The patient was a 1‐year‐old girl who had been healthy since birth and who had no remarkable clinical history in the prenatal or postnatal period. She was brought to a local physician owing to fever and cough as primary symptoms. Chest radiography revealed a well circumscribed area of reduced radiolucency in the right upper lung region Fig. , and becet al. reported a recurrence rate of 14%–25% and that most recurrences were owing to incomplete resection.Lipoblastoma is a relatively rare benign mesenchymal tumor with a predilection for the limbs in children aged under 3 years.In conclusion, a primary lipoblastoma of the chest wall is difficult to diagnose by visual or physical examinations, and it must be included in the differential diagnosis if a well‐circumscribed convex lens‐like lesion is detected by imaging examinations.The authors declare no conflict of interest.S.F. treated the patient and drafted the manuscript. H.M., D.I., and M.H. performed the surgical treatment and reviewed the manuscript. Y.H. reviewed the manuscript and provided conceptual advice. All authors read and approved the final manuscript.The patient's guardians provided written informed consent for the publication of this case report and accompanying images.


Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. In most instances, os subfibulare is found incidentally on radiographs. While os subfibulare typically remains asymptomatic, some cases may present with ankle pain or instability. To initiate appropriate treatment and maximize patient outcomes, it is crucial to accurately visualize the accessory ossicle. Here, we report a symptomatic case of os subfibulare diagnosed with ankle radiographs and a 3D water selective cartilage scan  magnetic resonance imaging sequence and treated surgically with open ossicle excision and a modified Broström procedure. Os subfibulare is a supernumerary bone of the lateral malleolus at the distal end of the fibula found in 1% of the general human population, usually in adolescents . In mostIntervention for os subfibulare can range from conservative treatment, consisting of orthoses and/or physical therapy, to operative treatment. When conservative treatment fails to resolve the initial symptoms, surgery is indicated to prevent or address chronic pain and ankle instability. Depending on the size of the ossicle when excised, a Broström procedure, an anatomical reconstruction of the lateral ankle ligaments, particularly the anterior talofibular ligament (ATFL), may be necessary . To initA 12-year-old female presented with pain and swelling in her left ankle. Physical examination of the lower extremity revealed slight swelling over the left distal fibular styloid process with lateral ankle instability and increased inversion on the left side.Two years prior, she presented with left ankle pain after playing on a trampoline. Ankle radiographs revealed an artifact at the left distal fibular epiphysis Figure . This waThe patient returned to the clinic two years after the initial injury because the ankle pain and instability did not resolve with conservative management. Radiographs at this time demonstrated ossific fragments at the distal tip of the fibula comparable to the exam from two years prior, and the question of variant ossicles was posed Figure .To narrow the diagnosis, a left ankle MRI was performed. Initial T1 and T2 weighted MRI with and without contrast revealed the presence of chronic-appearing well-defined ossific fragments of the distal fibular epiphysis without surrounding edema or inflammation. 3D_WATSc MRI revealed fragments that were surrounded by non-articular cartilage. In addition, the distal fibular epiphysis demonstrated facets corresponding to each fragment in a non-linear morphology, suggesting a developmental variant rather than an old fracture  study performed by Canagasabey et al. demonstrated that ultrasound had high sensitivity and specificity in identifying significant foot and ankle fractures . HoweverIn comparison, radiographs are more commonly used to diagnose os subfibulare. A study by Lee et al. noted that while traumatic or congenital etiology of the accessory ossicle could not be determined from initial plain radiographs, additional images taken over time could be used to infer posttraumatic etiology based on the increasing size and roundness of the fragment . HoweverFinally, MRI techniques have also proven to be reliable not only in diagnosing os subfibulare but also in prognostication. An investigation by Kim et al. concluded that T1 and T2-weighted MRI of the ankle may be used to predict rehabilitation outcomes in patients with symptomatic os subfibulare based on the size of the ossicle, interposition of fluid signal intensity between the os subfibulare and fibula, and the presence of bone marrow edema within the ossicle . Their sTo solidify our diagnosis of os subfibulare, we performed 3D_WATSc MRI sequencing to highlight the accessory ossicle at the tip of the patient’s left fibula. 3D_WATSc is an MRI sequence that uses water excitation to suppress fat resulting in greater image resolution and contrast . While tWe believe the use of 3D_WATSc MRI clearly defined the accessory ossicle to make the appropriate diagnosis of os subfibulare and inform treatment. In comparison to other case reports Table , our casOs subfibulare may be difficult to diagnose and should be explored further through appropriate imaging modalities. One of the difficulties in diagnosing and treating os subfibulare relates to the difficulty in distinguishing between a fracture nonunion and an accessory ossicle on radiographs. The utilization of alternative MRI sequences helps to more clearly define accessory ossicles and guide the patient to the most appropriate treatment. In this case, 3D_WATSc MRI clearly demonstrated this patient's os subfibulare by highlighting the confluent cartilage surrounding the ossicles, which informed the eventual decision to perform an open excision with a modified Broström procedure to treat this patient's pain and instability. Therefore, we posit that this imaging technique is useful in maximizing recovery and positive outcomes in patients with os subfibulare.


Primitive neuroectodermal tumour is a poorly differentiated small round cell neoplasm that primarily affects children and is very rarely seen in adults. Peripheral primitive neuroectodermal tumours are rare compared to the central type and resemble soft tissue sarcoma. Primitive neuroectodermal tumours involving the subcutaneous tissue are rare and only a few cases involving the subcutaneous tissue of the anterior abdominal wall have been reported. However, no cases involving the subcutaneous tissue of the shoulder region have been reported. We report the case of a peripheral primitive neuroectodermal tumour arising from subcutaneous tissue of the right shoulder in a young adult. They rarely involve the retroperitoneum, paraspinal region, neck, kidney, liver, cervix, lung, uterus, ovaries, penis, pancreas, urinary bladder, skin, and subcutaneous tissue.2Primitive neuroectodermal tumour is a rare family of malignancy comprising osseous Ewing sarcoma, extraosseous Ewing sarcoma, Primitive Neuroectodermal Tumour (PNET), and Askin tumour. These tumours show small round cells with varying degrees of neuroectodermal differentiation. PNET shows evidence of neuroectodermal differentiation, whereas Ewing sarcoma lacks this differentiation.A 30-year-old female presented to the emergency outpatient department with swelling in the right shoulder region for two months. The swelling was progressively increasing in size with no skin erythema or pus discharge. On examination, the lump was measured to be approximately 5x5 cm in size and firm in consistency. There was a full range of motion in the right shoulder joint which excluded shoulder joint involvement.The laboratory reports were within normal limits. Ultrasound revealed a well-defined solid-cystic lesion measuring approximately 6x5 cm in size with peripheral solid components involving the subcutaneous plane of the posterior superior aspect of the right shoulder region. On the colour doppler, mild vascularity was noted in the solid component.MRI scan showed well-defined heterogeneous predominantly cystic lesion measuring 6.9x6.8 cm involving the subcutaneous plane of the posterior superior aspect of right shoulder appearing hypointense on T1 and hyperintense on T2 with peripheral solid component appearing isointense on both T1 weighted imaging  and T2 FThe patient underwent excision of the cyst and it was sent for histopathological examination. Grossly, the specimen was a grey-brown multiloculated cyst measuring 6x5x4 cm. On the cut section, it showed congested solid areas with bloody fluid. The maximum cyst wall thickness was 2 mm. On microscopy, multiple sections showed lesions composed of sheets of small round cells with a prominent capillary network. These small cells had scanty cytoplasm with a round to ovoid nucleus .Diagnosis of small round cell tumour was made and was sent for immunohistochemistry evaluation which showed positive Vimentin, Synaptophysin, MIC-2 (CD99), CD56, and neuron-specific enolase that suggested PNET.3PNETs are malignant tumours of neuroectodermal origin consisting of small round cells and are classified under Ewing's sarcoma family of tumours. It is divided into central PNET involving the central nervous system and peripheral PNET. Peripheral PNETs are rarer than central PNETs and resemble soft tissue sarcoma. PNET/Ewing sarcoma family exhibit common histology phenotype, expression of MIC-2 protein (CD99), CD56, and neuron-specific enolase.4 Clinically, PNET appears as a rapidly growing mass with symptoms of pain, skin erythema, and compression. It can occur at any age but children and adults are commonly affected. It can occur at any location, but the thoracic pulmonary region, extremities, head, and neck are comparatively more common. Diagnosis of PNET should be considered if tomography image shows a large, ill-defined, aggressive cystic-solid mass with persistent moderate enhancement, with or without osteolytic bone destruction.5Peripheral PNETs including those in the eye, maxillofacial region, peripheral limbs, gynaecological organs, intra-abdominal, skin, and subcutaneous tissue have been reported previously. However, involvement of subcutaneous tissue of the shoulder region presenting as a shoulder lump has rarely been reported.6 Subcutaneous PNET is frequently underdiagnosed. Correct diagnosis can be made based on histology features, demonstration of neuroendocrine granules on electron microscopy, and combination of MIC-2 ( CD99), CD56, and more than one neural marker positivity.7Large size tumours often show cystic changes or necrosis due to inadequate vascular supply compared to the size. MRI shows variable findings appearing iso to hypointense in T1 and iso to hyperintense in T2 weighted imaging. They show heterogeneous enhancement with areas of necrosis or cystic degeneration. Tumours usually have ill-defined borders and irregular shape.8Histologically, PNET consists of sheets of small round cells with a high nuclear to cytoplasm ratio. The cytoplasm is scanty, eosinophilic, and contains glycogen with stain PAS. Nuclei are round, with finely dispersed chromatin and a few tiny nucleoli with occasional rosette formation. The tumour often shows necrosis with viable cells on perivascular distribution. On immunohistochemistry, PNET shows a membranous expression of MIC-2 or CD99. Depending on their degree of differentiation, tumour cells express positive to neuron-specific enolase, synaptophysin, and S-100 protein. A combination of light microscopy pictures of small round cells and immunohistochemistry findings of CD99, CD56, and neuron-specific enolase help to make a diagnosis of PNET.There are many tumours in the small round cell family showing positive CD99 and PNET as one of the members of the small round cell tumour family should be considered a differential diagnosis in case of any soft tissue tumour. Furthermore, cells must demonstrate the panel of immunohistochemistry to reach a definite diagnosis.


Arthrogryposis multiplex congenita is a rare condition that mainly involves the lower limbs, characterized by severe joint deformity and contracture, muscular atrophy, and functional impairment. Its clinical manifestations are heterogenous and may involve the maxillofacial district as well.This case report describes a 20-year-old patient with arthrogryposis multiplex congenita with skeletal crossbite, facial asymmetry, reduced mouth opening and absence of lateral mandibular movement on the left side. After clinical evaluation, the following exams were required: postero-anterior cephalometric tracing, head and neck electromyography, computerized axiography, computed tomography scan, and maxillofacial magnetic resonance imaging. Orthognathodontic evaluation indicated skeletal asymmetry, reduced condylar movements on the left side and abnormally low electromyography activity of the masticatory muscles on the left side. Computed tomography and magnetic resonance imaging revealed unilateral left mandibular hypoplasia, hypotrophy, and fatty infiltration of masticatory muscles on the left side, as well as immobility of the left condyle during mouth opening, and hypoplasia of the left articular disk, which was however not displaced. Surgery was not indicated and conservative orthognathodontic treatment with function generating bite was suggested to balance the occlusal plane, as well as stretching exercises.A rare case of arthrogryposis multiplex congenita with maxillofacial involvement illustrates that a patient-centred, multidisciplinary approach with accurate diagnosis is required to formulate the best treatment plan. Because of the considerable damage to the masticatory muscles, conservative orthognathodontic therapy may be the best treatment option. Arthrogryposis multiplex congenita (AMC) is a rare form of arthrogryposis, characterized by congenital, non-progressive, and symmetric joint contractures that involve at least two different body areas; both upper and lower limbs are usually involved . It is aThe incidence of AMC is variably reported to be between 1/3000 and 1/10000 births. Statistical variability is due to the different criteria adopted in defining the disease, which may be easily confused with other syndromes. Involvement of the cranium and maxillofacial region has been observed in 22–24% of cases of arthrogryposis .AMC usually occurs sporadically, but different patterns of inheritance have been described, as well as more than 200 genes associated with this disease; however, the molecular mechanism of AMC is not known . ReductiA 20-year-old patient with AMC was referred to the Orthodontics Department, University of Turin, for temporomandibular joint (TMJ) surgical evaluation. Informed consent was obtained from the patient.Prior to TMJ evaluation, the patient was diagnosed with AMC, involving mainly the lower limbs and the maxillofacial district, with severe mandibular hypomobility. The patient had undergone different surgical procedures, including right knee extension, left hip extension and left achillotenotomy, followed by cycles of physiotherapy and functional re-education. These treatments were partially successful in correcting the lower limb deformities.At visual inspection, the patient showed macroscopic facial asymmetry, mostly on the left side, and a severe dental and skeletal crossbite of the right hemiarch with relevant functional impairment. Clinical examination showed a reduced maximum opening of the mouth (29 mm) with deviation towards the left side. Lateral excursion of the mandible towards the right side was normal (11 mm), while on the left side it was completely impaired (0 mm).Postero-anterior (PA) cephalometry, showing a severe mandibular asymmetry with deviation of the medial line towards the right side.Computerized axiography, performed with a Condylocomp LR3 , indicating that the protrusive and the maximal opening paths showed limitation in extension with a good repeatability on the right side, while on the left side there was total movement blockage.Electromyography, performed with an electromyograph K6-I . According to Jankelson test I (at rest) an increase of the value of the superior trapezius was observed while the remaining muscles showed physiological values. In test II (maximum clenching) extremely reduced values for the left anterior temporal and masseter muscles were observed and were not modified by the interposition of cotton rolls between the dental arches; the muscles on the right side contracted normally.To investigate the extent of the functional impairment, the following instrumental examinations were performed:iv)Spiral CT was performed with helical scans in the axial position from the chin tip to the cranium vertex. Slice thickness was 3 mm, reconstruction gap 1 mm. The scans obtained were sent to a Workstation  for 3D reconstruction. Computed tomography (CT) did not show significant anomalies of the condylar structures. On the other hand, significant underdevelopment of the left hemimandible was observed Fig. .v)MRI was performed with a Sigma 1.5 MR Unit  to evaluate disk morphology and position, and TMJ mobility. Condylar asymmetry was observed, as the left structure appeared smaller and on a different angle compared to the contralateral. On the left side, anterior tubercle of the temporal bone was less pronounced, the articular cavity was shallow and the coronoid process slightly hypertrophic Fig. . FunctioHaving found a severe functional impairment on the left side of the mandible, imaging with spiral computed tomography (SCT) and magnetic resonance imaging (MRI) were considered to assess the morphology of the TMJ and the masticatory muscles:The case of AMC described in this paper is of special interest, due to the rarity of the maxillofacial involvement in this disease. The MRI and Spiral CT with 3D reconstruction underlined the value of imaging techniques in the diagnosis and the evaluation of the extent of damage in this disease –10. The To assess the most appropriate therapeutical strategy, the patient was evaluated with both orthognathodontic examinations and imaging. Cephalometry, axiography, and electromyography were able to clearly identify the functional impairment but could not give an explanation for the immobility of the left TMJ. Therefore, orthognathodontic evaluation alone would not have been sufficient to formulate a treatment plan.A more sophisticated investigation of mandibular morphology and masticatory muscles condition was obtained with both CT with 3D reconstruction and MRI of the maxillofacial region. CT showed significant hypoplasia of the left hemimandible Fig. . Both CTImaging with CT and MRI made it possible to establish that the left TMJ locking and hypoplasia of the left hemimandible were due to severe muscular pathology, information that was crucial to choose the correct treatment plan. In such conditions, the patient would not have benefited from surgery –20. A moDiagnosis of arthrogryposis is based on clinical examination and molecular studies. Instrumental investigations generally do not show any significant alterations.Long-term orthopedic management and physiotherapy is required. Physiotherapy soon after birth is helpful in mobilizing joints and preventing disuse atrophy. Sometimes surgical procedures are required.Treatment of AMC is multidisciplinary and patient-specific, aimed at restoring mobility, ambulation, and the ability to care for oneself. However, in the case of severe maxillofacial involvement, steps should be taken in order to fully investigate the extent of the limitations imposed by the disease on orofacial functions, and to choose the therapeutic means best suited to the specific clinical situation.This case report highlights the importance of a multidisciplinary approach to the treatment of rare diseases, especially when presenting with unusual features. The treatment of choice should be tailored to the individual patient, after a meticulous diagnostic process. In selected cases, AMC patients with maxillofacial involvement may benefit from conservative orthognathodontic therapy.


Case Report.To report a case of a paraganglioma presenting in an uncommon location in the abdomen.A 24-year-old man with an abdominal lesion presented with one-year history of severe headaches and palpitations.The tumor was surgically resected and was later diagnosed as an extra-adrenal paraganglioma.The unique location of a paraganglioma could prove misleading, making it easier to confuse it with other malignant lesions, but it still can't be excluded, and with proper techniques it can be surgically excised. •Paragangliomas (PGLs) are slow-growing tumors of neuroendocrine origin.•PGLs in the portocaval region are considered extremely rare.•Their unusual location has its own implications that must be carefully considered.•Clinical findings with imaging techniques and laboratory tests are key to diagnosis.•Surgical resection remains the gold standard of treatment. They arise from either sympathetic or parasympathetic paraganglia found throughout the body.While there exist reports of retroperitoneal paragangliomas, a paraganglioma situated between the portal vein and the inferior vena cava has only been described once in the literature.This paper presents a case of a portocaval paraganglioma mainly for its unique location and the implications it had on patient's management.This case report has been reported in line with the SCARE criteria .2A 24-year-old Caucasian man presented with a one-year history of severe headaches not responding to medications, palpitations, sustained hypertension and generalized hyperhidrosis. He also complained of erectile dysfunction and loss of libido.The patient was non-alcoholic, but he was a light smoker and has smoked less than one pack-year. His past medical history revealed well-controlled diabetes mellitus by metformin and diet. He also had no family or allergy history.Upon physical examination, the presence of hypertension was confirmed with measurements ranging from 160/90 mmHg and up to 190/100 mmHg.Differential diagnosis considered the possibility of a primary tumor in the abdomen, including pheochromocytoma (PCC), paraganglioma (PGL) and other adrenal tumors. It even included a possible prolactinoma which was excluded later on due to normal prolactin levels and lack of visual field defects.Laboratory investigations were carried out. Increased levels of 24-h urine normetanephrine (5933 mcg/dl) were noted. All other tests  yielded normal results.Evaluation with ultrasonography of the abdomen showed a hyper-vascular iso-to hypoechoic lesion located in the porta hepatis region, and both the adrenal glands were unremarkable.Neck ultrasound was normal.Intravenous (IV) contrast-enhanced computed tomography (CECT) of the abdomen showed a 7.2-cm × 6.5-cm × 5.4-cm, well-defined, irregularly-spherical, heterogenous, arterial enhancing lesion in near proximity of the caudate lobe of the liver, which confirmed the ultrasonography findings.Both axial and coronal views of the mass in the arterial phase of CECT are demonstrated in The mass demonstrated no invasion to the caudate lobe, pancreas, portal vein, IVC and the adrenals, as they were all spared, and this was later confirmed by surgery.While it's true that functional imaging performed with iodine-123 metaiodobenzylguanidine (MIBG) and single photon emission computed tomography (SPECT) has high sensitivity and specificity for detecting primary tumors and metastases, in our case it didn't help as the lesion showed no uptake of the isotope.Further evaluation with gadolinium-enhanced magnetic resonance imaging (GEMRI) was performed, and showed the lesion to be iso-to hypo-intense on T1-weighted images, and iso-to hyper-intense on T2-weighted and fat saturation images, with intense and heterogenous enhancement with no signs of invasion.Both axial and coronal views of the lesion on GEMRI are shown in No enlarged lymph nodes were seen.1H-MRS) were performed, and resulting spectra, which were acquired using single-voxel spectroscopy (SVS) along with manual shimming, showed no evidence of a singlet succinate peak at 2.42 ppm as seen in Additional sequences for in vivo proton magnetic resonance spectroscopy  single photon emission computed tomography (SPECT) study gave a false-negative result, the most logical being the patient undergoing a contrast-enhanced computed tomography (CECT) study 2-weeks prior, which is highly plausible.1H-MRS.The other explanation is that some paragangliomas associated with SDHB gene mutations might give false-negative results thanks to their rapidly growing nature. Though, this is highly unlikely as such tumors are mostly metastatic and suffer from poor prognosis, which isn't the case here as the imaging findings clearly show, and as later confirmed by surgery. This fact is furthermore supported by the lack of a singlet succinate peak on Postoperative surveillance was carried out for 6 months, with 24-h urine normetanephrine levels being normal when measured at the second- and fourth-week intervals following surgery. Hypertension had been normalized and antihypertensive agents were discontinued. Patient was recommended for normetanephrine level measurement on a quarterly basis during the first year following surgery, then semiannually for at least 5 years, and was also recommended for weekly blood pressure monitoring for the first year and monthly thereafter.4Functional paragangliomas in the portocaval region are an extremely rare presentation of paragangliomas. The unusual location makes it easier to confuse them with other abdominal malignant lesions, particularly retroperitoneal ones, but the diagnosis of a PGL still can't be excluded. Utilizing proper radiographic and imaging techniques is key to diagnosis, and total surgical resection remains the gold standard treatment for managing such tumors.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This case report did not require review by the ethics committee in Aleppo University Hospital (AUH), Aleppo, Syria.Not applicable.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.•Duaa Ghajar: contributed in data collection and interpretation, and writing the paper (First Author)•Firas Khana: contributed in data collection and interpretation, study design and writing the paper (Coauthor #1 and Corresponding Author)•Mohammed Deeb Zakkor: contributed in data interpretation, study concept and writing the paper (Coauthor #2)•HACHEM AlHussein: contributed in reviewing the paper (Coauthor #3)•Alae Kayyali: contributed in reviewing the paper (Coauthor #4)Firas Khana.Not commissioned; externally peer reviewed.All authors declared no conflict of interest.


Ocular myxomas are very rare and can involve the orbit, eyelids, and conjunctiva. Conjunctival myxoma can be misdiagnosed as amelanotic nevus, conjunctival cyst, or ocular surface squamous neoplasia, among others. They can appear as an isolated lesion or can be associated with systemic manifestations as part of the Carney complex or Zollinger-Ellison syndrome.We describe a 64-year-old healthy male who presented with a right eye painless peri-limbal salmon-colored patch lesion in the infero-temporal bulbar conjunctiva over a period of 2 years. There was no of ocular trauma or surgery and no effect on vision. The mass was not tender, raised, and mobile with fine intrinsic vascularity. Excisional biopsy with the presumed diagnosis of lymphoma revealed a typical sub-conjunctival myxoma.The recognition of ocular myxoma necessitates systemic evaluation to rule out possible associated cardiac myxoma in Carney complex, thus can prevent life-threatening events. The excised mass in our patient showed an area of pseudo-elastotic degeneration, which has further complicated the clinical appearance of the lesion, however, the color, and consistency of the mass were highly suspicious of lymphoma. The diagnosis of myxoma by histopathology was helpful especially in presence of atypical appearance such as in our case.The histopathological characteristics of conjunctival myxoma can aid in the diagnosis. The lesion in our case was associated with focal severe pseudo-elastotic degeneration and prominent salmon-patch appearing area thus was initially misdiagnosed clinically as a conjunctival lymphoma. •Conjunctival myxoma is a rare benign tumor that can be easily misdiagnosed.•Histopathological typical features are essential to confirm the diagnosis.•We describe a salmon-colored conjunctival myxoma mimicking lymphoma.•Our case was successfully managed by total excisional biopsy. Ocular myxomas are extremely rare; however, they can affect the orbit, eyelids, and conjunctiva Here, we describe the clinical presentation and histopathological characteristics of a salmon-patch-like conjunctival myxoma, which was initially misdiagnosed as conjunctival lymphoma due to its clinical appearance. This case report has been prepared and reported in accordance with the SCARE criteria 2A 64-year-old healthy male presented to the Ophthalmology department of our tertiary care hospital with ocular discomfort and an infero-temporal peri-limbal painless slow-growing, pinkish nodular lesion involving the bulbar conjunctiva of the right eye (RE), which has been present over the last 2 years. The patient didn't report any history of ocular trauma or surgery. His family history, drug history, and medical history were unremarkable. The uncorrected visual acuity measured 20/30 in both eyes. Slit lamp biomicroscopic examination of the left eye was normal, while that of the RE showed a non-tender, pinkish, mobile, raised lesion on the temporal part of the bulbar conjunctiva, measuring 9 mm × 7 mm in diameter with fine intrinsic vascularity : a & b. 3Conjunctival myxomas are extremely rare tumors, with a rate of incidence of 0.001–0.002 %, as compared to other conjunctival tumors. They usually appear in older individuals, as in our present case Normally, conjunctival myxoma tends to present as a painless, slow-growing, translucent, yellow-pinkish conjunctival mass that can be cystic, and according to the literature, it is more frequently present in the bulbar conjunctiva, being characteristic in the temporal quadrant as in our case Although most conjunctival myxomas reported in the literature present as isolated lesions, it is worth mentioning that some of them could appear as a part of the Carney complex or the Zollinger-Ellison syndrome. Therefore, a clinical suspicion of such conjunctival lesion mandates taking into account atypical forms, and early recognition if possible with an excisional biopsy and an initiation of systemic evaluation is advisable in order to prevent life-threatening events since ocular presentation may precede the embolic vascular events, especially in the previously mentioned syndromes Immunohistochemistry is characterized by positivity for vimentin and negativity for smooth muscle actin, SOX10, and GLUT1 Regarding management, excisional biopsy seems to be the preferred pattern, according to the results from a review by Alvarado-Villacorta et al. 4Conjunctival myxomas are a rare condition which can mimic other benign and malignant ocular lesions. Surgical excision is required to confirm the diagnosis and to exclude other malignancies. Furthermore, these lesions can be associated with systemic syndromes; therefore, an early recognition and initiation of systemic evaluation is necessary to prevent life-threatening events. We would like to highlight the possible atypical appearance as well of conjunctival myxomas. Therefore, myxoma should be always considered within the differential diagnosis of a conjunctival lesion.Not commissioned, externally peer reviewed.This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.IRB is not required for case reports. However, information was obtained and reported in a manner that was compliant with the standards set forth by the Health Insurance Portability and Accountability Act, and the Declaration of Helsinki as amended in 2013.General informed written consent was obtained from the patient including permission for anonymous use of photos and for reporting. A copy of the written consent is available for review by the Editor of this journal upon request.•Majed Al-Kharashi: The primary treating ophthalmic surgeon providing clinical images.•Wael Otaif: Chart review for data collection, literature review and first draft of the case report.•Ahmed Alhumidi: Histopathological examination as consultation.•Hind M. Alkatan: Final tissue diagnosis and images. Critical overall review and revision of the manuscript for submission as Corresponding author.Not applicable.Hind M. Alkatan.None.


Neuroendocrine tumors are mainly located in gastrointestinal tract, pancreas and lungs. The primary hepatic origin of neuroendocrine tumors is extremely rare.A 57-year-old female with a history of cholecystectomy presented to our hospital for right upper abdominal pain lasting for 2 months. Abdominal computed tomography revealed a large exophytic soft-tissue mass in the left liver lobe. Tumor markers were within the normal range. Octreoscan confirmed the primary hepatic origin of neuroendocrine tumor. The patient underwent left hepatic resection. Pathological and immunohistochemical examination of the resected specimen showed a well-differentiated grade 2 neuroendocrine tumor.Primary hepatic neuroendocrine tumors represent rare hepatic tumors. These tumors may occur at any age with an average of 50 years. Diagnosis algorithm includes two key steps: firstly, the confirmation of the endocrine nature of the tumor and secondly the confirmation of its primary nature.Neuroendocrine tumors are a very rare entity. The primary hepatic location is exceptional. The diagnosis is based on pathological and immunohistochemical examination as well as the result of the octreoscan. •The primary hepatic origin of neuroendocrine tumors is extremely rare. She had consulted for upper abdominal pain evolving for two months, without jaundice or other associated signs. The clinical examination was without abnormalities. Abdominal ultrasound examination found a liver mass.A computed tomography(CT)scan revealed a voluminous soft mass of the left liver with exophytic development evoking a malignant lesion in first a hepatocellular carcinoma on healthy liver or a malignant degeneration of an old hepatic adenoma . A magneThe patient is currently alive without recurrence at 20 months postoperatively.3NETs originate from neuro-ectodermal cells that migrate from the neural crest from the neural crest to the entire body during embryogenesis .They develop from enterochromaffin cells capable of secreting functional hormones . These tPrimary endocrine tumors of the liver are an uncommon pathology. These tumors occur at any age with an average age of 50 years, with a female predominance of 58% . ClinicaDiagnostic procedure involves two key steps: the first is the confirmation of the neuroendocrine nature of the tumor and the second is the confirmation of its primary nature. The immunohistochemical study remains the only reliable tool to confirm the neuroendocrine nature of the tumor. The specific markers are chromogranin A, NSE and synaptophysin ,10,11. TAfter surgical resection, the prognosis is generally favorable with a low recurrence rate of 18% .4NETs are a very rare entity and hepatic primary location is also rare. The diagnosis depends on pathological examination and immunohistochemistry as well as the result of the octreoscan. Surgical resection of the tumor remains the gold-standard treatment and long-term prognosis remains favorable.No ethical approval was necessary.The author(s) received no financial support for the research, authorship and/or publication of this article.Dr Bouzayan Laila: Have written the article, have consulted the patient, and participated in the surgery.Dr Ayoub Madani: supervised the writing of the manuscript.Dr Malki Samia: Interpretation of histological data.Dr Abbou Widad: Interpretation of radiology.Pr Skiker Imane:(radiology professor): confirm the radiology Interpretation.Pr Benani Amal (anatomopathology professor): confirm the histological diagnosis.Pr Jabi Rachid: supervised the writing of manuscript.Pr Bouziane Mohammed (oncology surgery professor): have supervised the writing of the paper, and has been the leader surgeon of the case.Not available.Dr Bouzayan Laila,Pr BOUZIANE Mohammed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.The authors declared no potential conflicts of interest concerning research, authorship, and/or publication of the article.


The lesion showed intense uptake on gallium-68 DOTATOC positron emission tomography-computed tomography scan. The patient underwent surgical resection of the tumor with resolution of bowel obstruction events. He had elevated pancreatic polypeptide levels, which are known to delay gastric emptying and could explain his symptoms.A 56-year-old man presented with recurrent gastrointestinal obstruction. Computed tomography showed fluid-filled, distended stomach, small intestine, and large intestine. Extensive workup including esophagogastroduodenoscopy, colonoscopy, magnetic resonance enterography, push enteroscopy, and video capsule enteroscopy showed no mechanical obstruction. Endoscopic ultrasound–guided biopsy of peripancreatic nodes detected on  Neuroendocrine tumors (NET) are a rare cause of bowel obstruction. At the time of diagnosis, most tumors have metastasized. Knowledge of unique diagnostic methods is imperative to timely diagnosis and management.A 56-year-old man was transferred to our hospital after over 10 admissions to an outside facility for gastrointestinal (GI) obstruction over the preceding year. He had lost 50 pounds of weight during this period. He had no history of abdominal surgeries. He presented with epigastric abdominal pain, distension, nausea, and emesis. He was managed nonoperatively with nasogastric tube placement and bowel rest.Previous computed tomography (CT) scans of the abdomen showed variable distension of the stomach, or fluid-filled small intestine with concern for transition point at the ileum, or distended large intestine. He had formerly undergone 2 esophagogastroduodenoscopies, which did not reveal gastric outlet obstruction. His current CT abdomen showed a fluid-filled stomach and duodenum, suggestive of gastric outlet obstruction Figure . MagnetiPush enteroscopy revealed esophagitis and severe aphthous ulcerations in the small intestine, but no obstruction. Colonoscopy did not reveal any obstructive pathology. Video capsule enterography revealed erythematous mucosa with villous blunting and nonobstructive luminal narrowing in the duodenum through which the capsule passed easily.18F-fluorodeoxyglucose positron emission tomography (18FDG PET)/CT scan was performed to further evaluate the mesenteric lesion seen on MRE. It showed multiple mild to moderately FDG avid cervical lymph nodes (LN), the largest a 4-cm left supraclavicular LN. It redemonstrated the soft-tissue lesion anterior to the duodenum with mild to moderate FDG uptake and multiple borderline retroperitoneal LN. There was no abnormal uptake in the intestines, which could explain the recurrent obstruction. Ultrasound-guided biopsy of the left supraclavicular LN revealed a hemangioma.An 18FDG PET/CT scan. The visualized liver was normal.Endoscopic ultrasound performed to investigate the FDG avid mass showed a hypoechoic lesion, 18 mm in maximum diameter at the porta hepatis correlating with the suspicious findings on the Fine-needle biopsy of the porta hepatis lesion revealed a well-differentiated NET. gallium-68 DOTATOC PET/CT scan showed a 2.3 × 2.2-cm intensely somatostatin receptor positive lesion anterior to the duodenum and 2 intensely positive peripancreatic nodules adjacent to the uncinate process, larger measuring 1.4 cm  duodenal NET with metastatic peripancreatic LN; stage pT1N1. The postoperative course was uneventful. Because there was no residual tumor, he was not started on octreotide. Repeat gallium-68 PET DOTATOC scan was negative for residual disease. Postoperatively, serotonin and chromogranin A levels normalized , whereas PP decreased to 1,510 pg/mL. Since discharge, the patient has not developed any further episodes of mechanical small bowel obstruction and has gained 33 pounds of weight.1 Because of improved diagnostic modalities, their incidence has increased over time. They are, however, rare, and knowledge of appropriate diagnostic modalities is of utmost importance for timely diagnosis and treatment because they can often be missed on conventional imaging.2 At the time of diagnosis, most patients have metastatic disease.3NET arise from neuroendocrine cells and are most commonly found in the lung, small intestine, and pancreas.5 In the present case, despite convincing symptomatology and CT findings with intestinal dilation and a transition point, extensive workup including esophagogastroduodenoscopies, colonoscopy, MRE, push enteroscopy, and video capsule enterography failed to show obstructive pathology. No obstruction was noted on surgical exploration.We could not pinpoint the exact etiology of recurrent obstructive events in this patient. NET presenting with bowel obstruction usually result from a mechanical cause.7 Chromogranin A has no effect on intestinal motility.8 Somatostatin can reduce GI motility, but levels were normal.9 Serotonin and gastrin levels were mildly elevated. The patient had evidence of gastritis/esophagitis. However, gastrin levels were not high enough to suggest Zollinger-Ellison syndrome. Moreover, the patient was on a proton pump inhibitor.Levels of PP and chromogranin A were markedly elevated. PP can delay gastric emptying, although this effect has been questioned.10 Hence, these tumors can be associated with a mesenteric desmoplastic reaction, resulting in GI obstruction.11 A mesenteric inflammatory reaction that, if allowed to persist, might have progressed to a desmoplasia could also cause recurrent obstructions in this patient. However, no fibrosis was appreciated on exploratory laparotomy. We believe the NET were the cause of bowel obstruction in this patient because his symptoms improved after resection and he regained weight.Metastatic LN in NET can cause mesenteric fibrosis through the release of angiogenic and fibroblast-inducing mediators.12 In this case, known nodal metastases precluded endoscopic resection. Moreover, the primary tumor was not definitively identified until laparotomy. Although a Whipple procedure represents the standard therapy and would provide a more complete lymphadenectomy, the patient's nutritional status placed him at high risk of complications from such an extensive operation. The tumor's small size and antimesenteric location made a lower-risk local resection feasible without compromising later radical resection if needed after improvement in nutrition.Most duodenal NET <2 cm do not have nodal metastases and may be resected endoscopically.Clinical persistence, appropriate diagnostics, and attention to detail were instrumental in his diagnosis and treatment. Because NET can often lead to bowel obstruction because of neurohormonal effects or desmoplastic reaction, and they are not always detectable on conventional imaging modalities such as magnetic resonance imaging or CT scans, a gallium-68 PET DOTATOC scan may be a reasonable investigation for a patient presenting with recurrent bowel obstruction and no identifiable cause on routine imaging.Author contributions: R. Sharma: conception, analysis and interpretation of data, and writing manuscript, accountable for all aspects of work. H. Zafar: analysis and interpretation of data. SK Sherman: critically revising manuscript. F. Niyazi: conception, critical review, accountable for all aspects of work, and is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.


Myxoma is a benign tumor of mesenchymal origin. It frequently occurs in the muscles of the hip and extremities; however, it rarely occurs in the head and neck region. This report describes the second case of an intramuscular myxoma of the tongue. A 23-year-old woman was referred to our institution for the diagnosis and treatment of a left tongue lesion. T2-weighted magnetic resonance imaging revealed an 8 × 6-mm mass in the tongue. Based on a clinical diagnosis of a tongue tumor, excisional biopsy was performed under general anesthesia. The histopathological diagnosis was an intramuscular myxoma. The postoperative course was uneventful, and there was no evidence of tumor recurrence 3 years after surgery. Myxoma is a benign tumor of mesenchymal origin. It frequently occurs in the muscles of the hip and extremities; however, it rarely occurs in the head and neck region . The symIn the head and neck region, odontogenic myxomas develop in the maxilla or mandible. They are neoplasms of odontogenic origin and thus differ from soft tissue myxoma, which is classified as a tumor of uncertain differentiation . BecauseWe herein report the second case of an intramuscular myxoma of the tongue, together with a literature review.A 23-year-old woman was referred to our institution for the diagnosis and treatment of a left tongue lesion. She had first noticed the lesion approximately 1 month earlier. The patient's medical and family histories were unremarkable. Intraoral examination revealed a 10-mm-diameter elastic soft mass in the left tongue. The overlying mucosa was normal . There wMagnetic resonance imaging (MRI) was performed with a 3.0-Tesla system . On T1-weighted axial images, the mass in the left tongue showed low signal intensity relative to muscle. On T2-weighted images, increased signal intensity was noted within the lesion . The lesBased on a clinical diagnosis of a benign tongue tumor, excisional biopsy was performed under general anesthesia. A spindle-shaped incision was made on the lateral surface of the left tongue. The specimen was pulled outward with slight lateral traction and cut using a surgical scalpel. Finally, the whole tumor with surrounding soft tissue was obtained as a surgical specimen . HistopaThe postoperative course was uneventful. There was no evidence of tumor recurrence 3 years after surgery.Intramuscular myxomas in the head and neck are rare. To the best of our knowledge, 33 cases of intramuscular myxomas in the head and neck, including the present case, have been reported in the literature to date . These cTypical MRI findings of intramuscular myxomas are homogeneous low signal intensity in T1-weighted images and high signal intensity in T2-weighted images . Luna etPreoperative fine needle aspiration cytology was performed in 8 of 33 intramuscular myxomas in the head and neck. Only one case was correctly diagnosed as a myxoma . A diagnThe histopathological differential diagnoses of intramuscular myxoma include low-grade myxofibrosarcoma, myxoid liposarcoma, nerve sheath myxoma, and oral focal mucinosis. Low-grade myxofibrosarcoma exhibits infiltrative behavior ; howeverMazabraud syndrome, which was first reported by the French physician Mazabraud  in 1967,An intramuscular myxoma in the head and neck region is treated by surgical excision. Recurrence is rare; only two myxomas in the posterior neck  and in tIn conclusion, this is the second reported case of an intramuscular myxoma of the tongue . A corre


Biliary mucinous cystic neoplasms (BMCNs) are rare and slow-growing lesions that are usually discovered incidentally. They can imitate various other liver tumors. Here, we present a 31-year-old female patient who presented with complaints of abdominal pain, nausea, shortness of breath, and obstructive jaundice. Ultrasound showed a large, lobulated, cystic liver mass. Abdominal computed tomography (CT) scan showed features suggestive of a hydatid cyst or complicated liver cyst. A laparoscopic deroofing was performed and showed a liver cyst involving segments 2, 3, 4A, and 4B. Histopathology showed that the cyst wall was lined by columnar mucin-producing epithelium with multifocal areas of ovarian-like stroma, and the diagnosis of biliary mucinous cystic neoplasms was made. A one-year, follow-up radiological examination did not show any recurrence.BMCNs are quite rare. The nonspecific nature of the symptoms and radiological characteristics makes the diagnosis of BMCN challenging. Imaging modalities can aid in the diagnosis, but pathological examination is essential in confirming a definite diagnosis.  Mucinous cysts are complex, multiseptated cysts in which mural thickening, nodularity, debris-containing fluid, and hemorrhagic or protein-containing materials are frequently observed . BiliaryA 31-year-old Arabic female presented with jaundice, right upper quadrant pain, and nausea that was associated with loss of appetite, shortness of breath, and pleuritic chest pain. The abdominal pain was in the right upper quadrant, colicky in nature, and radiating to the back. The patient noticed yellowish discoloration of the eyes and face. On examination, the abdomen was soft and distended. Massive tender hepatomegaly was noted reaching the right lumbar and epigastric regions.The patient is a nonsmoker and doesn’t drink alcohol or use any substances. Laboratory tests revealed abnormal liver function tests  scan showed a large hepatic cyst measured 13*17*20 cm seen arising from the left hepatic lobe with a double-wall sign and suspicion of focus of calcification. However, no abnormal enhancement was seen. The spleen measured 15 cm, without a focal lesion, and the right ovarian cyst with blood or fluid level noted measured 2.7 cm  without contrast showed a large, right, upper quadrant cyst without internal soft tissue nodules or membranous part causing compression on the adjacent structures in addition to the intrahepatic biliary tree Figure .The patient underwent laparoscopic surgery, during which the cyst roofing was partially removed. An examination of the cyst cavity did not reveal any evidence of a hydatid cyst, and a specimen was sent for histological examination.A microscopy exam showed a cyst wall lined by columnar, mucin-producing epithelium, and the underlying stroma shows multifocal areas of ovarian-like stroma with ovoid to spindle cells that are immunoreactive to the estrogen receptor, progesterone receptor, and inhibin  immunohistochemical stains. The histopathological features were consistent with mucinous cystic neoplasm Figure .However, these lesions are described to be multilocular; the examined sections show no evidence of high-grade dysplasia or invasive malignancy. The liver's non-invasive mucinous cyst tumor was confirmed histologically. Following the procedure, there were no complications, and a year later, the patient showed no signs of recurrence.Cystic liver lesions are a diverse collection of diseases with varying origins, prevalence, and clinical symptoms. The majority of liver cysts that are incidentally found are benign . MalignaCalcifications, in addition to positive serology tests, are often linked with echinococcal cysts . MicroscTo conclude, biliary cystadenomas are rare tumors and should be examined with multilocular, hepatic cystic lesions, particularly in patients with obstructive jaundice, especially in women. The therapy of choice is complete excision due to its potential malignant transformation and its natural history of gradually increasing and recurring after partial excision.We present a case of a young lady in which BMCN caused the narrowing of the bile duct with the presentation of abdominal pain and jaundice. BMCN with extrahepatic biliary tract involvement is a rare, slow-growing tumor that arises more commonly in women and has the potential for malignant transformation. Clinically, it presents with a prolonged course of epigastric fullness later followed by obstructive jaundice.In summary, BMCN may present with abdominal pain and features of obstructive jaundice. Clinical presentation, complemented with imaging and histopathological evaluation, is essential for diagnosis. Complete surgical resection is the treatment of choice to prevent recurrence and malignant transformation.


Taenia saginata (T. saginata) is one of the most common cestodes in humans. Isolated perforation of the small bowel after blunt abdominal trauma is infrequent and the diagnosis should be based on exclusion.We report a case of a 34-year-old man who presented following a car-pedestrian accident. Clinical examinations and symptoms suggested an acute abdomen. Investigations led to the diagnosis of hollow viscus perforation, so emergency laparotomy was performed. At the exploration of peritoneal cavity, unexpectedly, a live tapeworm was found in the peritoneal cavity. The perforation was repaired and medication were continued by anthelmintic. He was discharged with good condition.We discuss this rare incidental finding in a patient with bowel perforation and suggest the taeniasis as a possible cause of intestinal perforation. The medical literature and reviews have been searched to find more information about taeniasis and its cause-effect in GI tract complications.Increasing the public knowledge about food hygiene and encouraging eat well-cooked meat can control the cycle of transmission of cestodes. Taeniasis should be considered a possible cause of intestinal obstruction or perforation, especially in endemic areas. •Taenia saginata, the incidental find in the case of abdominal blunt trauma with Intestinal Perforation.•Isolated perforation of the small bowel after blunt abdominal trauma.•Taeniasis should be considered as a cause of acute abdomen.•The intestinal perforation has remained a rare complication in parasitic diseases. This case is reported by the department of general surgery of this hospital.This article is modified according to the SCARE 2020 criteria 22.1A 34-year-old man was presented as a car-pedestrian accident to emergency department. Based on ATLS in trauma assessment, primary survey was done. Vital signs were BP: 110/80, PR: 90 Saturation of oxygen: 96. He was not completely conscious (GCS: 8). We Resuscitated and intubated him. He had not active bleeding or ecchymosis. His father (source of information) did not remember any relevant past medical or surgical history. His drug history was adverse. They had no familial history of specific chronic diseases or any cancer. He was not married and lived with his parents. They were low in the socioeconomic state. He was educated and had no psychological history.2.2Because of his loss of consciousness (GCS = 8), the abdominal examination was not assessable. FAST ultrasound was done, and it was negative for free fluid in the abdomen and pelvis. His vital signs were stable. His temp was 37 °C. His relevant first lab results were WBC: 18/Hb: 15. For other aspects of injury, CT scan of brain and thorax was done.His brain CT scan showed diffuse axonal brain injury. CT scan of the thorax was cleared, and there was no pneumothorax or rib fracture. In the second FAST ultrasound after 30 min checking, mild inter-loop fluid was seen. Whether the next plan was CT scan with IV contrast enhancement, but because of country problems and some medical sanctions on IRAN, we did not have the contrast agent, therefor diagnostic peritoneal lavage (DPL) was performed. Food particles were found in DPL fluid. So for urgent laparatomy, he was taken to OR.2.3Laparotomy under general anesthesia through mid-line incision was performed by an expert attending general surgeon and senior resident. In exploration of peritoneal cavity, 3 cm and 2 cm perforations were seen in 220 cm distal to the treitz ligament and 5 cm proximal to ileocecal valve, respectively. Unexpectedly, a 2-m length tape worm and also 2 cm and 5 cm worms were seen there. The peritoneal cavity was washed with warm normal saline, the first perforation site was resected and primary end-to-end anastomosis was performed. In addition, because of ileocecal valve damage, right hemicolectomy and side-to-side ileocolic anastomosis was also performed with linear cutter (LC) stapler. Finally, two hemovac drains were established close to anastomosis sites. Postoperatively, medical treatment with broad-spectrum intravenous antibiotics and anthelminthic therapy was started , Fig. 3.2.4According to patient's state, he was admitted to ICU for three days and regained full consciousness. There was no sign of leakage or failing of the anastomoses. The intestinal function was normal, he tolerated regular diet with no nausea or vomiting, leukocytosis decreased, and he was discharged with well general condition and normal defecation function. After three weeks, the stool exam was clear and parasite eggs were not detected.3Taenia spp. includes T. saginata, T. solium and T. asiatica which is very close in features to T. saginata. T. saginata is the most common tapeworm infestation in humans, which may cause gastrointestinal tract complications due to obstruction, perforation or anastomotic leakage Taeniasis is usually asymptomatic; most of the time, patients complain of proglottids in the stool. However, sometimes mild constitutional symptoms and consolidation from infesting, like nausea, weight loss and abdominal pain and discomfort, happen. Infrequently, the tapeworm can lead to severe medical conditions such as jejunal perforation and peritonitis The most surgical manifestation of taeniasis is abdominal pain, mall nutrition, obstruction, inflammation and perforation of the small intestine, appendix or colon T. saginataSome articles reported taenia complications in humans, like perforation or obstruction, and one remarkable case reported gall bladder perforation by saginata & asiatica), and fewer happen with T. solium, but it causes systemic complications more Mechanical intestinal obstruction due to bolus of Taenia and mucosa contact, leading to gross inflammatory edema, is the most accepted theory for bowel perforation T. saginata, there is a theory about some treatment with medications or some peripheral trigger that can provoke and activate adult worms. So they perforate the tracked to invasion to other parts or scape from anthelmintic agents Despite of usual nature of The standard treatment for all tapeworms is praziquantel, with a dose of 10 mg/kg orally in a single dose for any taeniasis Overall, there are no strong evidences in this case to show that there was a connection between intestinal rupture caused by trauma and Taeniasis.DPL is a safe and cost-effective method of evaluating patients with potential intra-abdominal injury, but CT scan with IV and oral enhancement should be performed if available. In this case, we did not have the contrast agent because of limitations and sanctions. So DPL can be helpful in these situations.4Taeniasis and complications remain a health problem in developing countries. Increasing the public knowledge about food hygiene and encouraging to use of well-cooked meat can control the cycle of transmission of cestodes. Delay in diagnosing such infestations by cestodes is critical as it can lead to fatal outcomes. Cestodes in the bowel can cause obstruction, mall-nutrition, ischemia and sudden perforations. Taeniasis should be considered a possible cause of intestinal obstruction or perforation, especially in endemic areas with poor sanitation.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The patient gave the official and ethical approved, informed consent for this publication and images.Ethical approval is exempt/waived at our institution.Not applicable.Dr. Behzad Nemati Honar is the main author and he has designed this report. He is our mentor and specialized general surgeon.Dr. Seyed Pedram Kouchak Hosseini is the senior resident of general surgery and he collected datas.Dr. Alireza Haghbin Toutounchi is the intern of surgery and the writer of this article and coresponding author.Dr. Behzad Nematihonar accepts all responsibility of this article.Not applicable.All authors declare that they have no conflicts of interest.


Endometrial stromal sarcoma is a relatively rare malignant tumor that derives from the malignant transformation of primitive uterine mesenchymal cells. It can lead to distant metastases. High-grade endometrial stromal sarcoma is extremely rare. The adrenal glands are an unreported site of metastasis.18F-FDG PET/CT. The right upper lobe mass was diagnosed as a high-grade endometrial stromal sarcoma metastasis after postoperative pathology. Due to the patient’s high risk of surgery, as she had many underlying diseases, we performed adequate preoperative preparation. The physical examination revealed that a hard mass was palpable in the right renal area. The right adrenal mass was resected in our hospital. Immunohistochemistry showed ER (-), PR (-), CD10 (+), P16 (+), Ki-67 (50%). The final diagnosis on pathological examination was a high-grade ESS metastatic to the right adrenal gland. The patient continued treatment in other hospitals after surgical resection. After four months of postoperative follow-up, metastasis was detected again during a PET/CT examination at an outside hospital.A 71-year-old woman with a diagnosis of endometrial stromal sarcoma 30 months ago. After receiving treatment with radiotherapy and chemotherapy, the patient was kept asymptomatic during the follow-up until 2 years later, when she complained of dyspnea. Pulmonary and right adrenal gland metastases were detected by Endometrial stromal sarcoma is rare, and the adrenal glands are an unreported site of metastasis. It has no specific clinical symptoms and mainly found for other reasons. The diagnosis still depends on pathology and immunohistochemistry. If there is no relevant past history, it is difficult to exclude a primary adrenal tumor. Endometrial stromal sarcoma (ESS) is a rare malignant tumor of mesenchymal origin . CurrentA 71-year-old woman with diagnosis of ESS 30 months ago. After receiving treatment with radiotherapy and chemotherapy, the patient remained asymptomatic during the follow-up until 2 years later, when she complained of dyspnea.18F-FDG PET/CT was performed to identify if there was a potential malignancy tumor. The maximum intensity projection image . The levels of CA-199 were abnormal . Plasma ACTH, angiotensin and renin concentrations were within the normal range. Other laboratory tests showed no significant abnormalities.18F-FDG PET/CT examination at an outside hospital. The PET/CT of the outside hospital showed thickening of the left adrenal gland union with increased metabolism.With adequate preoperative preparation, an open right adrenal tumor resection was performed. The intraoperative exploration revealed a cystic solid mass with a size of about 11.0 cm×10.5 cm. In a pathological view, the lesion was a round, dark red in color, and surrounded by a thick membrane and adhered to the surrounding tissues. On histopathological examination, the tumor cells were seen arranged in a swirling flow structure  is a relatively rare malignant tumor, which accounts for 0.2% of all uterine malignancies. The annual incidence of ESS is 1-2 per million women .Chromosome translocations and rearrangements are common events in ESS and reflect distinct mechanisms of occurrence . Low-graOwing to its aggressive behavior, ESS can metastasize to lymph nodes, lungs, and bones, but it is relatively rare . MeanwhiESS lacks specific clinical manifestations and imaging features. Microscopic examination showed that the tumor cells are arranged in a swirling flow structure and are located around the small arterial network of the hyaline wall . NecrosiIf there is no history of endometriosis, diagnosing ESS remains challenging. Some patients have no history of endometriosis , 10. PatBecause of the low incidence, there has been no consensus on the standard treatment of high-grade ESS . For ESSIn conclusion, ESS is a rare malignancy, and the symptoms differ greatly depending on the location. High-grade ESS can metastasize throughout the lungs, lymph nodes, and bone. High-grade ESS is particularly rare and this is the first report of a metastasis to the adrenal glands. The diagnosis of metastatic ESS should be considered when the patient has a history of ESS and presents with a mass at a distant site. However, the diagnosis depends on the pathology and needs to be differentiated from other diseases. Surgical resection is used as the first treatment of choice, and high-grade ESS needs to be followed by concurrent chemotherapy and requires follow-up after surgery.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.TZ, R-LF and S-FY collected data and drafted the manuscript. R-LF and HW provided figures and pathology results and drafted the manuscript. W-BF and Z-YY review the manuscript. HW and C-XK edited the manuscript and critically revised the draft. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pediatric benign fibro-osseous lesions of the nose and paranasal sinuses are considered rare neoplastic entities. These fibro-osseous lesions are difficult to accomplish owing to the multifaceted anatomy of the skull base in addition to the closeness to neurovascular configurations. Methods and Settings. This is a case series study of a single-center experience.  The study aimed to study different clinical presentations, radiological manifestations, surgical management, and consequences of different benign fibro-osseous lesions in the pediatric age groups.  Four different cases were presented and discussed (osteoma, fibrous dysplasia, and ossifying fibroma.  We reported four different cases of osteoma, ossifying fibroma, and fibrous dysplasia. All of these cases were managed endoscopically with no postoperative complications. Endoscopic management is considered highly effective with reduced morbidity. Preoperative radiographic studies are highly essential for diagnosis and operative planning. A diverse category of illnesses known as benign fibro-osseous disorders of the maxillofacial skeleton comprises developmental, reactive (dysplastic), and neoplastic lesions. The utmost prevalent benign fibro-osseous disorders comprise fibrous dysplasia, osseous dysplasia, aneurysmal bone cysts (ABCs), calcifying fibroma, and juvenile ossifying fibromas, despite the fact that their categorization has indeed been revised numerous times over the years (JOFs) –3.These fibro-osseous lesions are difficult to accomplish owing to the multifaceted anatomy of the skull base in addition to the closeness to neurovascular configurations. It is also challenging for physicians to differentiate between lesions due to the significant overlay of histologic and radiographic types in these conditions. These tumors could only really be recognized by their growth decoration, which is visible on the face and head CT scans or conventional radiography .Osteoma remains the greatest shared category, shadowed by fibrous dysplasia and then petrifying fibroma . Bone dyα [Fibrous dysplasia could be monostotic or single bone, or else polyostotic meaning multiple bones. It is characterized by the normal bone marrow, and cortical bones are substituted with immature fibro-osseous tissue intermixed with woven bone. Craniofacial contribution of fibrous dysplasia is frequent, with 10% to 27% of monostotic patients and up to 50% of polyostotic patients having an association with one or more craniofacial bones. Fibrous dysplasia is initiated mainly by a mutation in GNAS 1α . The lesOssifying fibroma lesions can be distinguished from conventional fibrous dysplasia by 2 primary features. Well, first of all, it has been established that lesions do not include the GNAS 1 mutation. Furthermore, postcranial lesions are typically absent in individuals with this fibro-osseous lesion , 10.Based on clinical appearances, radiographic characteristics, and related morbidity, these lesions are treated. Owing to such tumors' intricate anatomical positions inside the orbits and skull base, as well as the growing propensity that encircles the nearby neurovascular pathways, surgical excision and histopathological examination of such tumors are frequently difficult .The study aimed to explore different clinical presentations, radiological manifestations, surgical management, and outcomes of different benign fibro-osseous lesions in the pediatric age groups.This is a case series study of a single-center experience.The study included all the pediatric patients diagnosed with benign fibro-osseous lesions of the nose and paranasal sinuses in a tertiary referral hospital, King Fahad Specialist Hospital, Dammam, KSA. The study did not follow up nor perform survivorship analysis. However, for full disclosure, the clinicopathological records and management plans applied to the included subjects are reported.The hospital's ethics board permitted us to access all relevant medical files, office papers, pictures, and surgical and pathological reports. All operations were carried out in accordance with the ethics committee's recommendations regarding patient confidentiality. Age, sex, symptoms, tumor location and size, as well as a management plan, were all retrieved.The study included four patients that were diagnosed with four different benign fibro-osseous lesions. Among four patients, three (75%) were males. The age group of cases was from 4–15. The mean age (±SD) was 9.2 (±5.8). The pathologies diagnosed were osteoma (25%), fibrous dysplasia (50%), and ossifying fibroma (25%).#1) who presented to the clinic complaining of a chronic left-sided headache and left-sided nasal obstruction. He denied any history of epistaxis, allergic rhinitis, or sinusitis. Nasal endoscopy was performed and showed a mass lateral to the middle turbinate in the left nasal cavity with no other findings. A left ethmoid tissue mass having inferior expansion further into the superior portion of such a left maxillary antrum was visible on a CT scan of such a maxillary sinus. It really has calcification densities just at the perimeter as well as heterogeneous densities that resemble ground glass. The lateral aspect of the mass results in the renovation of the leftward medial orbital partition  tumor, and just as many lesions affecting numerous bones, which would be more common (oligo- or polyostotic) .Ninety percent of the bones involved in craniofacial FD manifest even before the age of five and include numerous bones. The hazard of sarcomatous deterioration exists despite the rarity of malignancy (less than 1%), and it is heightened by occupational exposure. Typically, histopathologic, radiological, and clinical characteristics are used to make the diagnosis of FD . MedicalA hazy, radiolucent, or ground-glass structure caused by the improper calcification of young hypoplastic bones is the hallmark radiological sign of fibrous dysplasia. This arrangement is typically remarkably distinct from the radiological image of bone structure, calcified cartilage, or soft tissue. Radiology and computed tomography (CT) imaging of fibrous dysplasia in the neck and head reveal a vaguely understood tumor that blends with nearby bone . In thesThe best way to treat FD depends frequently on the unique presentation of each patient. Excision of bothersome tumors, avoidance or repair of pathogenic fracture, and rectification of undesirable aesthetic or practical abnormality are a few of the justifications for operation after confirming biopsy. A further crucial factor is the current age of manifestation. The operative method might be as conservative as curettage, bone remodeling, and contouring, or as drastic as complete excision of the affected bone followed by rapid repair. The best course of therapy is intensive surgery since it allows for the entire excision of tumors , 22.We discussed two FD instances, one of which included the nasopharynx and the second of which involved the sphenoid sinus. The bilateral nasal blockage was the primary complaint of FD of the nasopharynx, whereas headaches and advanced or recurrent discomfort were the primary complaints of FD of the sphenoid sinus. Both of these patients were handled endoscopically and without any difficulties following the procedure. Total endonasal endoscopic excision of the lesion was described by Shkarubo et al., and control SCT was used to corroborate their findings. As the neurological state maintained at its pretreatment state, the straight exophthalmos slightly receded . In an iPediatricians classify juvenile calcifying fibroma as a heterogeneous, harmless fibro-osseous tumor of the craniofacial skeleton. It develops when a healthy bone is supplanted by something like a fibrous cellular stroma that contains mineralized or calcified foci .The jaw and zygomatic arch are by far the most common locations for osseous fibromas. They have rarely been reported to develop in the orbits and ethmoid sinuses . Since pPeople with OF exhibit more combative behavior earlier in the process, from infancy to the eighth decade of life. Here, between the ages of 20 and 40, there is a higher than average prevalence of OF, with a female preference . ComplaiThe radiometric findings that reveal the placement, thickness, and/or damaged and/or supporting structures of sinonasal tract ossifying fibromas are crucial to their management. According to radiographic descriptions, JOF is a large mass with sclerotic boundaries that is locally aggressive and damaging to the cortex . JOF is Consequently, whether or not a whole resection can be accomplished will determine whether to use an open operating technique using a transfacial, transoral, or craniotomy rather than an endoscopic or a mix of open and endoscopic endonasal approach . AccordiWhen performed by a skilled surgeon, endoscopic excision of sinonasal OF is a fantastic treatment option. Direct vision, magnification, the absence of outward deformity, and reduced morbidity are benefits. A skull base injury complication that results in cerebrospinal fluid leaking might be immediately treated by using an endoscope .In this case study, we described a right ethmoid cavity complex with active juvenile ossifying fibroma with the involvement of the orbit and skull base. The lesion was debulked, a lateral rhinotomy was performed, and a frontal craniotomy with reconstruction was all used to treat it. To ensure there was no recurrence, the patient was followed up. The majority of instances of ossifying fibroma in the sinonasal tract, including the ethmoid sinus and the orbit, have manifested with little to no intraorbital involvement, despite the fact that there are just a few examples recorded , 38–40. Pediatric benign fibro-osseous lesions of the nose and paranasal sinuses are considered rare neoplastic entities. We reported 4 different cases of osteoma, ossifying fibroma, and fibrous dysplasia. All of these cases were managed endoscopically with no postoperative complications. Endoscopic management is considered highly effective with reduced morbidity. Preoperative radiographic studies are highly essential for diagnosis and operative planning.


Hamartoma is the most frequently observed benign lung tumor, but its tracheal form is still exceptionally encountered. Cough, dyspnea, hemoptysis, and chest pain are all possible symptoms of tracheal hamartoma. The non-specific symptoms may also lead to a delayed diagnosis, and while the choice of treatment varies depending on the size and location of the lesion, conservative treatments remain strongly recommended. This report presents the case of a 57-year-old male who presented to our department with inspiratory dyspnea. Clinico-radiological data and bronchoscopy revealed a benign tracheal tumor of the lipomatous hamartoma type. The patient underwent a tumor resection by rigid bronchoscopy with satisfactory clinical results. Primary tracheal tumors are rare, and only 10% are benign . AccordiA 57-year-old man with a 30-pack-year of smoking presented with gradually progressive dyspnea (stage II of MMRC) associated with chronic dry cough and asthenia for one year. He had no family history of cancer, and no night sweats or known contact with a tuberculosis patient were reported. He had, however, a history of chronic alcohol consumption that he had withdrawn 30 years ago. We add that before the patient's visit to our department, he was first put on long-acting bronchodilators at an outside hospital for one year without any clinical improvement.Upon admission, the patient was stable and in a good general state with a 116/72 mmHg blood pressure, an 85 bpm heart rate, and a room air saturation of 98%. Furthermore, we found no reportable hemoptysis or weight loss upon investigation. Inspiratory stridor was found on pleuropulmonary examination. The rest of the physical examination found no significant abnormalities. The chest X-ray was performed but did not show any abnormalities. The CT scan showed a hypodense lesion in the proximal part of the trachea, obstructing almost the entire tracheal lumen  with satisfactory results. The patient is actually under regular follow-up, and the removal of the prosthesis was scheduled for three months after the surgery.The first introduction of the term hamartoma was by Albrecht in 1904, referring to a benign tumor that consists of cells derived from primitive connective tissue such as cartilage, fat, bone, and smooth muscle cells ,6.Hamartomas are the most common benign tumors of the lung . Only 1.The histological studies of endobronchial hamartomas show mainly adipose tissue; cartilage is not present or is present in very small quantities . Which mThe clinical manifestations of tracheal hamartoma result from mechanical obstruction of the tracheal lumen ,13. TheyThe endoscopic view of tracheal hamartoma presents as a polypoid lesion  with an The treatment of benign tracheal tumors varies according to the size and location of the lesion. Conservative treatments are often recommended, such as endobronchial electrocoagulation, laser therapy, and cryotherapy. However, surgical resection should be considered in cases where the tumor invades the tracheal wall . In our Tracheal hamartomas remain underdiagnosed as they are often missed by physicians due to the variety of their symptoms. Despite being the most frequent benign tumors of the lung, they are unusual and relatively rare. The choice of treatment varies depending on the size and location of the lesion, but conservative treatments remain the first choice. Surgical resection should be considered in cases where the tumor invades the tracheal wall. Our work aims to highlight the diagnostic challenge of tracheal hamartoma as well as the importance of early management in preventing fatal complications.


To report a 12-year-old patient with a rapid growing orbital mass and imaging findings suggestive of rhabdomyosarcoma that was found to be dirofilariasis after mass resection.Dirofilaria repens. The patient was well post-operation without morbidity. In this paper, we describe distinct clinical features and imaging findings of this interesting case.We describe a 12-year-old patient with a rapid growing orbital mass involving medial part of orbit and medial rectus muscle and imaging findings suggestive of rhabdomyosarcoma. Histopathologic examination showed the mass to be composed of granulomatous inflammation and the thread-like object to be Deep orbital lesions due to dirofilariasis, as in our case, is extremely rare. It is important to add dirofilariasis to the differential diagnosis of orbital mass lesions. Attention to the imaging clues, as provided in this report, can be helpful. Dirofilaria immitis and D. repens. Dirofilariasis is endemic in the Mediterranean countries, and has also been reported in many parts of the world.,3,4,5 Herein, we describe the clinical and imaging characteristics of orbital dirofilariasis that presented as a rapidly growing orbital mass in a young boy imitating rhabdomyosarcoma. The report adhered to the principles outlined in the declaration of Helsinki as amended in 2013.Parasitic infections of the eyes cause enormous ocular morbidity all over the world. Dirofilariasis is a zoonosis, affecting domestic and wild animals around the world. There are about 40 species of Dirofilaria but the species that most commonlycause human infection include A 12-year-old boy presented with a complaint of swelling above his left upper lid from a few months prior to admission. He did not experience pain, diplopia, irritation, and itching. Past medical and ophthalmic history were unremarkable. Visual acuity was 20/20 in both eyes. Slit lamp and fundus exams were normal. There was fullness above the medial part of left upper lid and globe was displaced laterally [Figure 1a]. Ocular motility was intact.in toto. Upon bisection of the mass on the operating table, the lesion showed as a multilayered wall, consisting of fibrotic bands, and a gelatinous center with a threadlike structure inside the core. There was putrid fluid and a thread-like object in the center of the lesion [Figure 3d], which were sent for histologic, parasitology, and microbiology laboratory work-up.Magnetic resonance imaging revealed a heterogeneous ill-defined mass in the superomedial part of the mid-orbit, involving the medial rectus and superior oblique muscles. The approximate size of the lesion was 1.5D. repens [Figure 4]. On the first follow-up visit, there was no palpable mass, nor any motility or visual disturbance. No other systemic involvement was found in the systemic evaluations. Considering the resolution of signs and symptoms and after consulting with infectious diseases specialists, systemic anti-parasite medications were not administered. At this time, when inquired about contact with probable infected animals, the boy disclosed that he was taking care of a stray dog. On the last follow-up about six months after the operation, the patient had no complaints, normal orbital exams, extra-ocular movements, and there was no recurrence of the disease [Figure 1b].Histopathologic examination showed the mass to be composed of granulomatous inflammation and the thread-like object to be ,7 Dirofilariasis mostly affects dogs, other canines , foxes, and cats. It is transmitted from the final host  to the intermediate host (human) by mosquito bites of the genus Aedes, Culex, or Anopheles. Humans may become accidental dead-end hosts of this parasite. The worm cannot reach maturity in humans and an infected human is not contagious. The clinical forms of dirofilariasis in humans are pulmonary, subcutaneous, and ocular involvement, and, rarely, infection of the other organs. The particularly atypical presentation of dirofilariasis may lead to an incorrect diagnosis and inappropriate management. This is particularly important in patients with orbital lesions that imitate inflammatory lesions and malignant tumors. There are reports showing that orbital dirofilariasis were diagnosed as lymphoma and metastasis. In this report we present a case that masqueraded orbital rhabdomyosarcoma. This is an important differential diagnosis that needs to be considered in patients with similar picture.,11 Among the ocular involvements, eyelids are most commonly affected, followed by subconjunctival tissue, anterior chamber, vitreous, and orbit. The diagnosis is based on the histopathology of the excised nodule that often demonstrates a lesion showing eosinophilic or necrotizing granuloma. Occasionally, a worm can be expressed from subcutaneous tissue or the conjunctiva as a large thread-like white structure. Treatment includes surgical excision of the nodule and removal of the worm, which most often results in complete resolution of the disease. Since most dirofilarial infections in humans are caused by a single worm and microfilaremia is unlikely, there is no need for systemic therapy with anti-helminthic drugs.,12Dirofilariasis is an emerging parasitic disease, with a progressive increase in incidence in recent years, possibly due to global climate changing. conjunctival tissue of a 27-year-old female and a 35-year-old male, and a superficial orbital dirofilariasis in a 24-year-old female. To the best of our knowledge, this patient is the youngest person with ocular dirofilariasis with a deep orbital involvement that involved the medial part of orbit. His young age as well as the superomedial location of the mass were in favor of diagnosing a neoplastic lesion, most probably an orbital rhabdomyosarcoma. A tubular structure within a nodular lesion may be regarded as a hallmark sign in imaging. However, in our patient, the dominant feature in orbital magnetic imaging was a solid mass. The lesion consisted of a core and an ill-defined perimeter. The central core of high signal in the T2-weighted image can be a clue to discovering the parasitic nature of the lesion. Knowledge of the history of contact with a stray canine might have also helped us consider parasitic infection preoperatively, but such information was only disclosed after the surgery along with the pathologic findings of dirofilariasis.Nearly all reported cases of ocular dirofilariasis are superficial. There are few reports of orbital dirofilariasis that mainly presented as a superficial lesion. Reports included one involving the lateral rectus muscle of a 20-year-old man,In conclusion, orbital dirofilariasis should be considered among differential diagnosis of orbital inflammatory lesions and malignant orbital solid tumors including rhabdomyosarcoma. Clinicians and radiologists can consider the clues to help differentiate these entities.The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.None.None declared.


Pneumatosis intestinalis is an abnormal presence of free air outside the lumen of the intestines in many shapes. It is classified based on its etiology to primary or secondary, it affects adults as well as infants and can involve any part of the GI tract.We report a case of a 55-year-old man with a past medical history of a surgically repaired perforated duodenal ulcer who presented with an acute abdominal pain, Flatulence and constipation. On examination of the abdomen; severe distension, tenderness and tympanicity on percussion were noted. An erect CXR was performed and showed bilateral sub-diaphragmatic air levels. We performed an abdominal Paracentesis under the right subcostal margin which led to evacuation of large amounts of air. Next, an investigational laparotomy showed that the reason was a gastric volvulus associated with an anterior and posterior gastric wall lacerations. The suitable surgical repair approach was taken, but another lesion was detected incidentally. A pneumatosis cystoides intestinalis (PCI) was extended along large length of the intestines in many shapes and without any symptoms or signs.Pneumatosis cystoides intestinalis has been reported continuously in relation to peptic ulcer disease (PUD). We aim to report a new association of a gastric volvulus and PCI secondary to pyloric stenosis caused by a duodenal ulcer; which we believe can aid in the diagnosing of dangerous complications, of a rare disease. Pneumatosis intestinalis (PI) is a condition where gas is accumulated inside or between the intestinal wall layers  . PI can We present a case of an asymptomatic pneumatosis cystoides intestinalis which have been discovered along the entire length of the intestines incidentally by investigational laparotomy following acute abdominal presentation due to gastric volvulus complicated by tearing of the gastric wall.An association between PCI and gastric volvulus was not found in the literature. We believe our case presents a rare presentation of an asymptomatic, complicated, incidentally discovered, widely spread PCI.A 55-year-old white male, with a past medical history of a surgically repaired perforated duodenal ulcer and no significant family medical history, presented to the emergency department of Aleppo University Hospital complaining of a 2-h period acute severe abdominal pain, flatulence, tachypnea and chest discomfort. The pain was sudden, dull aching in nature and periumbilical at first then quickly became generalized. The patient denied having any symptoms prior to presentation. On clinical examination, patient was alert, conscious, afebrile, tachypneic and distressed; with a pulse of 75 bpm and blood pressure of 140/90 mm Hg. His oxygen saturation was 96% in room air and ECG was normal. On examination of the abdomen, severe distension, tenderness and tympanicity on percussion were noted. Laboratory values included a normal white blood cell count and a normal serum urea nitrogen and creatinine levels, other serum laboratory values such as Na, K, Ca were measured to rule out electrolyte abnormalities and were within normal range.An erect CXR was performed and showed bilateral subdiaphragmatic air-levels , fever and leukocytosis [WBC 15.8] with neutrophilia. The patient was shortly intubated and broad-spectrum antibiotics were initiated immediately along with fluids and vasopressors but unfortunately the patient died soon afterwards. The presumed cause of death is probably either due to ischemia–reperfusion injury and reactive oxygen species or septic shock. Post-mortem pathology and/or autopsy was not performed due to refusal of family to consent.Pneumatosis intestinalis refers to gas accumulation inside the intestinal wall in different forms and causes with poorly understood etiology , 4. It cThis case shows a rare presentation of PCI. Over time, an obstruction of stomach outlet lead to a gastric volvulus which was complicated by gastric wall tearing and presented as an acute abdomen. This condition required investigational laparotomy which lead to the discovery of intestinal PCI.PI is usually defined by endoscopy or CT scan of the abdomen, secondary to gastrointestinal illnesses or other common diseases such as COPD, diabetes mellitus and connective tissue diseases, … etc. , 10. PI Multiple theories regarding explanation of PCI were introduced in the literature, including mechanical, pulmonary, bacterial and biochemical theories . The mecOur patient had a past history of a surgically repaired duodenal ulcer; PUD was mentioned in the literature as a common cause of PCI  and numeMost of PI cases are secondary to other diseases which makes them easier to detect in the context of the primary illness. On the other hand, PCI can be asymptomatic which means that the diagnosis is discovered either incidentally or because of its complications. Complications are rare in PI with 3% incidence rate, but being serious conditions makes diagnosis the earlier, the better. Most common ones are pneumoperitoneum, intestinal obstruction and perforation, volvulus, and intestinal ischemia , 14–16.Association between PI and volvulus is rare. One case report published in 2021 showed a pneumatosis intestinalis associated with a rare volvulus proximal to the ileocecal junction , Gillon A systematic review, published in 2013, showed that PI appeared more commonly in the colon, followed by the small intestine, followed by both of them combined in a really small number of cases . Our casAccording to a retrospective study by Morris et al. , half ofIn conclusion, PCI can be caused by multiple diseases including peptic ulcer disease, and it can be benign and managed conservatively, or present as a dangerous life-threatening complication that requires intervention. Knowledge of the possible complications is crucial in the diagnosis of such rare, but potentially devastating condition.


Intramedullary tuberculoma (IMT) is rare and usually indistinguishable from spinal cord tumors. Thus, the diagnosis of an IMT is challenging. Our case deals with an unusual presentation of a 55-year-old Asian man who had presented with lower limb weakness which was found to be caused by the dissemination of tuberculosis (TB) resulting in an IMT, a rare complication of tuberculosis. The patient also had a concurrent incidental hepatitis B infection. The treatment of IMT is anti-tuberculous medication. This case highlights the significance of the prompt diagnosis of an IMT, urgent intervention particularly in developing areas of the world where tuberculosis is still endemic, an increased probability of patients having an IMT, and their diagnoses being missed. Tuberculosis is the ninth leading cause of death worldwide . TubercuA 55-year-old male with no previous co-morbidities presented to the medical outpatient department with low-grade fever, cough, and two episodes of shortness of breath for the last 8-10 days. He also has a history of bilateral lower limb weakness for almost three months which was initially noted in the left leg and then gradually involved the right leg. He had documented low-grade fever on/off, associated with night sweats and occasionally dry cough with subjective weight loss. The relevant examination findings are depicted as follows  chest with contrast, and magnetic resonance imaging (MRI) spine to evaluate the probable cause of his symptoms. The chest X-ray showed numerous small reticulonodular soft tissue densities bilaterally with an enlarged right hilar lymph node indicative of miliary tuberculosis Figure .CT chest with contrast showed multiple randomly distributed nodules throughout the lung parenchyma with some being centrilobular (tree-in-bud) and others about the pleura. Additionally, enlarged lymph nodes were noted along the right hilum and azygo-esophageal recess. Subcentimeter lymph nodes were also seen along the aortic arch and aortopulmonary window with a bilateral pleural reaction, supporting the diagnosis of miliary tuberculosis Figure .The thoracolumbar spine MRI was requested to evaluate for his bilateral lower extremity weakness and revealed a well-defined small intramedullary space-occupying lesion located at T7/T8 level measuring 12 x 9 x 8 mm. This lesion was low on T2-weighted imaging with the mild expansion of the cord and extensive surrounding cord edema. Post-contrast sequences revealed peripheral contrast enhancement of the lesion Figures -6.The patient was placed on the standard anti-tuberculous regimen of rifampicin, isoniazid, pyrazinamide, and ethambutol (RIPE) along with supplemental pyridoxine. For better CNS penetration, oral steroids were commenced in a tapering dose, and Entecavir was also part of the treatment regimen since the patient also had a hepatitis B infection. He was discharged from the hospital and a one-month follow-up was advised. The patient was lost to follow-up, however.The CNS involvement in TB in the form of a tuberculoma is rare as it occurs in approximately 10% of the cases and concurrent involvement of the spine having a tuberculoma is extremely rare . The firSpinal IMT is mainly the consequence of the hematogenous spread of a primary infection or cerebrospinal fluid seeding. However, in a few cases, it can result from the local spread of pulmonary TB. Cases of isolated IMT are rare, and current reports suggest that silent dissemination of primary TB could potentially be responsible . It is eIt is important to identify the characteristic features of intramedullary spinal TB on MRI as it has other similarly presenting differential diagnoses like transverse myelitis or gliomas. During the initial phase of tuberculoma formation, there is extensive edema with a severe infection and the signal characteristics are a hypointensity on both T1-weighed and T2-weighed sequences. As time progresses and tuberculoma maturation occurs, there is cord expansion and hypointensity of the central tuberculoma present on T2-weighted sequence with a ring enhancement surrounding the hypointense area on post-contrast images. Our case presented with the characteristic findings of tuberculoma on a thoracolumbar MRI, i.e., a central low signal intensity lesion with surrounding high-intensity signal edema on T2-weighted sequence and ring-enhancement on post-contrast images. A ring-enhancing lesion with a hypointense center on a T2-weighted image, also known as the “target sign” on MRI points toward the diagnosis of IMT . AlthougAnti-tuberculous therapy is the mainstay therapy for IMT. Surgical resection might be an option in patients with an increasing size of a tuberculoma which is causing significant neurologic deficit . The proThis case is unusual because it emphasizes the importance of imaging with correct interpretation and having a low threshold for MRI of the spine in patients presenting with weakness who have been diagnosed with disseminated TB. Diagnosing IMT can be challenging as they appear similar to other lesions, present with nonspecific symptoms, and occur in the general population rarely. The association of these tuberculomas with hepatitis B or C infections needs further research.