This case report describes the procedure and outcome of regenerative endodontic treatment (RET) in a tooth with incomplete root apex and posttreatment apical periodontitis. A 44-year-old patient was referred to the endodontist because of a periapical lesion on tooth #21 and a recent episode of acute periapical abscess. On clinical and radiographic examination, this tooth presented with tenderness to percussion and palpation, periapical radiolucent lesion, external apical resorption, and incomplete apex formation. After coronal access, the filling material was removed, and the canal was gently prepared with hand files, using 1% NaOCl as the main irrigant followed by final irrigation with 17% EDTA, activated with XP-endo Finisher . The root canal was filled with a double antibiotic paste with ciprofloxacin and metronidazole (1:1). After three weeks, RET was performed by stimulating bleeding into the canal, and when a clot was formed, a bioceramic  plug was placed on it, followed by coronal restoration. The tooth remained asymptomatic since RET was concluded. Clinical and radiographic follow-ups showed complete repair of the apical periodontitis lesion and the absence of symptoms after eight months. This satisfactory outcome was confirmed after 34 months. Key words:Bioceramic material; ciprofloxacin; metronidazole; persistent apical periodontitis; regenerative endodontic treatment. Pulp necrosis and infection in immature teeth occur primarily because of caries, trauma, or dental anomalies such as dens invaginatus . DiffereRegenerative endodontic treatment (RET) has demonstrated promising outcomes, with potential to stimulate continued root formation (length and thickness), reestablish tooth sensitive function, and promote healing of apical periodontitis . This trRET has become the first treatment choice for immature teeth with pulp necrosis  and has The present case report describes the procedures and outcome of RET in a tooth with persistent apical periodontitis after previous root canal treatment.A 44-year-old female patient with noncontributory medical history was referred to an endodontist (R. L.). According to the report, she had developed an acute alveolar abscess in the left maxillary anterior area one month before. The abscess had been treated with systemic antibiotics  and analgesics . Dental history revealed a previous traumatic injury in the anterior maxillary teeth at the age of 12 years. Subsequently to trauma, conventional root canal therapy was performed in tooth #21, and at the age of 34 years, it was retreated.On clinical examination, tooth #21 presented full crown coverage and tenderness to percussion and palpation. Periapical radiographs showed a large poorly-filled canal space associated with a discrete periapical radiolucent lesion confirmed by cone-beam computed tomography (CBCT), which also revealed a slightly overextended root canal filling, external apical root resorption, and incomplete apex formation of tooth #21  ,9. The rAfter 3 weeks, the patient returned and the tooth was anesthetized with 2% lidocaine without vasoconstrictor, isolated with a rubber dam, and accessed. The intracanal antibiotic paste was removed using a hand K-file and irrigation with 20 mL 1% NaOCl. A final rinse was performed with 10 mL 17% EDTA. Next, bleeding was induced by passing a size 30 K-file 2 mm beyond the apex. After an intracanal clot was formed, a bioceramic  plug was placed in the coronal third of the root canal, followed by a permanent coronal restoration using composite resin.The tooth remained asymptomatic since RET was concluded. Clinical and radiographic follow-ups showed the complete repair of the apical periodontitis lesion and the absence of signs or symptoms of inflammation after 8 months Fig. . After 3Persistent intraradicular or extraradicular infections are the major causes of posttreatment apical periodontitis . TherefoRET is mostly indicated for immature teeth with necrotic pulps and apical periodontitis, with more predictable results in young patients . Dental In this case report, irrigation was performed with 1% NaOCl since it has reduced cytotoxic effects and less denaturing effects on the dentinal walls when compared to higher concentrations, mainly when EDTA is employed as the final rinse . The finAlthough the American Association of Endodontists recommends the use of low concentration antibiotic pastes or calcium hydroxide as options for RET, the European Society of Endodontology recommends calcium hydroxide as the first option because of some drawbacks related to the antibiotic pastes, including tooth discoloration, cytotoxicity, sensitization, development of resistance and difficulty of removal from the root canal. However, further studies are necessary to confirm the real impact of these issues, considering that the medication is confined to the root canal.Evidence suggests that proper regeneration of the pulp-dentin complex does not occur after RETs, and histologic analyses revealed cementum-like tissue and uninflamed fibrous connective tissue inside the root canal . AlthougThis case report shows that RET was successfully used to retreat a tooth with incomplete apex formation and posttreatment apical periodontitis. This approach led to a favorable and sTable outcome for almost 3 years, represented by the elimination of signs and symptoms and periradicular tissue healing. Continued root formation and thickening of the canal walls are generally not expected in cases like this. Randomized, prospective trials, with long-term follow-up examination, are required to establish if RET is a viable alternative to conventional root canal treatment/treatment to deal with infected mature teeth associated with apical periodontitis.


Generally, glomus tumors are considered tumors of the autonomic system arising from chromaffin cells of the parasympathetic paraganglia of the skull base and neck. Glomus tympanicum is the most common primary tumor of the middle ear cavity and it arises from the paraganglia of the middle ear.We present a case of glomus tympanicum presented in a 70-year-old woman, complicated with facial nerve palsy which at first sight was misdiagnosed as cholesteatoma. Patient presented in our clinic because of otorrhea, pulsatile tinnitus and hearing loss in the right ear. However, facial nerve function was good in the first examination (40 days before the surgery). Eventually, she treated successfully with a canal wall down mastoidectomy. Technique had been chosen because of the mass size and the involvement of external auditory canal, after a discussion with the patient.Although histologically benign, glomus tympanicum is slow growing and destructs adjacent tissues potentially. The two most common complaints are hearing loss (conductive) and pulsatile tinnitus. These neoplasms are more common in women and they can be diagnosed by CT or MRI scan. It is of high importance physicians suspect a glomus tumor when patient ‘s clinical findings are hearing loss and pulsatile tinnitus and use an intravascular agent in imaging so that the differential diagnosis will be supported. Glomus tympanicum is the most common primary tumour of the middle ear cavity  therefor A 70-year-old woman presented at our Ear, Nose, and Throat (ENT) clinic complaining about bad smell and otorrhea, pulsatile tinnitus and sense of ear fullness on the right side over the last 12 months. Her past medical history was otherwise normal. On otomicroscopy, there was identified a mass occupying completely the external auditory canal, which rendered impossible the overview of the tympanic membrane. Moreover, there was a mild and painless mastoid redness respectively. A pure tone audiometry was performed and it revealed a moderate mixed hearing loss in right ear and a mild sensorineural hearing loss in left ear . A computed tomography (CT) was scheduled revealing soft tissue density in the whole middle ear cavity with expansion in the mastoid and the external auditory canal (EAC), soft tissue ossification elements and smooth erosions of petrous part of temporal bone . Radiology report attributed these findings to middle ear cholesteatoma. The patient was prescribed local antibiotics with the aim to resolve otorrhea. Because of the excessive mass size, which occupied the whole middle ear and seemed to had affected the bone structure in CT scan and because our team wanted to be certain about the complete exclusion of the tumor, a radical mastoidectomy was planned one month later. The night before the surgery the patient presented facial nerve palsy (House-Brackmann III) . There was administrated intravenous steroid (methylprednisolone 500 mg) immediately. The following day, at the beginning of the surgery, fragments of the tumor of the EAC were biopsied. Biopsy caused continuous bleeding and the attempt for hemostasis doubled the surgical time. Eardrum perforation and ossicular erosions  had been found during the operation. Frozen section reported possible malignancy with concomitant inflammatory elements, without covering epithelium. Αn uncomplicated canal wall down mastoidectomy was performed. Facial nerve palsy resolved postoperatively (House-Brackmann I) . The finAn MRA and MRI was performed postoperatively (after 1 month) which revealed no evidence of disease in the vascular system, the presence of chronic inflammatory lesions in petrous part of temporal bone and some fluid in mastoid cells, that can be justified from the surgery and it is expected to be absorbed . At 1-yeGlomus tumor or chemodectoma or paraganglioma, constitute the most common primary neoplasm of the middle ear, and the second most common tumor of the temporal bone, called glomus tympanicum . There aAround 5% to 10% of these tumors secrete catecholamines  causing hypertension, headaches, flushing and cardiac arrhythmias  of the temporal bone and skull base ,9. AdditIt is of high importance that every otolaryngologist should recognize such a tumor and be aware of a possible disastrous bleeding event in case of probing in clinic. An imaging technique with intravascular contrast media would be necessary and helpful for an accurate diagnosis in future similar cases. The treatment is individualized since for older patients with poor physical condition radiotherapy is the treatment of choice, while younger ones are candidates for surgical removal after angiography and embolism ,12-14. Physicians should also be open to other modalities of treatment, including use of the gamma knife. Method of consent was verbal for this article.


Bezold’s abscess is a deep neck abscess related to otomastoiditis. Due to the insidious clinical presentation, diagnosis can be extremely challenging, leading to delays in treatment and possible life-threatening complications. The literature currently provides a fragmented picture, presenting only single or small number of cases. The present study aims at examining our experience and the literature findings (based on PRISMA criteria) of 97 patients with Bezold’s abscess, summarizing their epidemiology, pathogenesis, clinical presentation, imaging findings, and treatments. Bezold’s abscess is found at any age, with overt male prevalence among adults. The clinical presentation, as well as the causative pathogens, are strikingly heterogeneous. Otomastoiditis and cholesteatoma are major risk factors. A clinical history of otitis is commonly reported (43%). CT and MRI are the main diagnostic tools, proving the erosion of the mastoid tip in 53% of patients and the presence of a concomitant cholesteatoma in 40%. Intracranial vascular (24%) or infectious (9%) complications have also been reported. Diagnosis might be easily achieved when imaging (CT) is properly applied. MRI has a limited diagnostic role, but it might be crucial whenever intracranial complications or the coexistence of cholesteatoma are suspected, helping to develop proper treatment (prompt antibiotic therapy and surgery). Bezold’s abscess is a potentially life-threatening laterocervical/deep neck abscess complicating the course of an otomastoiditis ,2. FirstDespite the high incidence of acute otitis media, Bezold’s abscesses are rare, especially in the pediatric population . In a reThe PubMed database and Google Scholar were screened up to August 2021, using the following Keywords and Meshes: “Bezold’s abscess”; “Bezold” AND “abscess”; “Bezold’s mastoiditis”. The literature search was performed by two authors independently (SV and MM), according to PRISMA criteria .All the retrieved publications were evaluated to identify the most relevant articles. Duplications or aggregations of pre-existing data were excluded; only articles in English and Spanish were included. The reference lists of selected articles were also analyzed to identify additional studies.Every misalignment the authors had with regards to article eligibility was solved through discussion.Eighty-eight articles were identified: four were excluded due to unavailability of their full text both online and in main Italian medical libraries. Eighty-four studies were therefore considered; publication year ranged between 1898 and 2021.Our direct experience of four cases  were also considered for discussion and for imaging illustration.p < 0.05 was considered significant.The chi-square test and Student’s t-test were used when appropriate; a A total of 97 patients with Bezold’s abscess was found . Males were substantially prevalent .p = 0.4), whereas sex distribution differed significantly between pediatric and adult patients (p = 0.01). Bezold’s abscess occurred similarly in males and females who were up to 5 years old  and under 18 years old . In contrast, among adult and elderly patients, males were strikingly more frequently affected .There was no significant difference in age between males and females , with heterogeneous results .Bezold’s abscess clinical onset was also highly heterogeneous .p < 0.001).CT was performed in 80% of patients, MRI in 22%. Mastoid tip erosion was frequently documented , especially when underlying cholesteatoma was present. Among the 35 patients with concomitant cholesteatoma, 28/35 had mastoid tip erosion  and vascular complications .Bezold’s abscess is rare but can be found at any age. Its occurrence in the first five years of life has been considered anecdotal, due to the lack of pneumatization of the mastoid cells and the consequently thicker mastoid walls  that hamFurthermore, sex differences in mastoid development and pneumatization ,10 mightBezold’s abscess typically complicates the course of chronic/recurrent otomastoiditis, even though few exceptions have been reported . This specific type of abscess accounts for 6% of otogenic abscesses . Indeed,According to the currently leading hypothesis, the retained purulent collection can lead to erosion of the cortical bone in a locus minoris resistentiae, the digastric groove, forcing the drainage of the pus into the neck (Bezold’s abscess) . This hyCholesteatomas are slowly growing masses usually appearing in the middle ear, occupying the Prussak space, expanding upwards and displacing the ossicles . When a Among the 39 patients with cholesteatoma, only one showed an intact mastoid, as the lesion stemmed from the os tympanicum . In someMicrobiological cultures’ results were strikingly heterogeneous in the reviewed cases, possibly also because early empirical antibiotics therapy might hamper pathogen identification. The large spectrum of pathogens emerging from the analysis of existing literature has obvious implications for diagnosis and treatment.Bezold’s abscess might be difficult to recognize, as its clinical presentation is highly heterogeneous, ranging from signs of neck tissue inflammation or fever to otorrhea or facial paralysis. Neck symptoms are the most reported , even thThe evaluation through palpation is limited, as the purulent collection lies deep in the neck ,8, whereHowever, involvement of the neck’s subcutaneous layers or skin is not rare in the literature  its existence has been detected by simple otoscopy ,37,38,39 cases itLaboratory parameters are usually altered, with elevated leukocytes and C-reactive protein or erythrocyte sedimentation rate, consistently with a bacterial infection. In rare cases (four patients in literature) laboratory tests may be unremarkable or slightly above normality. In these cases, tuberculous otitis media ,40, poorDifferential diagnosis mainly includes lymphadenopathies, infected branchial cysts, temporal bone subperiosteal empyema, and other neck abscesses. The differential diagnoses are derived from available case reports investigating the main reasons for Bezold’s abscess diagnostic delay.Bezold’s abscess might mimic a lymphadenopathy accompanying otitis . Neck ulWhen dealing with suppurative processes originating from the mastoid bone, the diffusion pathway through the neck should be considered as this might be pivotal for subsequent evolution and for treatment planning. Suppurative processes from the mastoid might spread through bone erosion along three different paths: medial, lateral, or posteromedial . Due to A bone erosion medial to the mastoid allows the pus to spread to the posterior cervical and perivertebral spaces, deep into the sternocleidomastoid muscle (Bezold’s abscess); a posteromedial bone erosion can result in pus spreading posteriorly to the insertion of the digastric muscle and in the occipital region (Citelli’s abscess); a bone erosion lateral to the mastoid can give origin to a subperiosteal empyema that usually reaches the surface in the peri-mastoid subcutaneous spaces. However, this strict classification might not be appropriate in case of neck anatomy variants, erroneous identification of suppurative diffusion processes or coexistence of multiple paths. In fact, literature reports cases of Bezold’s abscess concomitant to subperiosteal empyema ,47,48,49Ultrasonography can represent a valuable first-line diagnostic tool, especially with children, to exclude reactive lymph nodes and detect neck abscesses that appear as anechoic or hypoechoic inhomogeneous collections .However, CT and MRI are the best tools in identifying abscesses and concomitant mastoiditis features and providing useful information for the surgical approach as simple neck abscess drainage might be insufficient for eradicating the infection and ultrasonography shows only the “tip of the iceberg” and not the source of infection . In addiIn the clinical suspicion of a Bezold’s abscess, temporal bone CT and contrast enhanced neck CT are the gold standard  for defiHowever, despite its crucial pathogenic role for the suppurative path, bone defects in the mastoid tip have been precisely outlined only in around half of all literature reports . Indeed, in 7/97 patients (7%) the mastoid tip was considered intact, revealing that the diagnosis of Bezold’s abscess can be achieved even without overt bone erosion, especially in younger children (3/7 patients were younger than 5 years old). The incomplete pneumatization of mastoid cells before the age of five is well known and is supposed to hinder the diffusion of the suppurative process across the thickened mastoid bone wall. Before the age of five, more destructive infectious processes or emissary vein bone canals likely allow Bezold’s abscess occurrence . A recenTemporal bone CT also allows for detection of intracranial bone erosions possibly leading to further life-threatening complications : sinus tContrast-enhanced neck CT aims at demonstrating and precisely defining the anatomical limits of the neck abscess that appears as a low-attenuation collection with typical rim enhancement  and surrIn some patients the abscess might trespass the deep cervical fascia and reach the surface see  subvertiThe role of MRI in the diagnosis of Bezold’s abscess is generally limited, being a “problem solving modality" used when intracranial complications or osseous disease are expected. In literature, MRI findings are reported for only 21/97 patients. Indeed, the first MRI report dates to 2001. The low rate of MRI reports likely depends on two concomitant factors: MRI was not available at diagnosis and CT was considered sufficient for proper surgical planning and patient management. However, MRI might be better in specific clinical circumstances  as diffusion-weighted imaging (DWI) best differentiates non-infectious fluid collections from bacterial abscesses.Bezold’s abscess entails a moderate risk of intracranial vascular (23/97) or further infectious (9/97) complications. MRI protocols should therefore include DWI and vascular imaging. DWI best recognizes suppurative collections  showing hyperintense signal on DWI with usually decreased apparent diffusion coefficient values . DWI also detects cytotoxic oedema and intravascular thrombi helping in recognizing recent ischemic strokes or sinus venous thrombosis. Artery and venous intracranial MR-angiography can detect vessel occlusion consistent with thrombosis, thus confirming CT-angiography findings and allowing a less invasive follow-up. These sole sequences cover most intracranial complications of mastoiditis associated with Bezold’s abscess and are therefore of utmost importance for subsequent patient management.In the literature, cholesteatoma ipsilateral to Bezold’s abscess was reported in around 40% of patients. Cholesteatoma likely favors repeated mastoid bacterial superinfections and facilitates, by bone erosion, the spread of suppurative process into the neck see . In seveAs far as neck evaluation, MRI usually shows a well-defined area of low T1 and high T2 signal with DWI restriction, a peripherally enhancing rim, and surrounding soft tissue oedema that raise up the mass effect. MRI is better than CT due to its better soft tissues contrast : involveIf Bezold’s abscess is present or suspected, broad spectrum antibiotic therapy with good cerebrospinal fluid penetration should be started, and appropriate imaging performed to evaluate location and size of the abscess collection. The routinely instituted empirical broad-spectrum antibiotic therapy should cover most of the Gram-positive and Gram-negative aerobic and anaerobic pathogens, given the incidence of polymicrobial infections . Early surgery is often mandatory to establish drainage of the middle ear  and mastoid cells. It is necessary to carry out a sampling of the purulent material. The results of pathogen tests allow to replace as soon as possible the initially administered, broad-spectrum antibiotic with one to which the pathogen has (or the pathogens have) a known susceptibility ,63. If aThese observations seem to be in line with a recent study that focused its attention on the management of Bezold’s abscesses in a subgroup of cases of the last 20 years .Bezold’s abscess entails a high risk for life-threatening intracranial, neck, and chest complications. The knowledge of some clinical, anatomical, diagnostic, and treatment aspects derived from literature and this comprehensive case analysis can support clinicians in the most appropriate management, especially considering the imaging features that can save time for a prompt diagnosis and treatment.


To describe the clinical, optical coherence tomography (OCT), and histopathological findings of a patient who was found to have ossification of a pre-retinal membrane after multiple surgical repairs for retinal detachment.The patient had comprehensive ophthalmic examinations during seven years of follow-up and underwent surgical removal of her pre-retinal membrane.A 24-year-old woman with a history of retinal detachment and multiple retina surgeries presented with baseline vision of 20/200 and refractory glaucoma in the left eye . OCT showed a thick epiretinal membrane with hypo-reflective intraretinal spaces in the macula, and exam revealed a chronic retinal detachment superotemporally surrounded by laser barricade. She was stable for six years and then experienced vision loss and decreasing eye pressure, concurrent with rapid evolution of pre-retinal fibrosis, leading to a vascularized consolidation in the mid-periphery, for which she underwent vitrectomy and membrane peel. The vascularized lesion over the area of detachment in the superotemporal retina was removed en bloc through the anterior chamber. Pathological findings revealed woven bone formation anterior to the internal limiting membrane, and the tissue was GFAP negative.Our case adds to the limited knowledge of the chronology, presentation, and surgical management of intraocular ossification, especially of the rarer pre-retinal type. Our patient highlights that development of ossification can happen more quickly than previously thought (year or years rather than decades), can be hidden under vascularized lesions, and is dynamic, with simultaneous release of traction in one area and increased traction in another. Diligent follow-up is indicated even in cases of vitreous membranes from retinal detachment that otherwise appear to have been stable for years. The patient's lesion was surrounded by a vascular capsule and localized in the pre-retinal space over an area of chronic retinal detachment, and bone formation and contraction were associated with concurrent release of traction over the macula. We also highlight the surgical technique of its removal, ultimately leading to improvement in the patient's vision.2trans-scleral cyclophotocoagulation in the left eye for glaucoma management with reduction of her intraocular pressure (IOP) to the low to mid-teens. Her ophthalmic examination (without intraocular inflammation) and visual acuity in the left eye remained stable until year five. She was then lost to follow up for two years due to the COVID-19 pandemic, and in year seven, her visual acuity declined to 20/400 in the left eye, and IOP dropped to 7 mm Hg. At this point, examination of the left eye showed an attached retina posterior to the laser scars, a vitreous membrane with tractional connection to a fibrovascular lesion superotemporally and a lesion nasally, and traction to anterior loop fibrosis as well  eight years earlier and four surgeries in the left eye , with the last surgery done five years earlier, and she was aphakic in both eyes. The original cause of the detachments was not clear given the lack of clinical notes and surgical reports from initial operations done elsewhere; however, there was no documented history of trauma to the eyes. On presentation, her vision was no light perception in the right eye and 20/200 in the left eye, stable from one year ago comparing to outside records. Ophthalmic examination of the right eye revealed band keratopathy with poor views beyond the cornea, and B-scan ultrasonography showed retained silicone oil. The left eye's examination revealed aphakia, absence of vitreous following prior vitrectomy, pale and atrophic disc (0.9 cup-to-disc ratio), attached macula with 360° of laser scars beyond the vascular arcades, and multiple retinal holes, membranes and retinal detachment anterior to the laser, as well as an encircling scleral buckle. Optical coherence tomography (OCT) of the left eye showed retinal thinning in the macula with schisis-like cavities  . In year as well A. OCT sh as well B. Two mo as well , and the3The surgical specimen showed pre-retinal membrane, predominantly composed of woven bone formation (ossification) in front of the internal limiting membrane (Periodic acid-Schiff positive) . No pigm4,,Prior reports of intraocular ossification have been postulated that it results from chronic inflammation and disorganization of the globe, often associated with phthisis after trauma or chronic unrepaired retinal detachment, or uveitis, with ossification as an end stage of disease evolution.,,,,In many of the examples in the literature, pre-, intra- or subretinal ossification is associated with chronic retinal detachment, as it is seen in our case.,It is also interesting that although literature suggests that bone tissue in the eye requires decades to develop,As our patient was already unicameral (aphakic), we were able to remove the calcified lesion through the anterior chamber without the need for an additional sclerotomy. Using endodiathermy to relieve the traction from the fibrous membrane before removal of the calcified plaque also prevented intra-operative breaks that can occur with these procedures.In our patient, bone formation happened concurrently with contraction of the fibrovascular tissue and release of the epiretinal membrane traction upon the macula, leading to resolution of cystoid macular edema. Although calcification is not typically thought of as a dynamic process, our case highlights that it is at least associated with changes in the tractional forces on the retina and therefore should be monitored closely. In addition, ossification may not take as long to develop as had been thought and may warrant diligence in following even stable patients with chronic retinal detachments.Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient.10.13039/100001818Research to Prevent Blindness and All May See Foundation.Financial support: All authors attest that they meet the current ICMJE criteria for Authorship.The following authors have no financial disclosures: CJM, MP, JMS.


Jejunal diverticula are rare medical conditions with an incidence of 0.3%–2.5%, mostly discovered perioperatively. Our patient, 60 years old female, presented in an emergency with complaints of constipation, vomiting, abdominal pain, and distension. On examination, her abdomen was markedly distended with generalized tenderness. An erect abdominal X‐ray revealed multiple air‐fluid levels, which suggests small bowel obstruction. A diagnosis of jejunal diverticula was made on exploratory laparotomy. No evidence of granuloma or malignancy was seen on histopathological examination. Segmental resection of the affected jejunum was carried out, followed by end‐to‐end primary anastomosis. The patient was discharged on postoperative Day 6 with complete recovery at 2 weeks follow‐up visit. Jejunal diverticulosis can cause abdominal pain, but the association with intestinal obstruction is less commonly reported. This case report highlights the need for healthcare providers to be aware of this rare association and to consider the possibility of jejunal diverticulosis in the differential diagnosis of patients with symptoms of intestinal obstruction. It can be caused by various factors such as mechanical blockage, inflammation, or cancer.The management of jejunal diverticulosis presenting as intestinal obstruction can be challenging as it requires a thorough understanding of the underlying pathophysiology and appropriate selection of treatment modalities.Due to delayed diagnosis, patients often present critically and warrant operative intervention, conventionally a segmental resection. Recently, a trend towards conservative management is being increasingly reported to have favorable outcomes. Hence, high index of suspicion and a novel approach to diagnostic deduction are key when confronted with such patients. A timely diagnosis can save the patient from unnecessary exploration.We are presenting the case of a 50‐year‐old female patient who presented to us with complete small bowel obstruction. The novelty of this case report lies in the rare association between jejunal diverticulosis and intestinal obstruction. While it is well known that diverticulosis can cause abdominal pain and other symptoms, the association with intestinal obstruction is less commonly reported. This case report highlights the need for healthcare providers to be aware of this rare association and to consider the possibility of jejunal diverticulosis in the differential diagnosis of patients with symptoms of intestinal obstruction.2A 60‐year‐old normotensive, normoglycemic female patient was referred to our emergency department with complaints of constipation for 10 days, vomiting for 3 days, and abdominal pain and distension for 1 day. There was no relevant family or drug history. The pain and distension were worsening in the last 24 h. There were no aggravating or relieving factors. Her vital signs were slightly abnormal with a pulse rate of 92 beats per min, blood pressure of 112/70 mmHg, and a body temperature of 98.6. On abdominal examination, her abdomen was markedly distended with generalized tenderness and her bowel sounds were slightly sluggish on auscultation.Baseline blood work showed leukocyte count 8.2 10^3u/L, serum amylase 96u/L with remaining parameters in the normal range. Her radiological investigations were carried out and erect abdominal X‐rays revealed multiple air‐fluid levels suggesting intestinal obstruction in the small bowel  which macroscopically revealed the diagnosis of jejunal diverticula. Two jejunal diverticula at 1 and 2 feet from the DJ were present, and the second diverticula was adherent at the ileocecal junction, causing intestinal obstruction. A segmental (20 cm) resection of the affected jejunum was carried out, followed by an end‐to‐end hand‐sewn primary anastomosis (Figure Histopathological examination confirmed the diagnosis and showed a small bowel lined by intact epithelium. Sections from the diverticula showed a moderately dense inflammatory infiltrate composed of lymphocytes, plasma cells, neutrophils, eosinophils, and histiocytes. No evidence of granuloma or malignancy was seen.3Small Bowel Diverticula are a rare and unusual entity and are significantly less prevalent than their colonic counterparts.Jejunal diverticula are mostly multiple and occur predominantly in older men in the sixth or seventh decade.Mostly asymptomatic, JD is discovered at autopsy or preoperatively for unrelated surgery and increasingly during imaging studies. When symptomatic, the presentation can either be vague or it can be life‐threatening in case of ensuing complications. Mostly they tend to mimic colonic diverticulitis.Obstruction can also be caused by intussusception or by extrinsic compression from a nearby loop containing a diverticulumEnteroscopy and enteroclysis are the most sensitive and specific diagnostic tools in hemodynamically stable patients.In asymptomatic JID no intervention is required and when mandated, it is tailored to the presenting complication.In our case, we opted for enterectomy and anastomosis consistent with the approach widely reported.4JID is a rare and intriguing variation of the normal small bowel pathology. They warrant attention not just on account of the potentially fatal clinical implications but also based on the pathophysiological enigma that they pose. Surgeons must be adequately primed to be alert to the presence of this entity as often a conservative approach can be steered at rather than a physiologically disrupting invasive exploration.Munema Khan: Investigation; methodology; writing – original draft. Ruqia Arshad: Investigation; methodology; writing – review and editing. Irfan Malik: Investigation; methodology; writing – review and editing. Ali Kamran: Investigation; methodology; writing – review and editing. Fahad Gul: Investigation; methodology; writing – review and editing. Ka Yiu Lee: Investigation; methodology; writing – review and editing.None.None.Ethical approval was not required as per country guidelines.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Senile gluteal dermatosis (SGD) is a common but seldom recognized condition. It is characterized clinically by unilateral or bilateral hyperkeratotic, lichenified plaques on the gluteal area, being attributed to prolonged sitting, particularly in the elderly. SGD also encompasses the recently proposed entity of prurigiform angiomatosis. Histologically, there are features of lichenification, such as epidermal hyperplasia and a preserved granular layer, with prominent dermal angioproliferation. We report 4 cases of this condition as well as novel findings of variably increased mast cells and superficial lymphatic vessels in addition to the proliferation of dermal blood vessels. We propose a unifying name for Reactive Epidermal hyperplasia and Angiogenesis of the Rear (REAR) to encapsulate the characteristic clinical and histological features of this distinct entity. Senile gluteal dermatosis (SGD) is a common but seldom recognized condition, mainly reported in elderly patients in association with prolonged sitting. It is characterized by unilateral or bilateral hyperkeratotic, lichenified plaques on the gluteal area. Histological features reported have been described as mild and nonspecific, with hyperkeratosis, psoriasiform epidermal hyperplasia, vascular dilatation/proliferation in the upper dermis, and reactive lymphohistiocytic perivascular infiltrate. The clinical and histological features of SGD encompass the entity proposed as prurigiform angiomatosis, which is characterized by the clinical presentation of prurigo/lichen simplex chronicus-like epidermal hyperplasia with prominent dermal angioproliferation. We report four cases of this condition with the aim of highlighting a distinct triad of clinical and histopathological findings of this entity, namely (1) the sitter’s triangle formed by the coccygeal apex and the ischial tuberosities in a person with a history of prolonged sitting, in association with (2) histopathological features of lichenification, and (3) prominent reactive vascular proliferation within the dermis. The authors also propose a unifying name for Reactive Epidermal hyperplasia and Angiogenesis of the Rear (REAR), which highlights both the characteristic clinical and histological features of this condition.The first patient is a 68-year-old Chinese male with hypertension and gastrointestinal reflux disease. He presented with rashes over both buttocks for 2 years, with intermittent pain on sitting. The rash did not improve with topical mometasone ointment. On examination, there were symmetrical erythematous plaques on bilateral buttocks a, inferiThe second patient is a 73-year-old Chinese male with diabetes mellitus, hypertension, hyperlipidemia, asthma, benign prostatic hyperplasia, cognitive decline, and pulmonary tuberculosis. He presented with a lump over his right buttock of 2 years duration, which had been growing recently, with some mild discomfort on sitting down. On examination, there were erythematous plaques on the bilateral buttocks, with scaling and lichenification a. The plThe third patient is a 68-year-old Chinese male with a history of foot eczema. He presented with a right buttock lump of 3 months duration. There was some discomfort in sitting. There had been some improvement with previous cryotherapy and the use of beprosalic ointment. On examination, there was a unilateral erythematous plaque over the right intergluteal fold, just inferio-lateral to the coccygeal apex, with scaling and surrounding erythema a,b. SkinThe final patient is a 94-year-old Chinese male with a history of hypothyroidism, atrial fibrillation, and benign prostatic hyperplasia. He presented with a lump over the left buttock for a few months, which had become painful in the last few weeks. On examination, there was a small tender 0.5 cm rounded dermal centered nodule over the left gluteal fold with hyperpigmentation and lichenification of the surrounding skin a. The noA summary of the clinical and histopathological features of these four patients is presented in Senile gluteal dermatosis (SGD) was first reported by Yamamoto et al. in 1979 as hyperkeratotic lichenified skin lesions of the gluteal region . The incClinical findings are the presence of unilateral or, more often, bilateral hyperpigmented and hyperkeratotic plaques in the gluteal region, often adjacent to the perianal area. The plaques are typically located overlying the bony prominences of the ischial tuberosities and the coccygeal apex, characteristically located within the sitter’s triangle formed by these three bony prominences. The plaques are usually non-inflammatory, but there have been reports of psoriasiform-like plaques, erosions, and ulcerations ,6. CharaThe histopathological changes of SGD are usually mild and nonspecific . HistoloSGD also subsumes the recently suggested entity of prurigiform angiomatosis (PA), which is characterized by the clinical presentation of prurigo/lichen simplex chronicus-like epidermal hyperplasia with prominent dermal angioproliferation . The autTo our knowledge, our study is the first to describe mast cell (MC) infiltration in SGD. MC density appears to be positively correlated to the degree of vascular hyperplasia . Marked MC infiltration has long been recognized in hemangiomas and vascular malformations; their roles have been more accurately delineated in recent years . It has While many patients may be elderly, SGD has been reported in younger patients who are in their 50s, making the term “senile” inappropriate. On the other hand, the term “prurigiform” in PA references the histological resemblance to prurigo/lichen simplex and also suggests that most cases are pruritic, when only a minority of patients 5–36%) experienced itch over their lesions 6% experi. To encoOnce recognized, the mainstay of treatment should be directed at pressure relieving measures. Other treatment options have shown varying degrees of success and include the use of topical steroids with or without keratolytic and topical tretinoin ,3.In summary, we present 4 cases of what has been described as senile gluteal dermatosis or prurigiform angiomatosis. We highlight novel findings of an increase in lymphatic vessels in addition to capillary-type neovascularization within lesions. We also note an increase in mast cell numbers in proportion to the degree of vascular proliferation. Lastly, we would like to propose a unifying terminology of Reactive Epidermal Hyperplasia with Angiogenesis of the Rear (REAR) to describe better and define this entity.


Choriocarcinoma is a highly malignant trophoblastic tumor that occurs mostly in women of childbearing age. The main mode of metastasis is hematogenous metastasis. The most common sites of metastasis are the lung, vagina and brain, while splenic metastasis is rare. Because of its rapid development, extensive metastasis can occur in a short period, and some patients only show metastatic symptoms, which are often missed or misdiagnosed as ectopic pregnancy or other diseases. We describe a rare case of splenic metastatic choriocarcinoma with acute abdominal pain caused by nontraumatic splenic rupture. In addition, we review the previous literature on splenic metastasis of choriocarcinoma and summarize the clinical manifestations, management measures and prognoses. Our case and literature review indicate that splenic metastatic choriocarcinoma is rare and difficult to distinguish from splenic ectopic pregnancy and other diseases. Clinicians should strengthen their understanding of this disease and avoid misdiagnosis. Choriocarcinoma is a highly malignant trophoblastic tumor that occurs mostly in women of childbearing age and can be secondary to hydatidiform mole pregnancy or nonhydatidiform mole pregnancy. Its main characteristic is that trophoblasts lose their original villi or hydatidiform mole structure and infiltrate into the myometrium, causing serious local damage. Choriocarcinoma can metastasize to all parts of the body, mainly in the lung, vagina and brain, but rarely in the spleen ,2,3. TheA 30-year-old Chinese woman was admitted to a local hospital because of pain in the left upper abdomen for 10 h. A chest and upper abdomen CT showed an apical space-occupying lesion of the upper lobe of the right lung , and multiple splenic nodules (multiple metastatic tumors of the spleen with rupture and subcapsular hematoma were considered). For further diagnosis and treatment, the patient was transferred to the Department of General Surgery, Xiaogan Hospital, affiliated to Wuhan University of Science and Technology. Her past medical history showed that she suffered from hepatitis B. Her menstrual history suggested regular menstruation, but was suspended for 48 days, and her childbearing history included three pregnancies, two deliveries and one miscarriage; the interval from the index pregnancy was 2 years.12/L, hemoglobin level of 100 g/L, hematocrit of 29.40%, neutrophil ratio of 81.20% and lymphocyte ratio of 15.30%. The tumor markers showed that her serum human chorionic gonadotropin (β-HCG) level was >5000 mIU/mL and her Cyfra21-1 level was 9.78 ng/mL. The T-SPOT.TB assay was negative. An enhanced chest and abdomen CT showed space-occupying lesions in the upper lobe of the right lung  were performed. Approximately 10 g of tissue was scraped out of the uterus, without obvious villi, pregnancy tissue or blister-like structures. On the first day after D&C, β-HCG levels were 11,835.0 mIU/mL and progesterone levels were 3.07 ng/mL. The pathological results reported the endometrium to be in the secretory phase. On the third day after D&C, the patient said that the pain in the left upper abdomen was worsening. An ultrasound of the liver, gallbladder, pancreas and spleen showed that a 7.57 × 7.26 cm high echo and irregularly shaped mass had been found on the spleen . The β-HEmergency laparoscopic exploration was performed after preoperative preparation. During the operation, a large amount of blood accumulated in the abdominal and pelvic cavities, especially in the splenic fossa, and a large number of blood clots could be seen in the splenic fossa. On the surface of the spleen, we found gestational sac-like tissue, which fell off to the omentum majus in the process of exploration, and the tissue was broken in the process of clamping, so no complete specimen was obtained. No obvious focus or bleeding was found in the exploration of the uterus, bilateral fallopian tubes and ovaries, and then a laparotomy was performed. After entering the abdomen, approximately 1000 mL of bloody fluid in the abdominal and pelvic cavities was absorbed. A 4 × 4 cm fissure was seen on the diaphragmatic surface of the spleen, and villous-like tissue was attached around it. Then, the spleen and part of the omentum majus were removed completely A,B. The On the third day after the operation, the β-hCG level was 17,694.0 mIU/mL, which was higher than before. Pathological examination suggested metastatic choriocarcinoma of the spleen, and no tumor infiltration in the omentum majus. Immunohistochemistry of the spleen suggested HCG-B (+), Ki-67LI (approximately 95%), PCK (+), PLAP (−), SALL4 (−), CK7 (+), EMA (−), p63 (focus +), P57 (−), CK8/18 (+) and Glypican-3 (+) . Then, tFor further treatment, she was transferred to the Department of Obstetrics and Gynecology of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. A chest and abdomen CT showed a mass in the upper lobe of the right lung, and multiple low-density nodules in the liver. According to the 2000 International Federation of Gynecology and Obstetrics (FIGO) Staging and World Health Organization (WHO) scoring system for gestational trophoblast neoplasm (GTN)  4], the, the4], Choriocarcinoma is a highly malignant trophoblastic tumor that occurs mostly in women of childbearing age and can be secondary to hydatidiform mole pregnancy or nonhydatidiform mole pregnancy. The incidence of choriocarcinoma is 5 to 202 per 100,000 pregnancies in China , respectThis patient presented with pain in the left upper abdomen as the first symptom. A chest and abdominal CT showed a pulmonary apical mass, multiple nodules of the spleen and subcapsular hematoma of the spleen. It was our accidental finding of an abnormal elevation in β-hCG levels that led to the consideration of pregnancy-related diseases. The special feature of this patient is that there are no typical reproductive system manifestations of trophoblastic tumors, such as abnormally enlarged uterine volume, vaginal purplish–blue nodules or abnormal intrauterine scrapes, and no obvious abnormalities were found via a TVS. The mass at the tip of the lung is difficult to distinguish from lung tumors and pulmonary tuberculosis, which undoubtedly increases the difficulty of disease diagnosis. Choriocarcinoma has no chorionic villi in histology ; howeverThe overall cure rate of GTN is currently more than 90% due to the application of chemotherapy and other comprehensive treatments. The best regimen depends on the stage and classification . In the In addition, the significance of surgery cannot be undervalued. A postoperative pathological examination can clarify the diagnosis and avoid misdiagnosis, especially in metastatic choriocarcinoma. Hysterectomy or uterine artery embolization can be considered in cases of uncontrolled uterine bleeding. Laparotomy or laparoscopy may be needed to stop bleeding in organs such as the liver, gastrointestinal tract, kidneys and spleen. Neurosurgery is needed if there is bleeding into the brain or increased intracranial pressure. The resection of an isolated drug-resistant tumor may also be curative ,26.Reviewing the diagnosis and treatment of these patients, the experience is as follows: (1) For women of childbearing age and with a sexual history, when abdominal pain, irregular vaginal bleeding and no specific clinical symptoms occur, hCG detection by blood or urine should be performed to rule out pregnancy-related diseases; (2) For patients with elevated β-hCG combined with the occupation of the liver, spleen, lung, brain and other organs, attention should be given to the possibility of choriocarcinoma metastasis even if there are no obvious abnormal manifestations in the reproductive system; (3) Ectopic pregnancy is most common in the fallopian tube. An obvious increase in β-hCG levels is often seen in intrauterine pregnancy, or special cases such as cornual pregnancy and tubal interstitial pregnancy. The possibility of no positive findings in uterine and bilateral fallopian tubes and ovaries via ultrasound examination is very small. Therefore, gestational trophoblastic disease should be highly considered; (4) β-hCG levels should be decreased after resection of the focus in ectopic pregnancy, but if β-hCG further increases after the operation, the possibility of gestational trophoblastic disease should also be considered, and pathological examination is the gold standard for diagnosis; (5) If β-hCG levels cannot be reduced to the normal level after standard chemotherapy, isolated drug-resistant tumor resection can be chosen according to the patient’s condition.Splenic metastatic choriocarcinoma with splenic rupture and bleeding is very rare, the onset is acute and hemorrhagic shock can occur in a short period of time and even be life-threatening. These patients should be identified and treated as soon as possible. Dynamic monitoring of β-hCG levels, ultrasound and CT/MRI are helpful for early diagnosis. Once diagnosed, most patients should undergo an operation to save their lives, followed by standardized chemotherapy. The treatment of patients with drug resistance and relapse should focus on the development of individualized treatment plans according to the degree of disease and previous treatments. In addition to active chemotherapy, surgery can also be used to remove drug-resistant or recurrent foci. After reaching a full course of chemotherapy, patients still need close follow-up and regular reexamination of blood β-hCG levels, ultrasound and CT/MRI to observe the recurrence of choriocarcinoma.


Laparoscopic pancreatectomy is currently a widely used approach for benign and malignant lesions of the pancreas.The Clockwise Technique. This study aimed to describe how to perform a laparoscopic distal pancreatectomy using The Clockwise Technique. An 18-year-old female patient presented with a well-defined tumor in the pancreatic body with 4 cm in diameter that suggested a diagnosis of solid pseudopapillary tumor (Frantz’s tumor). The patient was recommended for laparoscopic distal pancreatectomy by using  The clockwise, caudal-to-cephalic approach appears to have other significant technical advantages that facilitate the performance of the procedure.The Clockwise Technique provides satisfactory outcomes. A laparoscopic distal pancreatectomy performed using  Minimally invasive surgery is currently a widely used approach for benign and malignant lesions of the pancreas,,Recent systematic reviews and meta-analysis of studies comparing LPD and open distal pancreatectomy (ODP) have suggested superior short-term outcomes and benefits for patients, including less intraoperative blood loss, shorter postoperative hospital stay, less morbidity, and reduced time to functional recovery for LPD compared to ODPThe Clockwise Technique.The objective of this study was to describe how to perform an LDP using An 18-year-old female patient presented with abdominal pain in the upper quadrants. An abdominal ultrasound, a diffusion-weighted imaging, and pancreatic magnetic resonance imaging (MRI) scan showed the presence of a well-defined tumor arising from the pancreatic body with a greater diameter of 4 cm, suggesting the diagnosis of solid pseudopapillary tumor (Frantz’s tumor). The patient was recommended for LDP, using a clockwise technique . PostopeThe operation is initiated with the patient in a modified right lateral decubitus position that would allow for rotation to the left or right during the procedure. The surgeon stands to the right of the operating table. The ports are placed as shown in The clockwise, caudal-to-cephalic approach appears to have other significant technical advantages that facilitate the performance of the procedure. The procedure is performed through the following steps :Step 1: Mobilization of the splenic flexure of the colon and exposure of the pancreas.Step 2: Dissection along the inferior edge of the pancreas and choosing the site for pancreatic division.Step 3: Pancreatic parenchymal division and ligation of the splenic vein and artery.Step 4: Dissection along the superior edge of the pancreas.Step 5: Mobilization of the spleen and specimen removal.The total operative time was 300 min with no transfusion. The surgical specimen was removed through a small suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. Recovery was uneventful and patient was discharged on postoperative day 4. Postoperative MRI showed no evidence of the disease 12 months after the procedure.The Clockwise Technique consists of a systematized approach, aiming to facilitate the surgical procedure in a uniform method and well-defined steps,,The Clockwise Technique in the laparoscopic approach to pancreatic lesions were initially described in 2011The Clockwise Technique and observed a very low conversion rate (5%), reserved for situations in which the surgeon had difficulty with the anatomy, being mainly early and in the curve of learning,LPD is a safe and effective method for surgical approach of the pancreas and has significant advantages compared to ODP. The advantages of Abu et al.The Clockwise Technique, and this systematic approach demonstrated this technique as a reproducible, safe method with low complication rates and, as a consequence, lower morbidity and mortality to the management of lesions on the left side of the pancreas.LPD was performed using


We needs to study Primary Large cell Non-Hodgkin’s Lymphoma of the cranial vault, which is rare, and its association with COVID19 has not been reported, which may have an immunosuppressive effect to aggravate its progression.Our patient, a 53-year-old male, noticed fast growth of posterior cranial vault lesion from 2 to 10 cm size in last 6 months after COVID 19 affliction. MRI brain with contrast revealed lesions suggesting meningioma. The whole-body PET scan was normal. Following Subtotal excision of the mass, histopathology revealed large B-cell Non-Hodgkin’s lymphoma (DLBCL). Immunohistochemistry showed positive results for CD10, CD20, CD45 (LCA), ALK, and BCL-VE with a Ki-67 index of 90–95%. Following radiotherapy and chemotherapy patient is disease-free on imaging and doing well at 5 months of follow-up.Early intervention with excisional biopsy and timely chemo and radiotherapy in favorable immunostaining may add survival benefits even in malignant features induced by immunosuppressing diseases such as COVID19 in diffuse large B-cell lymphoma (DLBCL) of the scalp. Primary cranial vault lymphoma is rare, and nearly 50 case reports are available mentioning it. Once it converts to a high-grade lesion, it presents as an osteolytic lesion, uncommonly as an osteoblastic lesion, and rarely with permeative transmission through the cortex . Among tA 53 year male presented with multiple nodular huge scalp mass on the right side, which was noticed by the patient as a single lesion of grape size, 5 years back on the posterior cranial vault but in due course of the last 6 months, there was a progressive enlargement in size with an increase in lesions to 10 cm size. On the RT-PCR test, the patient had a history of COVID 19 positivity reported twice in the last 6 months. We did not find any enlarged lymph nodes or organomegaly on general examination. At that point, the clinical diagnosis was soft tissue sarcoma. On local examination, lesions were firm in consistency, nodular with an irregular nodular surface, with the largest scalp mass measuring about 10 cm in the right frontal and parietal region, which was painless and non-pulsating. The skin over the Swelling was normal, with patchy loss of hair, no tenderness, and no transparency or translucency. Neurological examination revealed no abnormalities, and the serological tests for human immunodeficiency virus, Epstein–Barr virus, and human T-cell lymphotropic virus were negative, and before surgery, he was COVID 19 RT-PCR test negative.Brain Non contrast computed tomographic (NCCT) examination showed Swelling (soft tissue opacity) in the right frontoparietal region with the exclusion of the skull invasion Fig. a. No conWe treated the patient with gross total excision of the large right parietal calvaria mass and curettage of the underlying bone. Gross total resection of the tumor was performed without excising small Dural deposits in the anterior frontal and left parietal region. We found the tumor-infiltrating galea, frontalis, and occipitalis muscles. It was firm to hard in consistency, mildly vascular, and yellowish. Microscopic examination of the tissue showed discohesive malignant cells arranged in sheets infiltrated by neutrophils and lymphocytes. Cells were large with marked pleomorphism, a high N:C ratio with prominent nucleoli, and scant cytoplasm. There were extensive areas of necrosis with frequent atypical mitotic figures. The pathological diagnosis was diffuse large B-cell NHL (DLBCL) Fig. a. ImmunoNon-Hodgkin’s lymphoma of the cranial cavity may be present due to metastatic deposit of systemic lymphoma in 1–6% cases and cranial vault in less than 1% cases, but primary NHL of the cranial vault is rare.  Not moreIn the El Asri et al. meta-analysis, the average age at presentation was 60 years without any gender prevalence. The average duration was the onset of symptoms was average of 1 year . In the In the present study, tumor characteristics on T1 and T2 weighted MRI were almost similar to the other reported patients with similar histopathology, and it homogenously contrasts enhanced with Dural tail sign. We noticed selective permeation of tumor mass through the cranial vault with tumor deposit on the inner table of calvaria and seeding of the dura in the anterior frontal region, causing mass effect and no visualization of the anterior sagittal sinus. On DSA tumor was being fed from bilateral ECA with tumor blush present suggesting vascular lesion, and left transverse sinus was also not visualized. Angiographic findings favor meningioma as lymphomas are not reported to have vascular blush on angiography except in 2–3 reported patients in the literature .Our patient’s MRI findings did not reveal any widening of diploic space, and there were slightly cortical changes and patchy contrast enhancement suggestive of permeation of calvaria cortex by malignant lymphomatous cells. Anterior sagittal sinus was not visualized, probably due to overlying compression by tumor mass and metastatic deposit through emissary’s veins. As the lesion was high-grade permeation of left transverse sinus through emissary veinous channel leading to thrombosis may be the reason. Such selective permeation of malignant lymphomatous cells was reported in the study by Ochiai et al. and Galarza et al. , 8. In tSuch atypical radiological findings probably have not been reported.Faster progression of the tumor was reflected by high KI-67 proliferation index, but one good prognostic feature was the absence of BCL-2 staining, which helps in good chemotherapy and radiotherapy response as reported in different studies . In the We thought to report this case due to unusual association with COVID 19 and atypical presentation, which was not reported in the earlier reported case, presenting a diagnostic and management dilemma to us. Patients having cranial vault primary DLBCL with the benign course may convert into aggressive lesions following infliction with the immunosuppressed state as in the present patient study and may present as a diagnostic dilemma. However, early excisional diagnosis and favorable immunostaining with BCL-2 may add survival benefits.Cranial vault primary lymphoma as DLBCL may have slow progression, but it may acquire aggressive features induced by immunosuppressing infection and medication and present a challenge in diagnosing and management. Early intervention with excisional biopsy and timely chemo and radiotherapy in favorable immunostaining may add survival benefits even in the presence of malignant features.


The incidence of acute pancreatitis in pediatric patients has increased in the last decade. We present the case of an eight-year-old boy who presented to the emergency department from another healthcare facility for the evaluation of appendicitis and was found to have acute pancreatitis secondary to hypertriglyceridemia. Clinical suspicion of pancreatitis should remain high in the pediatric patient population with nausea, emesis, and abdominal pain considering that pancreatitis’ often atypical and non-specific presentation may lead to delayed diagnosis. The incidence of pancreatitis in the pediatric patient population has become increasingly common in recent decades, reaching the level of adults . DespiteA previously healthy eight-year-old male patient presented to the ED via ambulance with four days of generalized abdominal pain. The patient’s mother reported associated decreased oral intake and several episodes of non-bloody, non-bilious emesis. The patient was checked at an outpatient urgent care facility earlier in the day and diagnosed with constipation with subsequent successful bowel movements after the administration of oral magnesium citrate. However, his abdominal pain persisted and migrated focally to his right lower quadrant, which prompted a return to care at another treatment facility prior to transfer to the ED for appendicitis rule-out. He received 300cc lactated ringers, ondansetron, morphine, and acetaminophen prior to arrival at the ED. During the physical examination, the patient complained of right lower quadrant pain with tenderness at McBurney’s point, rebound tenderness with palpation of the left lower quadrant, and pain upon jumping on his right leg; all of these findings were consistent with the diagnosis of appendicitis. There was no pain in the mid-epigastric region. Laboratory assessment was significant for hyponatremia (124mEq/L), leukocytosis (13.8mg/dL), elevated lipase (282U/L), and c-reactive protein (16.73mg/L).The appendix could not be visualized on limited right lower quadrant ultrasound. Following the hospital’s protocol, a fast acquisition magnetic resonance imaging (MRI) was subsequently performed; the imaging revealed a normal-appearing appendix but indicated concern for an extensive inflammatory process with free fluid throughout the peritoneum, retroperitoneum, and extraperitoneal pelvis Figure . Given tThe patient was admitted to the pediatric ward for the management of acute pancreatitis and euvolemic hyponatremia in the setting of gastrointestinal losses. His treatment consisted of supportive measures through IV fluids with slow correction of his hyponatremia and pain control with Tylenol. He was noted to have hypertriglyceridemia at 622mg/dL on admission and was subsequently treated as an outpatient for presumed lipoprotein lipase (LPL) deficiency. He did not require insulin at any point in his treatment course, and his triglycerides slowly normalized without a pharmacotherapy intervention. He had a normal MRCP as an outpatient with pending genetic testing at the time of this write-up.We present a case of acute pancreatitis in a pediatric patient; on initial presentation, it was believed that the patient was experiencing constipation, which was followed by a diagnosis of appendicitis. While previous reports have presented various etiologies for appendicitis, few have highlighted the unique challenges of initial diagnosis in an ED setting and the differences in the disease’s presentation in the pediatric population versus the adult population ,4.The diagnosis of pancreatitis requires the presence of at least two of the following symptoms: mid-epigastric abdominal pain, serum amylase or lipase values greater than three times the upper limit of normal, and radiologic evidence of findings consistent with pancreatitis ,6. In thAbdominal pain is a common presenting symptom of acute pancreatitis in pediatric patients, with 62-89% of these patients experiencing localized epigastric pain and 12-20% experiencing diffuse abdominal pain [The first-line choice of imaging modality for the diagnosis of pancreatitis is an abdominal ultrasound to visualize the pancreas. Although not typically needed, if these findings are equivocal, CT with IV contrast must be considered ,6. When The etiology of acute pancreatitis in children is more extensive than that of adults, with hypertriglyceridemia reported in one to four percent of the cases . TypicalLastly, although the differential diagnosis for abdominal pain in a child is extensive, anchoring on the well-known and widely used criteria for the diagnosis of pancreatitis may run the risk of missed diagnosis of pancreatitis in pediatric patients given the disease’s often non-specific or atypical presentation, as was demonstrated in this case. Thus, acute pancreatitis should be retained on the differential diagnosis for children presenting with nausea, emesis, and abdominal pain. Our patient was checked at three different healthcare facilities before the diagnosis of pancreatitis was made, highlighting the importance of providing strict return precautions in an ED setting when discharge is deemed appropriate.The incidence of acute pancreatitis in pediatric patients has increased in recent decades. The diagnosis of acute pancreatitis in a pediatric patient in an ED setting can be challenging given the disease’s vast variability of etiologies and often ambiguous presentation, which varies from that of adults. In this case, an eight-year-old male patient presented to the ED of a healthcare facility from another for appendicitis rule-out; he was found to have acute pancreatitis secondary to hypertriglyceridemia. The clinical severity and rate of complications in acute pancreatitis secondary to hypertriglyceridemia are often higher in comparison to other etiologies, making prompt diagnosis essential in preventing recurrence.


An obturator hernia is the protrusion of an organ/tissue through the obturator canal. Fondly called ‘little old lady’s hernia’, as they typically affect elderly thin female patients . They ar Obturator hernias are rare and difficult to clinically diagnose . MedicalThe mortality rate of obturator hernia is the highest among all abdominal wall hernias (13–40%) if untreated . Higher A 99-year-old lady presented at the Accident and Emergency department with a 3-day history of worsening lower back pain, decreased mobility, nausea, constipation and some urinary incontinence. She additionally reported right-sided flank pain, appeared dehydrated but with normal observations.An initial diagnosis of urinary tract infection was made and appropriate antibiotics prescribed as per the hospital guidelines. Medical history included hypertension, haemorrhoids, COVID vaccinations and presbycusis. Her routine medications were antihypertensive and cholecalciferol. Physical examination on admission revealed a soft, distended abdomen and an abdominal X-ray which showed dilated loops of small bowel was done due to the medical team’s worry about her physical examination findings.Following surgical review, a computerized tomography (CT) scan of the abdomen and pelvis was requested and showed small bowel obstruction, secondary to a left-sided obturator hernia  and 2.Explaining the diagnosis, intended procedure and obtaining informed consent were challenging due to the patient’s significant hearing loss. The risks of the procedure were, however, discussed, and the patient agreed to surgery. Her estimated mortality using the National Emergency Laparotomy Audit risk calculation tool was 8.2% and Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality risk for morbidity was 62.9%. A multidisciplinary team meeting between the medical, surgical and anaesthetic teams was held to discuss ceilings of care and a consensus to go ahead was reached considering her frailty and age.A lower midline laparotomy incision was done and opened to the peritoneum. Operative findings included some serous fluid in peritoneum, an incarcerated ileal loop in a left obturator hernia and distension of small bowel proximal to this point. The affected bowel loop was bruised and congested, but not ischaemic. Careful release of the obstructed hernia followed, with the released bowel loop warmed for 5 min. After warm saline lavage, Surgicel (oxidized regenerated cellulose) was placed into the pelvis to plug the hernia space. Mass closure was performed with polydioxanone suture (PDS) and the skin was closed with staples.The patient had an uneventful post op recovery and suffered no complications. She was surgically fit for discharge by Day 8 post-operatively but needed transfer to a rehabilitation facility to aid recovery to her pre-admission level of physical functioning.Clinical signs may be non-specific in the absence of signs relating to obturator nerve compression . The HowIn our case, her presenting symptoms of low back pain and decreased mobility provided no direction towards the right diagnosis. However, her abdominal examination and abdominal X-ray findings were suggestive of small bowel obstruction .The accuracy of CT scan with IV contrast in diagnosing obturator hernia is ment}90% , 4. Thisment}90% .In elderly frail patients, there is always an ongoing dilemma of balancing risk of surgical intervention versus benefits. Our case presented a similar dilemma which was promptly resolved by a best interest meeting.Open and laparoscopic approaches can be used, but in the emergency setting, an open laparotomy might be a more sensible option. This is due to technical difficulty of performing laparoscopic surgery on an obstructed bowel due to limited intraabdominal space .There are several open operative approaches described for the repair of obturator hernia. These include the abdominal, retropubic, obturator and inguinal approaches. In the emergency setting, the abdominal approach via a low midline incision is most commonly favoured, as it allows adequate exposure of the obturator ring as well as the identification and resection of any ischaemic bowel .The open approach was suitable in this circumstance, bowel resection was not indicated as the intervention was timely and bowel ischaemia had not occurred.Following reduction of the hernia, the hernia can be repaired using several techniques. There are several repair techniques that have been described: sac ligation alone, direct suture repair, use of autologous tissue or prosthetic repair. Many authors prefer a simple closure of the hernia defect if visible with one or more interrupted sutures as it leads to an acceptable recurrence rate of <10% . In our Despite many papers dealing with various surgical techniques used in the treatment of obturator herniae, it is important to emphasize diagnosis and early intervention is the most important aspect of management .Possible sequela of the untreated obstructed obturator hernia includes bowel ischaemia, perforation and faecal peritonitis. This significantly increases mortality.Whatever the approach, the emphasis should be on rapid evaluation, adequate resuscitation and early operative intervention to reduce morbidity and mortality .For the purposes of achieving a prompt accurate diagnosis, a CT scan is indispensable. Majority of patients with symptomatic obturator hernia are old and frail, with multiple comorbidities. Without operative intervention, these patients will likely die. However, with appropriate discussion, a 99-year-old can have a successful post op recovery from a laparotomy and open repair of an obstructed obturator hernia.Informed consent was obtained and all patient identifiable data anonymized in this report.


The glandular odontogenic cyst is a cyst that arises in development sites of the teeth; it is usually found in the mandible and maxilla,1 and is characterized by cuboidal or columnar epithelium on the surface and in crypts within the epithelium.This cyst generally is encountered in the anterior areas of the mandible; it is more common in adults aged over 40 years, and tends to recur. The recorded prevalence ranges from 0.012 to 1.3%.It is a slow-growing cyst that affects both sexes similarly.It is a relatively new entity that was first described in 1987, and recognized by the World Health Organization in 1992. Because of the paucity of reported cases, there is no consensus or established protocols about many aspects of management of this lesion.CRVM, a white female patient aged 27 years, residing in Caxias do Sul, self-employed, with a history of smoking, sought an outpatient clinic  complaining of pain and pruritus on the left maxilla, difficulty to eat, and halitosis. She reported fruitless previous treatments with amoxicillin and diclofenac. The physical examination showed edema and hyperemia in the anterior portion of the left maxilla.Laboratory work-up consisted of liver function tests, serum iron and preoperative tests, all of which were within normal limits.A plain radiograph of the face revealed a large bony lesion in the left maxilla.Computed tomography of the middle third of the face showed an osseous cyst with dense content, measuring about 6.0 cm along its longest dimension, located deep in the left maxillary sinus next to the lateral wall of the left maxillary bone; the dental alveoli were involved .Figure 1The patient underwent surgery, which consisted of enucleation of the maxillary cyst. Macroscopically it was a grayish, elastic tissue measuring 2.0 × 1.0 × 0.3 cm. Its liquid content was aspirated and the surrounding capsule was removed; both were sent to histology and pathology for analysis. The pathological diagnosis was glandular odontogenic cyst.The patient recovered uneventfully in the immediate postoperative period.The main clinical finding in this disease is painless local edema; the clinical picture, however, is non-specific.This cyst develops in the maxilla1 or in any area of the mandible, mostly in the anterior portion. It may mimic, on the surface, the central mucoepidermoid carcinoma.Lack of consistent clinical manifestations and the intraosseous development of these lesions mean that radiography is essential. Radiographic findings include a rounded or oval lesion, usually with well-defined borders.Most authors agree that there are no radiographic features specific of glandular odontogenic cysts. The differential diagnosis is made with botryoid cysts, keratocysts, residual cysts, the central mucoepidermoid carcinoma, and the ameloblastoma.A malignant potential for this lesion has been suggested in the medical literature; expansion and perforation occur in many of these cases. Computed tomography is indicated in cases with large multilocular lesions involving the facial sinuses, floor of the nose and orbit.Histologically it is a polycystic structure with a non-keratinized squamous epithelium and cuboidal or ciliated epithelium with mucus-secreting cells.There is histological similarity with the central mucoepidermoid carcinoma.Treatment options include curettage, enucleation, and en bloc local excision. Some authors recommend en bloc local excision with primary repair, which aims to cure the patient and avoid further surgery, since there is a high recurrence rate with the conservative treatment, and the lesion may become invasive.Although this is an uncommon disease that has been recognized only recently, and that opinions diverge about the proper strategy, this disease should be included in the differential diagnosis of mandibular or maxillary lesions that are loculated and radiolucent in radiographs.


Nesidioblastosis is a rare pancreatic disorder involving enlarged beta cells throughout the pancreas, causing elevated insulin production. We present the case of a 53-year-old woman with the initial symptom of fasting hypoglycemia. No pancreatic lesions were indicated on computed tomography and magnetic resonance imaging scans, and an octreotide scan was negative for insulinoma. Selective arterial calcium stimulation (SACST) showed increased insulin production from the stimulation of 3 out of 5 arteries. The SACST results suggested a diagnosis of nesidioblastosis, which was confirmed by histopathology after a subtotal distal pancreatectomy. The patient has normal glucose tolerance after surgery with no further problems of hypoglycemia, indicating that this is a rare case of nesidioblastosis extending only partially through the pancreas. Nesidioblastosis is an extremely rare disorder; first described in infants in 1938 by Laidlaw . We presA 53-year-old woman was referred to our clinic in 2017 with symptoms suggestive of hypoglycemia. An oral glucose tolerance test was normal. Fasting hypoglycemia was diagnosed after she underwent a 72-hour fast resulting in a low serum glucose of 3.1, with simultaneous inappropriately high insulin of 150 (NR < 95 pmol/L) and C-peptide at 1301 (NR: 325-1090). Imaging was then performed to try and determine the cause of her hypoglycemia. CT and MRI scans did not identify any pancreatic lesions or insulinomas, and an octreotide study did not show any areas of increased uptake. The patient's symptoms intensified, with nightly hypoglycemic symptoms that resulted in an inability to work. The patient's symptoms could not be controlled with medical management, so further investigations were undertaken in the hope of finding a lesion that could be surgically treated.Selective arterial calcium stimulation (SACST) with hepatic venous sampling was performed, using the methods described by Thompson et al. . There wOn the basis of the SACST results, a distal pancreatectomy was performed, removing the pancreatic tail region measuring 14.5 × 5.2 × 2.5 cm, and preserving the spleen and duodenum. The histopathology confirmed the presence of diffuse nesidioblastosis within the pancreatic tail, with increased numbers of islet cells , some ofThe patient has done well postoperatively with no further hypoglycemia and normal fasting glucose tolerance for 34 months.The differential diagnosis of endogenous hyperinsulinemic hypoglycemia in adults includes insulinoma and adult-onset nesidioblastosis. Insulinoma is significantly more common than nesidioblastosis, with approximately 1 to 3 cases per million . NesidioSelective arterial calcium stimulation can be used to aid in distinguishing between insulinoma and diffuse nesidioblastosis; if there is a significant relative elevation in insulin with the stimulation of 2 or more arteries, then nesidioblastosis is the probable diagnosis . This isNesidioblastosis is characterized by the presence of many beta cells with enlarged nuclei and large amounts of clear cytoplasm, in most islets throughout the pancreas . TypicalDiffuse nesidioblastosis is by far the most common form in adults . Rare caIn focal nesidioblastosis, abnormal beta cells are confined to exophytic lesions on the surface of the pancreas, whereas diffuse nesidioblastosis typically involves the entire pancreas .We believe that our case represents a form of nesidioblastosis that is intermediate between focal and diffuse nesidioblastosis, as it was functionally localized to the tail region, but was clearly spread throughout the pancreas and was not exophytic. The localization is evidenced by our patient's lack of hypoglycemia after distal pancreatectomy, which is fairly rare when compared to other cases.As shown in We believe that we report the first case of adult nesidioblastosis that is diffuse in nature but limited to a specific region of the pancreas. It supports the value of using SACST in the diagnostic evaluation of patients with fasting hypoglycemia who do not have a mass visible on imaging. Knowledge of this condition will help plan the surgical approach and also provide physicians and patients a realistic expectation of the likelihood that partial pancreatic resection will reduce hypoglycemia to a meaningful degree.


Leiomyosarcoma (LMS) is a rare type of mesenchymal tumor. Suspecting LMS before surgery is crucial for proper patient management. Ultrasound is the primary method for assessing myometrial lesions. The overlapping of clinical, laboratory, as well as ultrasound features between fibroids and LMS makes differential diagnosis difficult. We report our single-center experience in ultrasound imaging assessment of LMS patients, highlighting that misleading findings such as shadowing and absent or minimal vascularization may also occur in LMS. To avoid mistakes, a comprehensive evaluation of potentially overlapping ultrasound features is necessary in preoperative ultrasound evaluations of all myometrial tumors. Approximately 40–80% of women may develop leiomyomas, the most common benign gynecological disease, during their lifetime . UterineIt is important to correctly evaluate myometrial tumors before surgery to ensure proper patient management and avoid delayed treatment. However, distinguishing an LMS from fibroids can be difficult due to similar clinical, laboratory, and ultrasound features ,5,6.Ultrasound is a cost-effective, non-invasive, and widely accepted imaging method for evaluating the myometrium. The reporting of ultrasound characteristics of the myometrium and myometrial lesions has been standardized through the development of a consensus statement by the Morphological Uterus Sonographic Assessment (MUSA) group .The MUSA consensus statement advises evaluating certain predefined ultrasound characteristics, specifically the largest diameter of the myometrial tumor (mm), the number of lesions (single/multiple), the echogenicity of the solid tissue of the tumor (homogeneous/in-homogeneous), the tumor border (regular/irregular), the presence of cystic areas (yes/no), the presence of shadows (yes/no), subjective color score (1/2/3/4), and the vascular pattern of a myometrial lesion  .On ultrasound, uterine fibroids typically appear as multiple, distinct, round lesions within the myometrium. They may display shadows at the edge of the lesion and/or internal fan-shaped shadowing. The echogenicity of fibroids can vary depending on the various components within them, such as muscle cells, fibrous stroma, calcification, and lipomatous or hyaline degeneration . FibroidOn the contrary, an LMS generally appears on ultrasound as a single solid mass with a large diameter and inhomogeneous echogenicity of the solid tissue. Sometimes the masses contain cystic areas, typically irregular, with soft surfaces. Shadowing or calcifications are usually absent .Therefore, it is important to assess multiple ultrasound features established by the MUSA group when evaluating myometrial tumors on ultrasound.Hence, we aimed to describe the overlapping ultrasound features between fibroids and malignant myometrial lesions.Here we report our single-center experience in ultrasound imaging assessment in LMS patients referred to our tertiary care center between May 2020 and May 2022.During this observation period, 1000 patients underwent surgery for myometrial tumors. All patients received a preoperative transvaginal or trans-rectal ultrasound examination and additional trans-abdominal ultrasound when necessary. Ultrasound examinations were performed by a specialized ultrasound examiner with a 5.0–9.0 MHz vaginal probe or 3.5–5.0 MHz abdominal probe. All ultrasound reports and images were available for analysis.Any cases that were uncertain or suspected to be LMS underwent laparotomy.During the observation period, we evaluated 7 patients with LMS.All information from the original ultrasound reports was collected based on ultrasound features according to the MUSA consensus statement . We alsoThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Azienda Ospedaliera Policlinico Consorziale-University of Bari, Italy (protocol code 6398).In our series, patients had a mean age ± sd of 50.2 ± 7.0. The mean largest diameter of LMS was 152.2 ± 91 mm. Five patients (71.4%) had a single myometrial lesion.All LMS ultrasound images showed inhomogeneous echogenicity of solid tissue, intralesional vascularization, and soft consistency of the lesion at probe pressure.All cases except one (85.7%) had irregular tumor borders, and all except one (85.7%) had cystic areas.We found that four images (57.1%) had fan-shaped shadowing, and four pictures (57.1%) had minimal vascularization (CS2) .Unfortunately, LMS does not have any specific symptoms associated with it. Patients may experience pelvic pain, abnormal uterine bleeding, or a palpable pelvic mass, but these symptoms are also common in patients with uterine fibroids .In 2007, Exacoustos et al. published a series on LMS, which included eight patients. The LMS examples reported were larger in size, with 88% having a diameter greater than 8 cm. They also had inhomogeneous echostructures, with degenerative cystic areas present in 50% of cases, and intense central vascularization .In a study by Bonneau et al., 23 malignant myometrial lesions were described, including 3 LMS cases. The other cases were rhabdomyosarcoma, endometrial stromal sarcomas, undifferentiated endometrial sarcomas, stromal tumor of uncertain malignant potential (STUMP), and carcinosarcomas. Compared to benign lesions, malignant myometrial tumors appeared as single masses, without acoustic shadowing, and with a non-myometrial origin .Testa et al., reported that malignant myometrial lesions can be characterized by large diameter, inhomogeneous echostructure, irregular anechoic areas, and absence of “radial stripy echogenicity” .Given the complexity of the diagnosis, it is important to evaluate all individual clinical characteristics and ultrasound features to try to distinguish between benign and malignant myometrial tumors.growth of a myometrial lesion may be suspected. However, the meaning of “rapid growth” is not well defined [The rapid  defined ,14. Addi defined . It is i± sd of patients in our series was 50.2 ± 7.0 years and the median (sd) was 49.5 (7.0).Considering the age at diagnosis, some studies have reported that uterine fibroids are diagnosed at a younger age, with a mean age ranging from 40 to 51.7 ,17. Howecarbohydrate antigen 125 (CA125) to differentiate LMS preoperatively from fibroids are conflicting.Considering laboratory tests, studies that support the use of Some authors suggest that elevated levels of CA125 are indicative of LMS , others lactate dehydrogenase (LDH). The first study on this topic was conducted by Seki et al. in 1992, in which they found that serum LDH levels were abnormally elevated in three out of seven (42.8%) patients with LMS [Another laboratory test that has been studied to suspect the diagnosis of LMS preoperatively involves with LMS . In 2015with LMS . Howeverwith LMS ,26. TherTherefore, it is crucial to have an accurate imaging method to preoperatively identify suspected cases. Ultrasound is the primary method for assessing myometrial tumors, and this evaluation relies on the examination of several features established by the MUSA group.maximum diameter of the lesion, a number of studies have shown that myometrial tumors with a diameter greater than 8 cm may raise suspicion of malignant disease [Considering the  disease . In a st disease . Similar disease .These studies suggest that LMS and fibroids may not differ greatly in terms of largest diameter. However, our findings indicate that LMS at the time of diagnosis had a significantly larger size than previously reported, with a mean largest diameter of 152.2 (±91) mm and a median (sd) of 93.5 (91).Internal shadows and fan-shaped shadowing generally are typically seen in fibroids or adenomyosis and are not commonly reported in uterine sarcomas. However, a study by Bonneau et al. found that 20% of sarcomas had internal shadows, while only 2% had fan-shaped shadowing [hadowing . Ludovishadowing . Similarvascularization, typically an LMS may have moderate to high vascularization, with blood vessels concentrated in the center of the lesion as evaluated by power Doppler sonography [Regarding nography . Howevernography . In the nography . SimilarAt the same time, evaluating a benign mesenchymal tumor can often be challenging due to the presence of concerning ultrasound features or the lack of typical ultrasound characteristics. Additionally, degenerations of uterine fibroids and histologic variants of benign leiomyomas make this assessment even more difficult.In the series of Russo et al., in uterine myometrial lesions with high vascularization on ultrasound, the histological diagnosis was fibroids in 93% of cases, including leiomyoma variants in 45% and adenomyomas in 6%. Thus, the vascularization feature can be misleading.Typically, fibroids have homogeneous echogenicity on ultrasound, but in the study of Russo et al., 72.3% of benign lesions had inhomogeneous echogenicity .Regarding cystic areas, these features were present in 46.6% of LMS cases reported by Ludovisi et al., likely due to necrosis . HoweverTherefore, in a single benign myometrial mass may coexist suspicious and non-suspicious ultrasound features, making the evaluation complex.Ultrasound is a harmless and inexpensive useful tool for assessing myometrial tumors. Unfortunately, the presence of both suspicious and non-suspicious features in the same lesion and the finding of suspicious features in uterine fibroids make this assessment complex.We presented our single-center experience in ultrasound imaging assessment in LMS, highlighting that the misleading finding of shadowing and absent or minimal vascularization, generally considered benign ultrasound features, may also occur in LMS patients.Therefore, to avoid pitfalls, it is important to thoroughly evaluate all suspicious and non-suspicious ultrasound features, as well as the possibility of their coexistence, in all preoperative ultrasound evaluations of myometrial tumors.


Meckel's diverticulitis is an extremely rare event during pregnancy. Its diagnosis is often difficult and can result in higher maternal and fetal morbimortality. We describe a case of a 40-year-old healthy pregnant woman at 33 weeks of gestation who presented with abdominal pain and tender abdomen, leukocytosis, and elevated PCR. The imagiological exams were not conclusive. After an urgent caesarean section due to worsening of clinical status and nonreassuring fetal well-being, a laparotomy revealed a distended, necrotic, and perforated Meckel's diverticulum. Acute abdomen during pregnancy is a rare condition, with a reported incidence of one in 500-635 patients , 2. PerfA 40-year-old woman, primigravid, presented at our emergency department at 33 weeks of gestation with a diffuse abdominal pain for two days, more intense at the left iliac fossa, sharp and not responsive to analgesia. The pain was associated with nausea, vomiting, and constipation for a day. She had no previous medical, gynecological, or surgical history, and her antenatal course had been uneventful.On physical examination, the patient had a blood pressure of 117/67 mmHg and pulse rate of 93 bpm and was apyretic. The abdomen was distended and tender. There was no evidence of uterine contractions or fetal distress. The blood work revealed elevated white blood cell count  and elevated CRP . Abdominal ultrasound was normal so it was decided to perform an abdominal-pelvic computerized tomography scan (CT scan) that showed densification of pericolic fat tissue suggesting an inflammatory process of indeterminate nature and no other alterations.Corticosteroids for fetal lung maturation and empirical broad-spectrum antibiotics were initiated with temporarily clinical improvement. Despite that, on the following day, the patient presented intense pain, abdominal guarding, and rebound as well as an increase in inflammatory parameters. A second abdominal ultrasound was performed but was nonconclusive.Differential diagnosis included appendicitis, bowel obstruction, perforated ulcer, inflammatory bowel disease, and diverticulitis. Obstetrical and gynecological causes were not excluded but were less plausible.Facing an acute abdomen and also a pathological fetal cardiotocography, an urgent caesarean section was performed followed by a laparotomy. A male infant was born weighing 1966 grams with Apgar score of 9 and 10 at one and five minutes. It was identified purulent discharge on the abdominal cavity as well as a distended and necrotic Meckel's diverticulum with 9 cm in length and 3 cm in diameter, with a perforation site Figures , and 3. The histological report confirmed the diagnosis and reported no ectopic mucosa nor malignancy. The patient had an eventful recovery and was discharged after four days.Meckel's diverticulum (MD) is a true diverticulum containing all layers of the intestinal wall. It is the most common congenital anomaly of the gastrointestinal track and results from the failure of the omphalomesenteric duct to involute during the 5th to 7th weeks of gestation. The reported prevalence in general population is approximately 2%. Symptomatic Meckel's diverticulum during pregnancy is an extremely rare event. There are only 38 cases reported so far since 1949  and 21 cThis condition has been classically described as the “rule of twos”: prevalence of 2% in population, twice as common in men than women, located 2 feet from the ileocecal valve, and can be 2 inches wide and long . TypicalThe most common complications are obstruction, intussusception, inflammation or diverticulitis, hemorrhage, and perforation. Obstruction is more frequent amongst adults, whereas bleeding is most commonly observed in children due to ulceration caused by acid secretion by ectopic gastric mucosa . Rarely,The diagnosis of MD during pregnancy can be challenging as it often presents with unspecific symptoms such as abdominal pain, nausea, vomiting, and obstipation which overlap with other conditions and can also occur physiologically in pregnancy.Additionally, anatomical and physiologic changes like gravid uterus changes, mild to moderate leukocytosis, and tachycardia are considered normal, making the evaluation even more difficult. The main differential diagnosis is with appendicitis as it is the first nonobstetric cause of acute abdomen in pregnancy with an incidence of 0.04%-0.2%  and bothUltrasound is often the first and most used diagnostic modality . It is fManagement of MD usually involves an exploratory laparoscopy or laparotomy with surgical resection: either diverticulectomy or segmental bowel resection in case of ectopic tissue at the diverticular base, intestinal ischemia, or perforation at the diverticular base . LaparosRegarding pregnancy, the rate of MD complication does not seem higher than in general population but the question remains as to whether is there any mechanism during pregnancy that might help the occurrence of complications. Can the growing uterus compress the bowel facilitating an obstruction/loop process? On the other hand, there seems to be a higher rate of perforation of MD during pregnancy, between 40.7% and 57% , whereasObstetric outcomes are difficult to evaluate due to the low number of cases. It has been reported a maternal mortality of 16%, fetal mortality of 13%, and incidence of preterm delivery of 25% [Our case demonstrates the diagnostic challenge of an acute abdomen in pregnancy and the serious consequences that Meckel's diverticulum can have in pregnancy. The initial patient's evaluation was not easy considering a third trimester pregnancy and large uterus. The fact that the pain was more intense at the left abdominal quadrant was a confounding factor as well as the initial clinical improvement with antibiotics and analgesia. At first, the most likely diagnosis did not include MD but rather appendicitis and diverticulitis. Despite the general reluctance of performing radiation exams, we decided to do a CT scan at an early stage. Unfortunately, diagnostic imaging did not provide a clear diagnosis which reinforces the importance of clinical sense. Conservative management was attempted with no success as the clinical status continued to worsen. The clinical decision was obvious facing an acute abdomen and surgery was crucial to the resolution of the case. A multidisciplinary approach is fundamental in management of these cases . From thAlthough extremely rare, Meckel's diverticulitis is an important cause of acute abdomen during pregnancy. Its diagnosis implies a high index of clinical suspicion and must be considered especially when causes like appendicitis seem less plausible. Perforation of MD is more frequent in pregnant women. Symptomatic MD is associated with poor outcomes in pregnancy; therefore, a continuous monitoring, multidisciplinary approach, and an early and active management considering surgery are essential.