient had not had a bowel movement in several days, and the initial leading differential diagnosis was constipation. Physical examination was significant for fever and localized peritonitis. Pertinent laboratory investigations at current presentation included leukocytosis of 13,300 per cubic millimeter , neutrophilia of 9,870 per cubic millimeter , and an elevated C-reactive peptide to 1.4 milligrams per deciliter (reference range <0.5). After antipyretics, repeat assessment showed a reduction in fever; however, the patient still had severe abdominal pain. A point-of-care ultrasound showed a normal-appearing gallbladder and no dilation of the common bile duct but demonstrated an aperistaltic mass in the right lower quadrant (RLQ).After consulting with the pediatric surgery team, contrast-enhanced computed tomography of the abdomen and pelvis was performed and demonstrated surgical changes of appendectomy with staple lines at the blind end of the appendiceal stump. A high-density appendicolith was obstructing the base of the appendiceal stump, which was surrounded by mesenteric fat stranding . ThickenPathology confirmed that the stump was necrotic, in two 2 cm long portions, with one portion containing a large appendicolith.An 11-year-old female patient with a past medical history significant for appendicitis treated with laparoscopic appendectomy two months prior presented to a local ED with a one-day history of epigastric and right-sided abdominal pain, poor oral intake, and emesis. Prior to transfer to the university hospital, contrast-enhanced computed tomography of the abdomen and pelvis demonstrated a fluid collection in the right pericolic gutter at the site of surgical changes of appendectomy. The collection contained small stones  and smalUpon transfer, the patient was febrile and tachycardic. She was taken for laparoscopic appendectomy during which an inflamed, approximately 5 cm-long stump was encountered with an obvious appendicolith at its base adjacent to the cecum. The site of perforation was not readily evident, but there was evidence of recent peritoneal spillage and contamination. The previous staple line was readily apparent at the end of the stump. The appendectomy was completed by passing a stapling device proximal to the appendicolith and resecting the stump.Pathology confirmed an inflamed, 5 cm appendix containing two large fecoliths. After gradual clinical improvement, she was discharged on postoperative day 4. Residual postoperative pain was well controlled with acetaminophen.Stump appendicitis is an uncommon entity; consequently it is rarely entertained as a diagnosis in a patient who has previously undergone an appendectomy, which may lead to a delay in diagnosis. One case series found perforation at the appendiceal stump in 60% of cases.What do we already know about this clinical entity?Stump appendicitis has an estimated incidence of 1 in 50,000 and can occur after both open and laparoscopic surgeries, months to years after initial removal.What makes this presentation of disease reportable?Stump appendicitis is not well described in the emergency medicine literature. These patients had an evolving abdominal exam consistent with appendicitis despite their surgical history.What is the major learning point?These cases highlight the importance of being familiar with this unusual entity, as well as the value of serial abdominal examinations and use of imaging including ultrasound.How might this improve emergency medicine practice?Increased awareness of this disease process among emergency physicians could prevent delayed diagnosis and complications.The decision to use medical imaging in children can be difficult. While it is important to adequately rule out dangerous pathologies, it is also important to limit ionizing radiation doses in children. Ultrasound can be a screening tool to evaluate some etiologies of abdominal pain,Pediatric patients presenting with abdominal pain often have an attributable, nonsurgical cause such as constipation or gastroenteritis. In the first case, the patient was initially afebrile, decreasing concern for a serious bacterial illness. However, he developed a fever throughout his ED course, and his abdominal exam became more concerning, illustrating the importance of observation and serial examination when the diagnosis is uncertain. Anchoring on a common diagnosis, such as constipation, and discharging the patient prior to the evolution of the fever could have devastating consequences.Stump appendicitis is an uncommon complication after appendectomy. It is important for physicians to be aware of this entity to ensure timely diagnosis and treatment of this unusual condition. With the increased utilization of laparoscopy for appendix resection, there may be an increased incidence of stump appendicitis after appendectomy, and it is important not to exclude appendicitis from the differential diagnosis based on prior history of appendectomy.Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.


Management of pregnant women with brain tumors necessitates difficult decision-making especially for estimating or preventing its intratumoral hemorrhage. A 26-year-old, 19-week pregnant woman complaining of headache and vomiting was admitted to our hospital. Magnetic resonance imaging (MRI) revealed hydrocephalus and a mass lesion without contrast enhancement extending from the left thalamus. To resolve severe symptoms, a ventriculoperitoneal shunt was inserted, and a biopsy was taken via the right ventricle. Pathological examination suggested diffuse or pilocytic astrocytoma, but subsequent genetic analysis revealed the diagnosis of midline glioma with H3-K27M mutation. The patient opted not to terminate the pregnancy, and MRIs conducted every four weeks revealed no change in tumor aspect. The patient delivered a healthy baby by cesarean section, and postpartum day 1 was uneventful. However, she was found in a coma due to a massive intratumoral hemorrhage on postpartum day 2 and died 3 weeks after the hemorrhage. This is the first case report of diffuse midline glioma with H3-K27M mutation in a pregnant woman followed by fatal hemorrhage. It highlights the necessity of careful clinical management and frequent neuroimaging during the entire perinatal period, even if the tumor has hypovascularity or low proliferative potential on radiological or pathological findings. There are few reports of pregnant woman with brain tumors associated with intratumoral hemorrhage. Therefore, clinical management or estimation of this condition has not been well-established. Furthermore, it is difficult to predict the potential for fatal intratumoral hemorrhage, especially in hypovascular and noncontrast material-enhanced tumors. Herein we report the first case of diffuse midline glioma with H3-K27M mutation in a pregnant woman followed by fatal hemorrhage during the postpartum period.A 26-year-old, and 19-week-pregnant woman consulted her obstetrician about intermittent headaches with vomiting. Hyperemesis gravidarum was suspected, and she was treated with antiemetic and analgesic drugs. However, symptoms gradually worsened, and she was admitted to the obstetric hospital. Computed tomography (CT) revealed hydrocephalus and an iso-density mass lesion in the left thalamus , and theMagnetic resonance imaging (MRI) revealed a poorly circumscribed mass lesion extending to both the midbrain and the right thalamus from the left thalamus Figures  and magnThe patient's symptoms continued to worsen, and she became unable to eat. To alleviate symptoms and confirm the diagnosis, a ventriculoperitoneal shunt was inserted, and a biopsy was performed via the right ventricle at the 21th week of pregnancy. The postoperative course was good, and symptoms resolved. Routine pathological examination of cell morphology suggested anaplastic astrocytoma, but the lack of necrosis or hypervascularity also suggested the possibility of diffuse astrocytoma or pilocytic astrocytoma with degeneration Figures . ImmunohFollow-up MRIs conducted every 4 weeks showed no change in tumor size or intensity pattern Figures . ClinicaDiffuse midline glioma with H3-K27M mutation was newly established as a diagnostic category at the 2016 World Health Organization classification of the central nervous system and assigned to grade IV. However, it is difficult to diagnose diffuse midline glioma with H3-K27M through routine pathological examination because midline gliomas are widely diagnosed in various grades by many pathologists [The incidence of tumor-related intracerebral hemorrhage has varied between studies, ranging from 0.6 to 5% –5. Among∗ and no contrast material enhancement on gadolinium enhanced T1 on MRI. Further, immunohistological findings of CD34 staining indicated low tumor vascularity. We therefore assessed the risk of intratumoral hemorrhage as minimal, although we chose cesarean section as a precaution.To our knowledge, there are few reports of pregnant woman with brain tumors followed by intratumoral hemorrhage. Prior reports include intratumoral hemorrhage of pituitary adenoma , optic gIn the review of 75 cases of pregnant women with glioma, almost half of the cases chose vaginal delivery, and most were uneventful . TherefoThis is the first case report of diffuse midline glioma with H3-K27M mutation in a pregnant woman followed by fatal hemorrhage. Maximum clinical monitoring and frequent neuroimaging are necessary in pregnant women with brain tumors, especially at the perinatal period, even if the tumor has hypovascularity or low proliferative potential on radiological or pathological findings.


Epidermal cysts and squamous cell carcinomas (SCCs) are common skin lesions. However, a malignant change in an epidermal cyst is very rare. The incidence of a malignant change from an epidermal cyst to cutaneous SCC is 0.011–0.045%. In particular, malignant transformation of an epidermal cyst in the perineum is extremely rare. To date, three cases have been reported in the English literature.We report a case of 51-year-old male with an approximately 15-cm perineal mass. This mass started to grow suddenly 4 months previously and caused great discomfort in the perineum due to the large size. The patient underwent excision of the mass with a negative margin. Histopathological analysis confirmed a microinvasive SCC arising from a proliferating epidermoid cyst.Even if benign tumors are suspected, a change in size, pain, ulceration, or discharge should indicate the need for surgical resection due to the possibility of a malignant change. Epidermal cysts and squamous cell carcinomas (SCCs) are common skin lesions . HoweverA 51-year-old male was referred to our center due to a large perineal mass. The mass was first discovered 30 years ago as a chestnut-sized small movable cystic nodule. Subsequently, he watched himself for a long time because of no unusual changes. The cyst started to grow suddenly 4 months previous to the visit and caused great discomfort in the perineum due to its large size.On physical examination, an approximately 15-cm cystic mass was observed in the left perineum near the anus. There was no sign of inflammation such as tenderness or redness. Ulceration or discharge was not observed. On a digital rectal examination, there were no specific findings in the anus. A colonoscopy was performed and was unremarkable. Magnetic resonance imaging revealed a 6.7 × 16 cm lobulated mass in the medial aspect of the left perineum with an intermediate signal on T1WI, a high signal on T2WI, and peripheral wall and internal septal enhancement (Fig. The patient underwent excision of the mass with a negative margin. On exploration, a cystic mass with sebum and keratin was identified in the left perineum Fig. . It had The patient was discharged 2 days after the surgery without a significant postoperative complication. We performed regular follow-up examinations with CT every 6 months, and he showed no evidence of recurrence at 3 years postoperatively.An epidermal cyst is a benign disease caused by invagination of epidermal elements into subcutaneous fat from a hair follicle . AlthougThe cause of a malignant change in an epidermal cyst is not yet clear. It is known that chronic inflammation or infection can trigger this event, which seems to create dysplasia and/or malignant changes. The most frequent reports are SSCs in the head and neck regions, indicating that the change may be a side effect of ultraviolet radiation. Exposure to ultraviolet radiation and chronic stimuli can be triggered , 5. AlthClinically, it is difficult to distinguish between benign cystic lesions and malignant lesions. When an epidermal cyst changes in size or is associated with atypical conditions such as pain, ulceration, or discharge, cancerous transformation should be considered . In the Treatment is not different from that for other skin malignant lesions. Excision with a proper margin is the standard of care. It is recommended that minimal margin of excision be 4 mm, but for high-risk tumors, a 6-mm margin is suggested. Advanced cancer requires extensive surgery with a resection margin of 2 cm or more . The posIn conclusion, malignant transformation can occur, even in benign skin lesions. In particular, when there is an atypical situation such as a change in size, pain, ulceration or discharge, surgical resection should be performed due to the possibility of a malignant change. After complete resection, a thorough pathologic examination should be conducted to confirm a malignant transformation.


Clinical outcome after cutaneous reconstruction using genicular artery flaps has not been reported. Major cutaneous defects of the pelvic limb between the stifle and hock are frequent in dogs and closure is difficult due to lack of available skin from immediately adjacent areas.Here we report the first two clinical cases successfully managed by genicular axial pattern flap closure. A 2-year-old 38 kg (83.77-lb) intact male Labrador Retriever and a 14-year-old 42 kg (92.59-lb) spayed mixed breed female dog were admitted for the management of large skin defects in the lateral tibiotarsal joint. One defect was the result of a fibrosarcoma removal in the Labrador dog and the other defect was a chronic large wound caused by a car accident in the mixed breed female dog. Both defects were reconstructed by using genicular flaps. The bed of the wound in mixed breed dog was surgically debrided and underwent open wound management until a proper granulation tissue bed was formed before reconstruction. The skin defect in the Labrador dog was covered immediately after tumor removal. After surgery both dogs were bearing weight on the limbs normally. Small area of dehiscence occurred in both dogs 2 weeks after surgery. At follow-up examination one month after surgery, the surgical wound of the Labrador retriever still had a small area of dehiscence. Two months after surgery, the wound of the mixed breed dog was completely healed, covered with hair and no lameness was observed.Findings suggested that genicular axial pattern flap is a good option for reconstruction of large cutaneous defects of the lateral aspects of the tibia in dogs. Closure of major cutaneous defects of the pelvic limb between the stifle and hock is difficult due to lack of available skin from immediately adjacent areas , 2. DepeAxial pattern flaps incorporate a direct cutaneous artery and vein with terminal branches for blood flow supply and drainage of the subdermal plexus . The genAdvantages of axial pattern flaps over other methods of wound closure include the ability to close a large defect without tension, early closure without extended open wound management, coverage of areas with less than optimal wound healing conditions, and excellent flap survival rates , 7. The The genicular axial pattern flap has been described for repair of defects from stifle to tibiotarsal joint on the lateral or medial aspect of the hindlimb , 5, but,A 2-year-old 38 kg (83.77-lb) intact male Labrador and a 14-year-old 42 kg (92.59-lb) neutered mixed breed female dog were referred to the Department of Surgery the Faculty of Veterinary Medicine at the University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, Romania. On physical examination, the Labrador dog had a dense, 3X4 cm well-defined subdermal mobile swelling on the craniolateral aspect of the tibia  fibrosarcoma. Thoracic radiography and abdominal ultrasound revealed no metastatic foci. CT scan analysis was not available. No evidence of regional lymph node involvement was noticed. All results of CBC and serum biochemical analysis were within reference limits. A 3 cm surgical excision was performed, because histologic examination of tissue margins indicating complete tumor resection is predictive of nonrecurrence, and unaffected tissue margins of 2 to 3 cm in all planes are typically recommended to achieve this goal  Fig. 1bb1b.Cefazolin  was administered 30 min prior to surgery, and the patient was premedicated with butorphanol  and midazolam . Anesthesia was induced with propofol  and maintained with isoflurane in oxygen following endotracheal intubation. The patient was placed in lateral recumbency, and a hanging leg preparation was performed. The tumor was removed with 3 cm margins  neutered mixed breed female dog was referred because of a chronic and 14X6 cm extensive skin defect on the lateral aspect of the distal tibia and tarsus  was administered 30 min prior surgery, and the anesthesia was performed in a similar way to the previous case. The patient was placed in lateral recumbency, and a hanging leg preparation was performed. The proposed incision lines and measurements of the flap length and width were done in a similar way to the previous case.The genicular axial pattern flaps were marked with a sterile pen and the flaps were then developed on the lateral aspect of the limb. The base of the flap was located 1 cm proximal to the patella and 1.5 cm distal to the tibial tuberosity on the lateral aspect of the limb according to the recommendations [Assessment of flaps viability was made 10 days, 4 and 8 weeks postoperative and was based on skin color and hair growth. A small dehiscence occurred in both dogs in the first two weeks postoperative . Due to the small size of the dehisced area it was decided to let the area heal by secondary intention for both cases Fig. e. A smalReported complications in experimental cases included dehiscence of the donor site and necrosis of the flap. Mean flap survival was 89% in dogs that underwent genicular axial pattern flap elevation and rotation to cover a defect over lateral tibia . The degAlthough many cutaneous wounds of limbs heal by contraction and epithelialization, the process may be slow or incomplete, and the healed wound may have a fragile epithelial surface . Second Surgery alone is curative if the tumor can be removed completely . Open woThis study shows that genicular flaps provided a full thickness skin coverage in two dogs with cutaneous defects in the tibiotarsal region.


Simple renal cysts are one of the most common lesions in elderly. These cysts are usually asymptomatic but when the size of these cysts increase, we would see symptoms such as hypertension, hematuria, flank pain or urinary obstruction. In this study, we explore a case of small bowel obstruction that presented with nausea, repeated vomiting that causes hematemesis, and a submucosal obstructive lesion that was seen in Esophagogastroduodenoscopy (EGD). After endoscopic ultrasound (EUS) evaluation, we detected a large simple renal cyst and approved our diagnosis with CT scan. We planned a medical treatment for this patient that consist consuming small size meals, 5 to 6 times a day, and high calorie liquids in small volumes. We conclude that simple renal cyst can be one of the cause of extrinsic intestinal obstruction and EUS is affective for differentiation of intrinsic submucosal lesion from extrinsic compression. Simple renal cysts are benign masses which are formed in the kidneys for unknown reasons and can be inherited or acquired. These cysts are present in 10% of the general population and their prevalence increase with age . These cSubmucosal lesions are seen in 0.36% of upper gastrointestinal endoscopy cases . Gold stIn this study, we reported a rare case of duodenal obstruction secondary to a large simple renal cyst. An 81-year-old man presented to emergency department with the chief complaint of hematemesis which lasted for 7 days. His hematemesis started after three times none bloody emesis. He mentioned history of weight loss, recurrent epigastric pain and post prandial vomiting for one year. The vomitus occurred one to two times daily shortly after meal consumption. He had past medical history of a laparoscopic cholecystectomy five years ago, an ischemic brain stroke two years ago, and he was paraplegic due to a lumbar herniated disc about one year ago. His familial history was negative for GI disorders.On physical examination the patient was cachectic and extremely weak with a blood pressure of 90/40 mmHg and heart rate of 110 beats/min. Respiratory rate was 22/min and oral temperature was 36.8. The sclera of patient was not icterus, lymphadenopathy, abdominal tenderness or palpable mass were not found. Some of the laboratory finding of this patient summarized in Treatment initiated by infusion of crystalloid fluids and intravenous pantoprazole. After the supportive care, esophagogastroduodenoscopy (EGD) was performed. EGD revealed a linear clean base ulcer in lower third of esophagus , that has been caused by repeated vomiting, and also a Submucosal lesion which was observed in bulb area of duodenum . Endoscopic ultrasonography was subsequently performed and demonstrated one anechoic lesion measuring 45×55 mm that adjacent to duodenal wall although integrity of the duodenal wall layers was intact. The most possible location of the lesion was right kidney . Unenhanced and contrast-enhanced multi slice CT scan of the abdomen and pelvic were done. In the CT scan of abdomen and pelvic region, some evidence of multiple cortical cysts was seen in both kidney and one of these cysts with the size of 45×55 mm, pressured on duodenum .Conservative treatment was preferred according to the recent investigations , patientThis study reports a complication of simple renal cyst that presented with gastrointestinal obstruction which rarely been described in the Medline, Scopus and ISI Web of Knowledge database. Some case reports describe GI obstruction by multiple renal cyst in ADPKD , 12 and Sub mucosal lesions can be located from mucosa to serosa, so it is better to named them as sub epithelial lesions . CompresObstruction of intestine and specially duodenum could happen due to extrinsic compressions resulted from variety of lesions such as superior mesenteric artery (Wilkie’s syndrome), Pancreatic Adeno-squamous Carcinoma, Aortic aneurysm, and polycystic kidney disease such as ADPKD , 16-18. Since the presentation of a simple renal cyst as a cause of upper gastrointestinal obstruction is very rare, the management of such situations is unclear. In extra-luminal duodenal compression that caused by renal cysts authors have recommended conservative treatment and if the patient’s symptoms were not improved surgical intervention may be considered , 13. AccSubmucosal lesion could be caused by extra luminal compression and causing GI obstruction symptoms. Simple renal cysts should be one of the differential diagnosis of GI obstruction that caused by extrinsic factor.EUS is an affective modality for detecting any submucosal lesion. If the lesion caused by an extra luminal factor, we can use CT for further inspections.It is better to use medical treatment in extra-luminal duodenal compression that caused by renal cyst as the initial and principle approach.The authors declare that they have no conflict of interest.


Management of teeth with inflamed pulp has been always a challenge. Revascularization and vital pulp therapy are suggested as procedures for successful treatment of immature molars diagnosed with pulp necrosis and irreversible pulpitis, respectively. Management of teeth with inflamed pulp has been always a challenge. Revascularization and vital pulp therapy are suggested as procedures for successful treatment of immature molars diagnosed with pulp necrosis and irreversible pulpitis, respectively. This is not encountered in adult patients and may be due to the wide‐open root apex and thin dentin walls of an immature tooth. The treatment options for such immature teeth are dependent on the condition of the pulp tissue. When the pulp is diagnosed as necrotic, the traditional treatment option for immature teeth is apexification with calcium hydroxide.In this report, the immature mandibular right molar with necrotic pulp and left molar with pulpitis were treated using the new method of revascularization via induced bleeding and vital pulp therapy, respectively.22.1An 8‐year‐old female with chief complaint of great pain in the right mandibular molar was referred to the school of dentistry, QUMS. She had this severe pain since one month ago. Although there were several teeth with decay, no dental treatment was performed until the day of examination. The medical history was noncontributory. In clinical evaluation, extraoral examination showed no facial asymmetry or swelling. Normal Palpation of the cervical and submandibular lymph nodes was also noticed. Intraoral examination showed no swelling or sinus tract but deep carious lesions were observed in the mandibular right first molar. In the diagnostic tests, the tooth showed mild response to percussion/palpation. However, it did not show any response to the different pulp tests. The probing depth was within normal limits (< 3 mm around the tooth), and no pathologic tooth mobility was observed. The tooth had an open apex in the radiographs, with periapical radiolucency, deep carious lesions and PDL widening Figure A.Taking clinical findings into account, the concluding diagnosis was pulp necrosis with symptomatic apical periodontitis. Due to the disadvantages of the traditional apexification method, the revascularization procedure was selected as our optimal treatment option and was performed according to the AAE Clinical Considerations for a Regenerative Procedure. The treatment procedure, risks, and benefits were completely explained to the patient, and then a written informed consent was obtained from the patient's legal guardians. At the first visit, the preparation of canals was performed. After local anesthesia using inferior alveolar nerve block  and rubber dam isolation, then carries were removed by a round carbide bur and the access cavity was prepared using a fissure diamond bur and a high‐speed handpiece with water spray. The working length was determined by Root ZX electronic apex locator (J Morita MFQ) and confirmed with X‐ray  , and the next visit was appointed for three weeks later. At the second visit, after clinical examination, it was demonstrated that the sensitivity to palpation/percussion had been resolved. Local anesthesia was performed via inferior alveolar nerve block with 3% mepivacaine . Then, the tooth was isolated with rubber dam, the temporary fillings were removed and the removal of intracanal medicament was performed by irrigating with 17% EDTA  and then final flush with saline  Followed by drying with paper points. To induce bleeding, a precurved #25K‐file (Dentsply‐Maillefer) was rotated at 2 mm past the apical foramen. After blood clot formation, approximately 3 mm of MTA (Angelus) was placed over the canals and pulp chamber followed by the placement of wet cotton pellets on the top of the MTA. Then, the access cavity was sealed by the placement of the Cavit. At the third visit (the day after MTA placement), temporary fillings were removed to evaluate the setting of MTA and the access cavity was then sealed with zonalin  and then saline, . Throughout the procedure, irrigating needle was positioned at about 1 mm from root end. Later, the canals were dried using paper points and creamy Ca(OH)In the three‐month follow‐up visit, the patient was asymptomatic and all signs and symptoms were removed Figure A. Furthe2.2Four months after the revascularization in the right molar, the dental examination revealed that the mandibular left molar had deep carious lesions without any swelling or sinus tract. The patient's tooth has been sensitive to cold since one week ago. The tooth was also asymptomatic to percussion and palpation. The tooth did not respond to the pulp vitality tests such as heat and EPT. However, it showed response to cold test with sever lingering pain. The tooth had an open apex with deep carious lesions in the radiograph Figure A. Based In the second visit, MTA setting was checked and the patient was referred to the department of pediatrics to restore the tooth with stainless steel crown following coronal restoration with amalgam .In the three‐month follow‐up visit, the patient was asymptomatic and no signs and symptoms were observed. In nine‐month follow‐up, the periapical radiographs showed that the apices were almost closed with no sign of pathology. A long‐term follow‐up was performed for 24 months, and complete closure of apices was observed . In this case, TAP was excluded due to its drawbacks such as tooth discoloration and relatively high expense.2 has been demonstrated to have lower cytotoxicity to stem cells.Revascularization needs three key steps for successful regeneration of the pulp tissue: disinfection of intracanal space, application of a scaffold to organize host stem cells, and an appropriate coronal seal. In the present report, in contrast to several previous case reports,According to our clinical and radiographic examinations, mandibular left molar was diagnosed with irreversible pulpitis. Traditionally, it is regarded as an indication of root canal treatment (RCT).The authors have no conflict of interest to declare.: reviewed the literature, developed the concept and design of the study, and performed the procedure. PS: reviewed the literature, involved in data analysis/interpretation, and drafted the manuscript. NH: involved in concept/design, analysis, and data collection.MR


Reactive lymphoid hyperplasia (RLH) of the liver is an uncommon benign lesion. It is usually difficult to differentiate from hepatocellular carcinoma (HCC), peripheral-type cholangiocellular carcinoma (CCC), combined HCC-CCC, and liver metastases. On account of its rarity and controversial issues, we report a case report and review the literature to discuss its clinical features, treatments, radiological, and immunohistochemical characteristics.A 54-year-old woman had a history of primary biliary cirrhosis and chronic cholecystitis. She complained of finding a lesion in the right liver during her last medical check-up by abdominal B type ultrasound. The Contrast-enhanced computed tomography revealed a circular and low-density lesion in the right posterior lobe of the liver, approximately 22.0 × 18.7 mm in size. On magnetic resonance imaging, the lesion showed low-signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Laboratory test results were almost normal.After the postoperative pathological and immunohistochemical examination, the patient was finally diagnosed as having RLH.The patient received right posterior lobe hepatectomy and cholecystectomy.The patient was discharged 11 days after surgery. No evidence of recurrence was noted 1 year after the surgery.Although RLH of the liver is rare, it is necessary to be considered in a liver lesion, especially in female patients. This case report may advance the understanding of RLH of the liver and reduce the number of mistakenly diagnosed patients. RLH had been reported in various organs, including the skin, lung, eye orbit, intestine, and thyroid, but it is an uncommon benign lesion in the liver. It was usually difficult to differentiate from hepatocellular carcinoma (HCC), peripheral-type cholangiocellular carcinoma (CCC), combined HCC-CCC, and liver metastases. There are only 68 cases have been reported in the English literature. The precise etiology and pathogenesis have not yet been unknown, but it was speculated to represent a reactive immunological response to a chronic infection or inflammatory process and associated with malignant tumor. The diagnosis of RLH of the liver was usually difficult because the imaging findings and laboratory test results were nonspecific. The diagnosis usually had not been made until a pathological and immunohistochemical examination was performed after surgical resection. Herein, we describe a patient with RLH of the liver with right upper abdomen dull pain repeatedly.Reactive lymphoid hyperplasia (RLH), also known as pseudolymphoma or nodular lymphoid lesion of the liver was first reported in 1981 by Snover et al.2A 54-year-old woman complained of finding a lesion in the right liver during her last medical check-up by abdominal B type ultrasound. Further inquiry revealed recurrent right upper abdomen dull pain during the last few months. She was diagnosed of primary biliary cirrhosis 2 months ago in local hospital and had the history of chronic cholecystitis for >20 years. All physical examination findings were normal. No elevation of tumor markers including α-fetoprotein, carcinoembryonic antigen (CEA), cancer antigen 125, and cancer antigen 199 was observed. Hepatitis virus markers were all negative and liver function test was normal. HCC was suspected. Therefore, abdominal contrast-enhanced computed tomography (CT) scan was arranged to confirm the diagnosis.The CT Fig.  revealedThe patient was admitted for further examination and treatment. No abnormality was found by blood tests. Abdominal magnetic resonance imaging (MRI) Fig.  showed tThe patient received right posterior hepatectomy and cholecystectomy under the impression of HCC. During the operation, a gray firm lesion about 20 mm in size was found in segment VII of the liver Fig. A. The opThe postoperative course was uneventful and no adjuvant therapy, such as chemotherapy, was administered. No evidence of recurrence was noted 1 year after the surgery.3 It was first described in the lung by Saltzstein et al in 1963. RLH of the liver is an uncommon benign lesion and was first reported in 1981 by Snover et al. RLH is defined histologically as the aggregation of lymphoid follicles typically with reactive hyperplasia of germinal centers showing proliferation of polyclonal lymphocytes without atypia.We report the case of a patient with RLH of the liver. The etiology and pathogenesis of RLH of the liver has not yet been unknown, but it has been speculated to represent a reactive immunological response to a chronic infection or inflammatory process.We reviewed the published literature until 2018/12/25, using the keywords “liver,” “pseudolymphoma,” and “reactive lymphoid hyperplasia,” and we found 69 cases of RLH of the liver. These cases and our case (70 cases) are summarized in Table  most <20 mm. In other words, if we found a single and small (≤20 mm) tumor in female patients, the possibility of RLH of the liver should be considered.The mean age of the patients was 58.2 years . Of the 70 cases, 5 (7.14%) were male patients and 65 (92.86%) were female patients. RHL mostly affected women with single lesion ranged from 4 to 55 mm, However, this connection might be a result of more regular check-up in patients bearing with tumors, but not the tumors themselves.Among the 70 cases, 17 (24.29%) had malignant diseases, including thyroid cancer gastric cancer, colon cancer, uterine/ovarian cancer, renal cell carcinoma, pancreatic cancer, common bile duct cancer, and HCC. It had been reported the connection between RLH and malignant tumors. Among the 70 cases reviewed, 12 (17.14%) had extrahepatic autoimmune diseases, including Sjogren syndrome, autoimmune thyroiditis, Takayasu aortitis, antiphospholipid syndrome, and CREST syndrome, among others.Although the etiopathogenesis of RLH of the liver is unknown, RLH of the liver was considered to be resulted from mechanical stimulation in patients with extrahepatic autoimmune diseases.,15 In addition, lymphoid follicles are generally found in a liver with chronic liver diseases but not in a normal liver.RLH of the liver had been reported to be associated with chronic liver diseases. Among the 70 cases reviewed, 20 (28.57%) had chronic liver diseases, including primary biliary cirrhosis in 12cases, viral hepatitis in 6 cases, and nonalcoholic steatohepatitis in 2 cases. The present patient also had the history of primary biliary cirrhosis. RLH of the liver had been reported to develop after interferon treatment for chronic hepatitis. However, in this case, it was low-density lesion in arterial phase. The signal faded in portal phase and delayed phase. On MRI, the lesion tended to reveal low SI on T1WI and high SI on T2WI, which was consistent with our case. However, all these imaging findings were not specific for RLH of the liver. According to the reports of CT and MRI in this case, we also misdiagnosed with HCC preoperatively.Imaging findings of RLH of the liver are similar to malignant lesions of the liver, such as HCC, CCC, and liver metastatic tumor. Therefore, preoperative diagnosis of RLH of the liver is extremely difficult with imaging findings alone. Among the 70 reviewed cases, 29(41.43%) had been misdiagnosed with HCC preoperatively. And, to our best knowledge, there was no case diagnosed with RLH of the liver preoperatively. RLH of the liver tended to show low density on CT, slight early enhancement in arterial phase, and low to isodensity in the delayed phase.Hepatic biopsy had been considered to get a definitive diagnosis. But we did not think it would be able to provide an accurate diagnosis and hepatic biopsy may lead to malignant tumor cells metastasis. Therefore, we decided to perform the right posterior lobe hepatectomy and cholecystectomy rather than hepatic biopsy. Finally, the immunohistochemical results helped us to make the accurate diagnosis. In this respect, the difference between RLH of the liver and other liver malignant tumors, especially HCC, were obvious.–19 However, RLH of the liver is a benign lesion, and there are no reports of malignant transformation or local or distant recurrence of RLH of the liver from various follow-up periods ranging from 3 months to 5 years. Thus, if the preoperative diagnosis was established, surgical resection may not be necessary and routine follow-up was recommended. But as the radiological features of RLH was similar to malignant lesions, preoperative diagnosis was often challenging. Therefore, at present stage, surgery operation is still the most best treatment option.It was reported that malignant transformation of RLH into lymphoma in lung, stomach, and skin existed.4We herein described a patient with RLH of the liver with recurrent right upper abdomen dull pain. The diagnosis of RLH of the liver was not made until pathological and immunohistochemical examination was performed after surgical resection. This case showed that when a diagnosis of RLH of the liver is temporarily impossible, timely surgical treatment may be helpful for an early diagnosis, thereby improving the prognosis.Conceptualization: Wenyan Zhang.Data curation: Wenyan Zhang.Investigation: Wenyan Zhang.Project administration: Shusen Zheng.Resources: Wenyan Zhang.Writing – original draft: Wenyan Zhang.Writing – review & editing: Shusen Zheng.


The patient was asymptomatic and had undergone a non-contrast CT scan of the upper abdomen, which showed malrotation of the liver. The purpose of submitting this case report is to make radiologists and surgeons aware of this unusual anatomical variation. Malrotation of the liver as a part of heterotaxy syndrome or situs ambiguous has been reported, but isolated malrotation of the liver without polysplenia in an adult male is a rare entity. A similar case has been reported in the literature as an incidental autopsy finding. Relevant references to this case are given below.Congenital malformations of the liver are rare occurrences. We are reporting a case of  Lobar anomalies such as an accessory lobe or situs abnormalities are usually found as an incidental finding in all age groups during surgeriesinsitu, with the inferior surface and the gallbladder facing anteriorly (An 82-year-old Indian male presented to the surgical outpatient department with complaints of non-specific left flank pain. During the course of the investigations, a non-contrast CT scan was performed, which was unremarkable except for the liver. The liver appeared to be malrotated teriorly . The lefteriorly  and the teriorly . No evidteriorly . Anotherteriorly . No cont1 Usually anatomical variations related to situs anomalies are more commonly found in the paediatric population.3 Liver malrotation is an extremely rare event. Only two cases have been reported in the literature. One was in a patient with antiphospholipid antibody syndrome as an incidental post-mortem finding by Zhong,4 and the other in an adult with congenital diaphragmatic hernia.5 To the best of our knowledge, no such finding has been reported in a living patient. Owing to the patient's old age and financial constraints, a contrast study was not performed and we lost the patient to follow-up.From the middle of the third to early fourth week of development of a fetus, the hepatic diverticulum appears at the distal end of the foregut as an endodermal epithelium. The liver bud, after penetrating the septum transversum, divides into the right and left parts, which ultimately give rise to individual lobes. The pars cystica, which gives rise to the gallbladder and cystic duct, is a ventral outgrowth from the developing bile ducts. The bile duct, which initially opens in the developing duodenum ventrally owing to rotation of the gut, eventually opens dorsally. Anatomical variation of the liver is a rare incidental finding, with very few of them posing any physiological or functional limitations to the organ. Lobar or segmental agenesis or fusion constitutes the majority of anatomical variations.Anatomical variations of the liver as well as other gut structures should be noted and kept in mind before any operative procedure of the abdomen and pre-operative evaluation of such conditions is extremely useful. With recent advances in radiology and the increasing use of investigative procedures, radiologists should be aware of such anatomical variations. The occurrence of such a rare malrotation of the liver in a living subject makes this report a unique one.Anatomical variation of the liver is a rare entity and the majority of cases are seen with some rotational abnormalities of the gut.Isolated malrotation is an extremely rare condition wherein the inferior surface of the liver and the gallbladder face anteriorly.These conditions can create problems for clinicians and radiologists in making a diagnosis.Cholecystectomy, whether open or laparoscopic, needs a special incision as well as approach and the surgeon should be aware of the exact anatomy of the biliary tract in the patient. Hence preoperative MR cholecystopancreatography is necessary.Clinicians and radiologists should always look for signs and symptoms of associated congenital anomalies such as gut malrotation, congenital diaphragmatic hernia, etc.


Thymic carcinoids are a rare type of malignant neuroendocrine tumors which have a poor prognosis due to their distant metastasis, invasive behaviour, and postoperative recurrence. Surgical resection is still the fundamental mode for treating thymic carcinoids. Here, we report the rapid shrinkage of an atypical thymic carcinoid with multiple metastases following chemoradiation plus octreotide as a first-line therapyA 39-year-old Chinese man presented with chest tightness, dyspnea with a history of lumbago and untreated malignant thymoma.Thoracic computed tomography (CT) scan revealed an anterior mediastinal mass with pulmonary and multiple bone metastases as well as bilateral pleural and pericardial effusions. Percutaneous needle biopsy was performed on the mediastinal mass and the pathological diagnosis was neuroendocrine carcinoma of moderately differentiation The tumor was considered unresectable because of extensive invasion into the lung and various bones. The patient was started on paclitaxel and oxaliplatin per 21 days for 4 cycles, and on 20 mg of depot formulation of octreotide once per 21 days. After 2 cycles of chemotherapy, the patient received concurrently mediastinal radiotherapy (39.6 Gy × 22 fractions).A follow-up CT of the chest at the completion of his fourth chemotherapy regimen demonstrated, approximately 22% of tumor shrinkage. There were no signs of disease progression but the patient refused further chemoradiation treatment. The patient received monthly treatment of octreotide and zoledronate and his progression-free survival reached 18 months. Due to uncontrollable disease progression, the patient expired.Early diagnosis and radical surgery of thymic carcinoid are very important. However, radiotherapy (combined/noncombined chemotherapy) must be considered if radical resection is not performed. We believe that further study of chemoradiation and octreotide with the palliative intent of preparing tumors for shrinkage is warranted as a strategy to improve curative management of neuroendocrine tumors. These tumors are currently classified based on their histopathologic features as well-differentiated, moderately differentiated, and poorly differentiated neoplasms.,5 They have a poor prognosis due to their distant metastasis and invasive behavior as well as their high recurrence postoperatively. Over 70% of patients can develop local or distant metastases within 5 years after diagnosis. Based on the largest study to date, the most frequent metastatic sites include lymph nodes, lung, and bone. Surgical resection is still the fundamental course for treating thymic carcinoids due to lack of effective chemotherapy and radiotherapy. Here, we report the rapid shrinkage of an atypical thymic carcinoid with multiple metastases following chemoradiation plus octreotide as a first-line therapy in a 39 year-old man.Thymic carcinoids, a rare type of neuroendocrine tumors developing from the foregut, were first described as a separate entity by Rosai and Higa in 1972.2Standard care is performed, so ethical approval is not applicable in this study. Written informed consent was obtained from the patient.A 39-year-old Chinese man, in a compulsive semireclining position, presented to our hospital for investigation and treatment with chest tightness, dyspnea, and long-term lumbago in April 2010. Prior to this, he was radiologically diagnosed with malignant thymoma and underwent no treatment due to financial constraint in June 2009. Thoracic computed tomography (CT) scan revealed an anterior mediastinal mass measuring approximately 142 mm × 187 mm, with pulmonary and multiple bone metastases as well as bilateral pleural and pericardial effusions  and oxaliplatin  per 21 days for 4 cycles, and on 20 mg of depot formulation of octreotide once per 21 days. After 2 cycles of chemotherapy, the patient received concurrently mediastinal radiotherapy (39.6 Gy × 22 fractions). No treatment-related toxicity was observed. During the 4 cycles of chemotherapies and radiotherapy, the patient reported significant relief of chest pain, dyspnea, and lumbago. A follow-up CT of the chest at the completion of his fourth chemotherapy regimen demonstrated that the tumor measuring about 100 mm × 145 mm, approximately 22% of tumor shrinkage between pre- and postchemotherapy , with an average age of 43 years (range 39–60 years). Atypical thymic carcinoids are moderately differentiated neuroendcrine carcinomas of the thymus with a high rate of metastasis. These tumors show a 5-year survival rate of 60% and their recurrence is common.,9 Moreover, the severity of the disease is often neglected because the clinical presentation is relatively benign. Hence, thymic carcinoids are generally discovered at a far advanced stage, which may also account for the poor prognosis. Indeed, our patient presented with chest tightness, dyspnea, and long-term lumbago with an underlying thymic carcinoid, and finally was considered as inoperable due to tumor invasion into the other parts of the body. Therefore, a palliative approach was considered with the aim of relieving symptoms and thereby improving the quality of life. This suggests that it is urgent to consider these tumors in the differential diagnosis of mediastinal masses when detected by imaging techniques.Thymic carcinoids represent uncommon neoplasms. Their annual over all age-adjusted incidence has been reported to be approximately 1 of 10,000,000 It is proposed to outline atypical carcinoid by neuroendocrine morphology and mitotic counts between 2 and 20 per 2 mm2 of viable tumor or Ki67 index. It is believed that thymic carcinoids have the same biological behavior as small cell carcinoma. The case reported here was diagnosed as atypical thymic carcinoid with extensive metastases (in bone and lung). The prognosis of this disease is generally based on the following: tumor size: the tumor with diameter of < 1 cm is less likely to metastasize, and the one of > 2 cm will more likely metastasize; depth of tumor invasion: the deeper invasion, the more lymph node and distant metastases; tumor location: the closer the tumor from the head, the poorer the prognosis will be; and Others: syndrome of inappropriate secretion of antidiuretic hormone (SIADH) presages a worse prognosis.Thymic carcinoids are a type of neuroendocrine tumors, which comprise a spectrum ranging from well-differentiated to poorly differentiated ones. The criteria to differentiate between typical carcinoid and atypical carcinoid have been revised by European Neuroendocrine Tumor Society (ENETS).,10,12 If the tumor is unresectable, debulking surgery is still considered to be the best choice. There are different views on the role of chemotherapy and radiotherapy in the postoperative management of thymic carcinoids. Although adjuvant therapy may offer local disease control, it is not effective to eradicate tumors and to prevent the development of recurrence or metastases. Nonetheless, adjuvant radiotherapy has been reported in prevention of local-regional recurrence. Single agent or combination chemotherapies with 5-fluorouracil, streptozocin, carmustine, VP-16, and cisplatin have been used previously without any significant impact on the recurrence rate or overall survival.,15 Recently, antitumor effect of long acting octreotide on thymic carcinoids was reported.–18 Octreotide is a synthetic analog of somatostatin with a similar spectrum of actions but a longer biological half-life. It has been proven to have antitumor effects indirectly by inhibiting growth factors like vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and the growth hormone (GH)/insulin-like growth factor-I (IGF-I) axis. In our case, in addition to administration of paclitaxel and oxaliplatin, the patient received octreotide and concurrent radiation from the third cycle of the chemotherapy. Our patient experienced good radiologic response within 8 weeks. This is much earlier than the median time of about 3 months for a response to octreotide alone. Our patient's good response to the combination therapy indicates that octreotide in combination with paclitaxel and oxaliplatin or combination of paclitaxel and oxaliplatin alone was responsible for tumor shrinkage. To our knowledge, this is the first case where octreotide has been used in combination with paclitaxel and oxaliplatin and concurrent radiation as the first-line therapy for metastatic thymic carcinoid. The combination therapy that inhibits mitosis might be the most effective approach for this patient. Our patient had a good quality of life during the treatment and was discharged in good clinical conditions. However, a long-term follow-up is required as the unresectable tumor is still in high risk for disease progression and even causes death.Thymic carcinoids often behave aggressively. Radical surgical excision of the thymus is the first treatment of choice for thymic carcinoids as chemotherapy and radiotherapy are not effective for prolonging survival.We thank Jing Yu  for the technical advices in the preparation of this manuscript.Conceptualization: Zhu Mei.Data curation: He Wang.Formal analysis: Shengnan Ren.Project administration: Yanhong Gu.Writing – original draft: Zhu Mei.Writing – review & editing: Juan Wei.


A previously healthy 34-year-old man presented with a four-week-old upper arm injury that started with a cat scratch and progressed into painless erythematous nodular ascending lesions in the left upper limb. We made the diagnosis of sporotrichosis based on the epidemiological association of the contact with a cat and culture identification. Sporotrichosis is a mycosis implantation caused by the Sporothrix schenckii complex. We present the first Central American case of sporotrichosis associated with contact with a feline. Sporotrichosis is a subcutaneous mycosis caused by the dimorphic fungus Sporothrix schenckii (S. schenckii), which is usually found in tropical and subtropical zones but has been found worldwide on occasion -2. TypicThe number of reported cases of zoonotic infections from feline-related sporotrichosis is increasing. Zoonotic cases have been reported in the United States (US), India, Malaysia, Argentina, and Mexico, but no cases of zoonotic transmission have been reported from the Central American region until this one -5.According to Ministerio de Salud: Resolución No. 2283, “due to the high incidence of feline sporotrichosis, Rio de Janeiro is presently considered hyperendemic for cat-associated sporotrichosis”  and has Panama is considered a leishmaniasis hyperendemic area and has a population at 75% risk for contracting cutaneous leishmaniasis .The clinical presentation of sporotrichoid leishmaniasis has been observed in America and in our clinical practice. Differentiating cutaneous leishmania from sporotrichosis is a clinical diagnostic challenge given the similarity of the lesions and the epidemiologic antecedent of inoculation of the fungus through thorns, splinters, and small scratches received during leisure and occupational activities, such as floriculture, horticulture, gardening, fishing, hunting, farming and cattle raising, mining, and wood exploration -10.Our case presents an atypical zoonotic transmission of sporotrichosis and represents the first such reported case in Panama.A previously healthy 34-year-old man from La Espiga, Chorrera district, Province of West Panama, presented to our institution with ipsilateral, painless, erythematous, nodular ascending lesions in his left hand, forearm, arm, and axillary region. The lesions followed a lymphangitic path. The patient reported that one month before presentation, the lesions started as a cat scratch on the third finger of his left hand. The lesions were not associated with fever or signs of infection. The patient is a laundryman who is in regular contact with eight cats, and he has no history of trauma from the manipulation of plants, leisure, or occupational activities. Before presenting to our clinic, he went to a health center where he was administered topical silver sulfadiazine, but the condition did not improve.On physical examination, we noted a nodular, erythematous, ulcerated lesion on the middle finger of his left hand with additional nodular, erythematous lesions that were not painful on palpation and had no differences in temperature. Some of those lesions were ulcerated. We found three similar lesions on the dorsum of his left hand. On the patient’s forearm, we found nine lesions on the posterior forearm, four lesions on the anterior forearm, and one on the medial forearm. On his arm, we found three lesions in the anterior area, seven in the medial area, and four in the lateral area Figure . We noteThe 72-hour Montenegro skin test yielded a negative result. On the day-10 follow-up visit, we scraped the lesion for polymerase chain reaction (PCR) testing, culture and smear for Leishmania, and an acid-fast bacillus ) smear for cutaneous tuberculosis. The result of the AFB test was negative.We prepared Saboraud cultures to rule out sporotrichosis, placing the samples on two slides for visualization. On the first slide, we added a drop of 20% potassium hydroxide, in the other, a drop of lactophenol blue. After 10 minutes, we observed the slides at 400x and 1000x magnification for fungal structures. The positive sample was seeded on Saboraud agar and Micosel .2 segment of sterile Saboraud agar was taken with a sterile scalpel and placed on a clean slide. This segment was then inoculated with a needle loaded with the fungal culture. A sterile slide was mounted and placed in a Petri dish with a paper towel wetted with sterile water as a wet chamber. The culture was incubated at room temperature until growth was observed on the coverslip, which was then carefully peeled off to mount it on a slide cleaned with 70% ethanol with a drop of lactophenol blue for microscopic observation for structures such as conidia, hyphae, or spores indicative of the S. schenckii complex.After 15 days of incubation with notorious fungal growth, we incubated a culture. A 1-cmThe patient was treated with itraconazole 100 mg orally each day for 90 days and recovered with a full resolution of the lesions.The diagnosis of sporotrichosis in endemic areas consists of an epidemiological diagnosis and a history of accident, trauma, puncture, or contact with plants and vegetation, as well as any exposure risk associated with the patient’s occupation ,6. AdditIn any consultation of traveler's medicine , dermatology, or tropical medicine, samples should be collected with the intent to rule out both leishmaniasis and sporotrichosis. In our case, according to the Republic of Panama guidelines for leishmaniasis, we performed PCR, smear, and culture, and searched for mycotic isolation to arrive at the diagnosis of sporotrichosis ,8,11.Cutaneous leishmaniasis and sporotrichosis are managed differently. Cutaneous leishmaniasis is treated with pentavalent antimonials as the first-line treatment; sporotrichosis is treated with imidazole antifungals such as itraconazole. A correct differential diagnosis is important for implementing an adequate therapeutic approach ,8. Our cSporotrichosis is traditionally associated with occupational exposure in patients active in farming, gardening, or otherwise manipulating plants. Zoonotic transmissions are rarely considered when diagnosing this entity, and evidence suggestive of sporotrichosis is usually revealed while taking the patient’s history where accidental exposure to plants is disclosed. Our case represents the first report of the zoonotic transmission of sporotrichosis in the Central America region. Other researchers and healthcare providers in Central America should consider zoonotic transmission within their diagnostic algorithms, especially when evaluating patients with characteristics similar to those reported in this case who may have been in contact with animals such as cats or armadillos.