Fibroids, also known as uterine leiomyomas, are the most common solid benign lesions of the uterus. Fibroids are responsive to hormones and are stimulated by estrogens and commonly grow during pregnancy and involute as menopause progresses. The treatment is mostly conservative. When symptomatic, the treatment requires surgical intervention. We present a case of a 72-year-old post-menopausal female with a large, calcified parasitic fibroid, an extremely rare variant of uterine leiomyoma occurring outside the uterus. The number of cases reported about this pathology is minimal. Leiomyomas are a group of solid benign lesions of the uterus which are primarily responsive to estrogen. Hence, they are mostly seen in menstruating women and tend to aggravate in size during pregnancy and reduce after menopause . ParasitA 72-year-old post-menopausal female came to the orthopedics outpatient department with a history of slip and fall from the stairs, following which the patient could not get up and bear any weight on the left lower limb. Pain and swelling started immediately after the accident, which was sudden in onset and non-progressive in nature. The pain was severe in intensity, aggravated by movement, and partially relieved by rest. The patient was then advised to have an X-ray pelvis, which revealed a comminuted displaced fracture of the neck of the left femur. Incidentally, a well-defined radio-opaque mass lesion was found in the pelvis, separate from the urinary bladder, as shown in Figure Two days later, the patient complained of pain in the abdomen with a palpable mass in the left lumbar region, freely mobile and not attached to the skin. There was no history of fever, weight loss, or change in bowel and bladder habits. She was para three, live three, and all her children were from normal vaginal delivery. She had no history of any previous surgery and no family history of breast or gynecological malignancy.The patient was advised to have an X-ray abdomen which revealed a well-defined radio-opaque mass in the left lumbar and hypogastric region, extending from the splenic flexure to the upper border of the left iliac crest, as shown in Figure Sonography of the abdomen and pelvis revealed the presence of a large mass lesion in the left lumbar region extending from the spleen above to the left inguinal ligament below. It was abutting the spleen parenchyma and the left kidney. The lesion was obstructing the ultrasonic waves from passing through, and no organ could be visible posterior to the lesion, suggesting it to be a highly calcified lesion. Further, contrast-enhanced computed tomography (CECT) was advised to get a detailed description of the lesion. CECT revealed a well-defined, heavily calcified, predominantly hyperdense mass lesion showing a whorled appearance of size approximately 12.5 x 12 x 11.5 cm, Hounsfield unit ranging from +630 to +1050, in the left lumbar region inferior to the kidney at the level of L2 to L5 vertebra, not seen separately from the left adnexa, uterus, and the ovaries. Peripherally enhancing soft tissues were noted in continuity with the pelvic soft tissues. A diagnosis of wandering fibroid was made on the basis of imaging. The lesion is causing a mass effect by displacing the left psoas muscle and bowel loops medially. The fat planes, adjacent muscles, and abdominal organs appear normal, as shown in Figure The patient underwent surgical intervention for a comminuted displaced fracture of the neck of the left femur, after which an X-ray was performed, which shows the same radio-opaque mass in the pelvis and surgical implant in the region of the neck of the left femur as shown in Figure The patient was advised to follow up for the post-operative implant. An opinion was taken from the surgical team for the fibroid, and they advised conservative management for the same.Leiomyomas or fibroids are the uterus's most common benign neoplasm, originating from myometrial. These are most commonly composed of smooth muscle cells with variable amounts of fibrous connective tissue. They can be within the uterus and termed as intra-uterine or outside the uterus and termed as extrauterine. Intra-uterine can be classified into intramural, i.e., centered within the myometrium; subserosal, i.e., projecting outwards from the uterus; and submucosal, i.e., projecting into the uterine cavity. Extrauterine leiomyomas are classified into broad ligament leiomyoma, parasitic leiomyoma, and cervical leiomyoma . When muParasitic leiomyomas are extremely rare, and very few such cases have been published about them. Parasitic leiomyoma was described as a fibroid that has, for some reason, become entirely or partially detached from the uterus and receives its main blood supply from the extrauterine source . EarlierThe symptoms related to parasitic fibroids are usually vague, and the patient may present with pain in the abdomen, heaviness, or a palpable lump in the abdomen which can be migratory. Treatment is usually surgical, which can be either laparoscopic or open surgery.This pathology might be challenging to differentiate from ovarian or retroperitoneal tumors, as in our case.One of the rarest and severe complications of this entity is the rupture of the uterus and very few cases have been reported about this entity ,11. An aParasitic fibroids are an extremely rare group of leiomyomas under type 8 of the FIGO classification of uterine leiomyomas. This type of leiomyoma gets its blood supply from the extrauterine source. They increase in size similar to the other leiomyomas, i.e., by estrogens, and commonly grow during pregnancy and start to involute with menopause. The primary treatment of parasitic fibroid is surgical intervention by either laparoscopic or open surgery. Minimal cases have been published about this pathology, and it is essential to differentiate it from other differentials like ovarian or retroperitoneal tumors.


Peritoneal inclusion cysts (PICs) are reactive, fluid-filled lesions of the peritoneal lining, usually affecting women of reproductive age and with previous abdominal surgeries. Paraovarian cysts, hydrosalpinx, and low-grade cystic mesothelioma are usually considered in the differential diagnosis of PICs. In this case report, we present an 18-year-old female with a known case of bladder exstrophy and chronic urinary incontinence and a previous history of surgical bladder repair. She presented to the emergency department (ED) with urinary incontinence and lower abdominal pain. A computed tomography was ordered for her to rule out hydronephrosis, and incidentally, ovarian cysts were discovered that were then bilaterally excised via laparotomy. Our case report emphasizes the significance of considering such a diagnosis when coming across patients whose risk factors and symptoms match the diagnosis. Peritoneal inclusion cysts (PICs) are reactive, fluid-filled lesions of the peritoneal lining . Women oAn 18-year-old female with a known case of bladder exstrophy and chronic urinary incontinence underwent bladder repair and bladder neck reconstruction in 2016 and 2018, respectively. Despite these multiple repairs, the patient still suffers from urinary incontinence and presented to the emergency department (ED) complaining of urinary retention, lower abdominal pain radiating to the flanks, and dysuria. The patient was on clean intermittent catheterization (CIC), which she stopped six months ago because the patient was able to void freely. During the family history revision, the patient denied any genetic disorders in the family. She was not on any medications.Upon physical examination, the abdomen had multiple scars from previous surgeries; the abdomen was distended and soft with mild tenderness in the suprapubic area. There was no rigidity or guarding.Her urinalysis showed positive nitrates, traces of protein, moderate red blood cells (RBCs) and white blood cells (WBCs), and moderate blood; therefore, she was admitted with a case of urinary tract infection and was started on antibiotics intravenously for two weeks.Abdominopelvic computed tomography (CT) was ordered to rule out hydronephrosis. It illustrated smooth, diffuse bilateral urothelial enhancements, most likely related to inflammation. In addition, as an incidental finding, it showed bilateral elongated abdominopelvic cystic masses along the bilateral adnexal vessels and ovaries. The right and left masses measured 5.8 cm × 12 cm × 2.4 cm and 9 cm × 6 cm × 15 cm, respectively  inclusion cyst bilaterally.Although the etiology behind peritoneal inclusion cysts is still unclear, they are thought to be the result of benign inflammatory proliferation due to various risk factors like prior abdominopelvic surgeries, gastrointestinal inflammation, or pelvic inflammation . In regaPeritoneal inclusion cysts are often found at the bottom of the differential diagnosis list when addressing the associated symptoms in patients with prior abdominopelvic surgeries or gastrointestinal or pelvic inflammation. In our case, urinary tract infection and hydronephrosis were the main differentials given our patient’s history of bladder repair surgery. It is stated in the literature that 10% of cases are incidentally diagnosed, and our case is no exception . A CT inVarious treatment options are offered to treat peritoneal inclusion cysts. Such different modalities of treatment include but are not limited to observation, hormonal management, image-guided aspiration, image-guided sclerotherapy, potassium-titanyl-phosphate laser ablation, and surgical excision . ElectivThe multitude of presentations and subsequent treatment of peritoneal inclusion cysts is evident in the literature. Singh et al. reported a multiparous woman with a history of bilateral tubal ligation who presented with gradual lower abdominal pain . Her CT Although the occurrence of peritoneal inclusion cysts is relatively low, the rising evidence alongside our case reports emphasizes the significance of considering such a diagnosis in patients whose risk factors and symptoms match the diagnosis. Although the rate of mortality is low, prompt diagnosis followed by definitive management can aid in decreasing the high morbidity rate associated with peritoneal inclusion cysts. Management is best tailored to each individualized case as the pathogenesis is still unclear and the recurrence rate is high irrespective of the procedure. The literature still needs continuous data to effectively establish guidelines for approaching peritoneal inclusion cysts.


Lymphomatoid granulomatosis is an Epstein-Barr virus-associated lymphoproliferative B-cell neoplasm that typically involves multiple organ systems. This disease is exceedingly rare when confined to the central nervous system (CNS), usually presenting as a mass lesion or diffuse disease, with no existing standard of care. We present the case of a 67-year-old patient who had a unique and insidious course of isolated CNS lymphomatoid granulomatosis. The disease first presented with cranial neuropathies involving the trigeminal and facial nerves that were responsive to steroids both clinically and radiographically. Two years later, the disease manifested as a parietal mass mimicking high-grade glioma that caused homonymous hemianopsia. The patient underwent craniotomy for resection and was treated with rituximab after surgery. The patient has achieved progression-free survival more than three years after the surgery. Surgical debulking and post-procedural rituximab resulted in favorable survival in a case of isolated CNS lymphomatoid granulomatosis. An intracranial mass preceded by steroid-responsive cranial neuropathies should raise suspicion for lymphoproliferative disorder. Lymphomatoid granulomatosis is a mature, extranodal, lymphoproliferative, B-cell neoplasm associated with Epstein-Barr virus (EBV) . On histIsolated CNS lymphomatoid granulomatosis has no pathognomonic clinical, radiographic, or laboratory characteristics, requiring histology for diagnosis . RadiogrHere, we present a unique case of lymphomatoid granulomatosis. Our patient had an atypical, insidious course with repeated neuroimaging, first presenting with cranial nerve involvement, and later presenting with a mass lesion.A 60-year-old female presented in March 2018 with right facial numbness in the maxillary nerve (V2) and mandibular nerve (V3) distributions. MRI identified an abnormal T2-weighted fluid-attenuated inversion recovery (T2 FLAIR) signal and enhancement in the right trigeminal root entry zone (Figure One year later, she experienced identical symptoms on the contralateral side of her face. MRI revealed FLAIR signal abnormality and enhancement of the left trigeminal root entry zone Figure , Panel CFour months later, the patient experienced right facial palsy. MRI revealed the resolution of the previous abnormality surrounding the left trigeminal root entry zone, now with FLAIR signal abnormality and abnormal enhancement within the right facial nerve Figure , Panel DShe developed visual disturbance one year later. Neurologic examination was notable for left homonymous hemianopia. Contrast-enhanced MRI identified a peripherally enhancing 4 x 2 cm, partially hemorrhagic mass involving the right parietal lobe and splenium of the corpus callosum, with vasogenic edema and cortical and subependymal involvement concerning for high-grade glioma (Figure After informed consent was obtained, the patient was taken for a right parietal craniotomy. Intraoperatively, the brain was slightly swollen with a normal cortical appearance. The tumor was gray-pink and hypervascular. It had a heterogeneous texture with regions of necrosis and firm fibrinous portions.Postoperative MRI revealed near-complete resection Figure , Panel BPathologic findingsOn histology, there were perivascular lymphoid cuffs composed of numerous small irregular lymphocytes as well as areas of vessel wall destruction, thrombosis, and necrosis Figure . Focal lIsolated CNS lymphomatoid granulomatosis is a rare diagnosis with no standard of care. Interestingly, our patient first presented with trigeminal and facial nerve involvement separated in time, later presenting as a mass. Combined diffuse and mass-like presentations have been reported in 6% of cases .Prior reports of isolated CNS lymphomatoid granulomatosis have reported symptomatic cranial nerve involvement without cranial nerve enhancement. Our patient had enhancement of the trigeminal and facial nerves which corresponded to the onset and regression of neurologic symptoms. This has been demonstrated in systemic lymphomatoid granulomatosis with CNS involvement but not in isolated CNS lymphomatoid granulomatosis ,4.Systemic lymphomatoid granulomatosis treatment paradigms and survival depend on staging . Our patHistorical data has shown that patients with systemic disease and CNS involvement have reduced survival . When isOur case report highlights the challenges in lymphomatoid granulomatosis diagnostic workup and shows favorable survival for mass lesions after resection and rituximab monotherapy. Clinicians should be suspicious of lymphoproliferative disorder when an intracranial mass is preceded by steroid-responsive cranial neuropathies.


Carcinoma cuniculatum is an extremely rare and often indolent cancer that can mimic a benign process, such as osteomyelitis or odontogenic infections. This results in a definitive diagnosis that is delayed. To complicate the evaluation of this uncommon neoplasm, biopsies are often misinterpreted secondary to an incorrectly obtained tissue sample. Incisional biopsy needs to be done in a specific manner with a high degree of clinical suspicion incorporated into the patient assessment for the most accurate diagnosis. Local and distant failure rates are low with aggressive surgical resection and surgery upfront remains the treatment of choice when feasible. We present two cases that highlight the difficulty in accurate diagnosis and management of these rare cancers. Carcinoma cuniculatum (CC) is an extremely rare malignant neoplasm that is seen in the oral cavity. Often misdiagnosed, these tumors can mimic osteomyelitis, dental abscess, or odontogenic cysts in their presentation, and even with multiple incisional biopsies, the definitive diagnosis can be delayed ,2. CurreFrom an ablative standpoint, these malignancies often present with a lack of a clear clinical delineation of the tumor, making oncologic extirpation difficult. Prior surgery and delays in diagnosis can create an environment in which chronic inflammation and or tumor progression move beyond the border of what is clinically visible. Since complete surgical removal with negative margins provides excellent rates of local control it is imperative that these tumors be cautiously excised with adequate margins .Local and distant failure rates are low with aggressive surgical resection and surgery upfront remains the treatment of choice when feasible . We presCase 1A 51-year-old female nurse presented to a local surgeon for management of a presumed osteomyelitis, based on history, radiographic and clinical information. She reported extraction of a left mandibular molar approximately 1.5 years prior with a slow progression of pain. Two additional teeth were subsequently removed in the months prior to presentation without resolution of her symptoms.Past medical history was significant for osteopenia and Crohn’s disease, but otherwise unremarkable. Fosamax  had been started around the time of initial symptom onset but had been discontinued prior to her referral. She was an everyday smoker of one pack for 35 years and consumed alcohol socially. Medications on initial evaluation were Pentasa , ibuprofen and a multivitamin.Initial exam revealed mild left mandibular swelling with no overlying skin changes. Palpation of the left mandible elicited pain. Ipsilateral lymphadenopathy was noted. There was no trismus but the mucosa over the left posterior mandible displayed ill-defined erythema, edema, or tenderness. A panoramic radiograph was significant for a lytic lesion in the left posterior mandible with intact inferior border Figure . The plaTwo months following initial debridement there was an abrupt increase in pain and edema over the left face and a course of antibiotics was initiated (Ciprofloxacin 500mg q12h x 14 days) without improvement. After failing outpatient therapy, the patient was admitted to the hospital, a peripherally inserted central catheter (PICC) line was placed and infectious disease was consulted. Computed tomography at that time showed the progression of the lytic changes in the mandible, now involving the inferior border . The patient returned to his general dental provider within a month of the procedure with increasing swelling of the right maxilla and palate, now with luxation of adjacent teeth. The dentist subsequently referred the patient to a local oral surgeon who was concerned for an aggressive process secondary to his history and clinical presentation. Imaging confirmed a destructive ill-defined lesion encompassing the right maxilla with significant expansion Figure . The surVirtual surgical planning was utilized and the patient subsequently underwent a right maxillectomy, selective neck dissection, and reconstruction with a vascularized fibula-free flap. The patient underwent the planned procedure and has recovered well. The final pathologic specimen revealed CC with osseous invasion, negative margins, no perineural/lymphovascular invasion (PNI/LVI), and no pathologic lymph nodes (pT4N0). The patient did not undergo any adjuvant therapy and is currently well, at thirteen months from surgery, with no evidence of disease (NED).Initially described in a case series by Arid et al. in 1954 as a low-grade plantar neoplasm, CC has been described at various anatomic sites throughout the body . Oral CCThe diagnostic dilemma stems from the indolent course of the disease, inadequate harvesting of tissue for microscopic examination, and lack of awareness of both pathologist and surgeon on the clinical and morphologic characteristics of CC . Both caDuring surgical manipulation, i.e., drainage or debridement, these lesions may expel yellowish foul-smelling secretions or a thick keratinaceous debris similar in consistency to toothpaste. To prevent a delay in diagnosis it is recommended that a biopsy of the lesion be deep, as the characteristic infiltrative growth pattern of CC may not be evident at superficial levels -14. FollIt is imperative that providers who encounter these potential patients have a high degree of suspicion and critically evaluate the cases not behaving in a typical manner. Correlation between the clinical, pathological, and imaging findings often needs to be evaluated together to arrive at the diagnosis. CC is a distinct clinical entity and should be considered anytime an unexplained osteomyelitis or a verrucous growth of long-standing duration is encountered. The very nature of CC is that it mimics other clinical entities. Even the most experienced clinician must remain vigilant when evaluating these lesions. Subtle clues can avoid disease progression and increasing patient morbidity. Once identified, surgical resection with the standard oncologic approach followed by close surveillance should result in excellent disease control and survival rates.


Foreign body insertion inside the nose is not uncommon in pediatric age groups. It can pass unnoticed by parents, sometimes underdiagnosed or incompletely removed by a clinician. In another scenario, it may be incidentally discovered by imaging during dental workups commonly. This foreign body acts like a nidus for a rhinolith, as it gets calcified over years and becomes like a stone, causing unilateral nasal symptoms. Herein, we present a case of a young female with a rhinolith mistaken for fungal mud. We aim to emphasize this rare clinical condition that, if left unperceived, may lead to complications including, but not limited to, sinusitis, pressure necrosis to the surrounding structure causing septal perforation, or naso-palatal fistula. Rhinolithiasis is an uncommon condition seen in otolaryngology practice . It is fA 20-year-old healthy female presented to the otolaryngology clinic complaining of left-sided nasal blockage for nine months associated with unilateral nasal drainage. However, the patient denied hyposmia, facial pressure, facial edema, postnasal drip, headache, and nose bleeding. She also denies inserting a foreign body in her nose or having previous nasal trauma. Her family history was unremarkable for fungal rhinosinusitis or sinonasal malignancy.On clinical examination, using a zero-degree Hopkins rigid telescope , there was a pearly white nasal mass filling the left nasal cavity, which easily bleeds, tenders upon manipulation, and completely blocks the left side, obscuring both the middle turbinate and nasopharynx Figure . ExaminaComputed tomography (CT) imaging of the paranasal sinuses Figure  showed aThe patient underwent endoscopic nasal examination under general anesthesia with complete removal of the left nasal mass Figure . It was Two weeks postoperatively, the patient was seen in the clinic, completely asymptomatic, and nasal examination showed healthy healing nasal mucosa without postoperative adhesion or residual rhinolith.Rhinolith is a concrete-like structure formed by the deposition of mineral salts, such as calcium phosphate, calcium carbonate, and magnesium, around the nidus ,5. This A nasal foreign body is usually underestimated as a cause for unilateral nasal symptoms in the middle- to old-aged population. However, it can be found in any age group from an infant to 84 years old, as reported in the literature . AlthougUnilateral nasal obstruction, drainage, nasal and or oral malodor, headache, hyposmia, epiphora, and epistaxis are symptoms that can present in a long-standing rhinolith. However, rhinolith could be completely asymptomatic and discovered incidentally . In thisAn endoscopic nasal examination is essential to help diagnose rhinolith, which usually appears like a concrete whitish mass and is commonly found between the inferior turbinate and the nasal septum , as in oCT scan is required to support the diagnosis; exclude other causes of unilateral nasal masses with benign radiological features such as bone remodeling and hyperostosis or suspicious features, in particular, bone destruction, invasion, and soft tissue involvement; assess associated comorbidities such as sinusitis; and rule out any complications . PotentiRemoval of rhinolith under general anesthesia is favorable for patients with structural abnormalities such as deviated nasal septum, with chronic sinusitis reluctant to medical treatment, as well as in the presence of complications requiring repair such as perforation or fistula. If none are present, then removal of rhinolith under local anesthesia in adults or conscious sedation in pediatrics is optional. In this report, the rhinolith is removed under general anesthesia because the patient did not tolerate the procedure under local anesthesia, as the rhinolith was very adherent to the mucosa of the nasal septum and the inferior turbinate. The diagnostic approach to and management of rhinolithiasis are presented in Figure Unilateral nasal symptoms warrant an otolaryngologist for a localized disease process. Rhinolith is usually underestimated as a cause due to the rarity of the disease in young adults. Endoscopic nasal examination, imaging, and histopathological evaluation are needed to confirm the diagnosis of rhinolith.


We present a case of PUGS associated with a complex Mullerian malformation diagnosed in adult age after the integration of gynecological ultrasound with hysteroscopy, both performed by expert operators.27-year-old women was referred to our clinic because of frequent urinary tract infections and cyclic pelvic pain. She was virgo, with normal menstrual cycles and dysmenorrhea. A didelphys uterus and double vagina with bilateral hematocolpos was firstly diagnosed through transrectal and transabdominal ultrasound. An MRI was then performed and a monorenal and ipsilateral ureteral malformation were diagnosed; in addition, a complete absence of the lower third of the vagina and an abnormal origin of the urethra from the bladder were described. Patient underwent lower genital tract endoscopy: external vaginal orifice was obliterated, a PUGS was diagnosed and both vaginas' ostia were detected on the PUGS's posterior-lateral walls. The procedure was performed under transabdominal ultrasound guidance which confirmed the endoscopic anatomical suspicion, avoiding complications such as perforation and misdiagnosis.ultrasound guided endoscopy plays an essential role in the evaluation of complex anatomic anomalies, such as persistent urogenital sinus (PUGS), leading to a dynamic one-stop diagnosis; it avoids delays and misdiagnosis in preoperative assessment possibly related to the separately application of different radiological and endoscopic techniques. Persistent urogenital sinus (PUGS) is a rare condition characterized by abnormal confluence of the female genital anatomy in the urinary tract –5. PUGS Unlike Mullerian genital malformations, PUGS are typically diagnosed in pediatrics' age, due to the urinary tract symptoms, and immediately surgically corrected because of the short- and long-term consequence that may be associated .Correct preoperative evaluation is crucial for adequate surgical planning. Reported PUGS had been diagnosed with a combination of MRI-magnetic resonance imaging- and cystoscopy, requiring multiple diagnostic steps and a multidisciplinary approach , 13. We 27-year-old women was referred to our clinic because of frequent urinary tract infections and cyclic pelvic pain. She had had previous neonatal surgery because of unperforated anus. No family history of congenital uro-genital malformation was reported. She was virgo, with normal menstrual cycles, dysmenorrhea, and frequent urinary tract infections during menses. At the gynecological department of Policlinico A. Gemelli, Rome, Italy, a didelphys uterus and double vaginas with bilateral hematocolpos were diagnosed through transrectal and transabdominal ultrasound . A MulleThe external vaginal orifice was obliterated. A 5 mm hysteroscope with continuous flow was inserted through a misdiagnosed persistent urogenital sinus (PUGS), covered by squamous epithelial lining. PUGS was 7 cm long and ended in a dilated bladder that was full of blood clots and dense fluid. Multiple washings were performed until both ureteral ostia have been identified. Moreover, a dead-end residual urachus was diagnosed. The right ureter was cannulated and described as normal; the left ureter could only be cannulated for a few centimeters after entering in the bladder, demonstrating the presence of a complete obstruction . ExitingThe diagnosis of PUGS associated with a complex Mullerian malformation was completed thanks to the integration of ultrasound and hysteroscopy performed by expert operators. In this case, PUGS was misdiagnosed for years, and an incomplete surgical intervention had been performed in childhood. The gynecological ultrasound examination in adult age has revealed the presence of a complex Mullerian malformation and the subsequent MRI diagnosed the urinary tract malformations. The final dynamic integration of lower genital tract endoscopy and trans-abdominal ultrasound led to correct diagnosis.The strength of our reported case is the description of the achievement of correct diagnosis through the integrated technique of ultrasound guided performance of lower genital tract endoscopy in an adult woman affected by complex congenital uro-genital malformation. Limitations may be represented by the few literature data regarding this complex malformation and the single-case description.Complex congenital uro-genital malformations often represent a challenge for the gynecologist and the urologist to be diagnosed. The achievement of correct diagnosis usually requires multiple steps and techniques, different specialist collaborations and integration of multiple radiological and endoscopic techniques. Time to achieve correct diagnosis is often long, misdiagnosis are frequent and premature surgical interventions may be hazardous. The described integrated approach, ultrasound combined with lower uro-genital tract endoscopy, allows to completely and correctly evaluate the suspected complex Mullerian malformation previously studied by MRI.In conclusion, ultrasound-guided endoscopy plays an essential role in the evaluation of complex anatomic anomalies such as persistent urogenital sinus (PUG), leading to correct preoperative diagnosis. Suspected complex congenital uro-genital malformations should be evaluated by expert operators; we believe specialized center should integrate ultrasound and endoscopy in a dynamic diagnostic step in order not to delay diagnosis or to avoid misdiagnosis and unproper surgical interventions.


Lactobacillus rhamnosu. Given the late stage of the patient’s disease, hospice care was initiated. The patient passed away four months after the initial presentation.Carcinosarcomas of the biliary tract are an extremely rare type of malignancy and may be low on a differential when presenting as multiple metastatic masses. In this case report, we report a case of a female who presented with an aggressive late-stage disease whose initial workup did not indicate a malignant process. Further complicating her care, biopsy samples taken from extra-hepatic masses were culture-positive for  Carcinosarcomas of the bile duct are a relatively rare form of tumor appearing in the hepatobiliary system. Histologically, these tumors are characterized by both mesenchymal and epithelial tissues . To dateA 65-year-old female with a past history of type 2 diabetes mellitus (T2DM), hypertension, and systemic lupus erythematosus (SLE) presented to the emergency department (ED) with a six-day history of right upper quadrant (RUQ) pain associated with nausea, vomiting, and chills. Point-of-care ultrasound of the RUQ showed distention in the gallbladder with heterogeneous shadowing and non-shadowing hypoechoic material. Computed tomography (CT) imaging of the abdomen revealed a grossly distended gallbladder with focal irregular thickening of the gallbladder neck Figures -1b. BaseOne month later, the patient presented again to the ED with several weeks of worsening abdominal pain. CT imaging showed a 4.9 cm abscess in the gallbladder fossa, with multiple new hypoattenuating lesions in the liver that were suggestive of micro-abscesses Figures -1d. CT-gHistologically, the tumor was characterized as a high-grade malignant mesenchymal tumor with storiform and fascicular patterns arrangement of highly atypical spindled and polygonal cells as well as frequent foci of coagulative necrosis Figure . ImmunohLactobacillus rhamnosus from the wound and drained abscess contents.Carcinosarcoma in the hepatobiliary system is an exceedingly rare tumor, and as such, may be low on the differential for metastatic abdominal masses. Frustratingly, a preoperative diagnosis is difficult with serum markers such as CEA and CA 19-9 fluctuating between reported cases ,3. ImagiIt has been noted that carcinosarcomas are more locally aggressive and may metastasize earlier in the disease process . In the Given the relatively indolent progression of the disease, many patients only present for assessment when the disease is locally advanced. At this time, it is still undermined what roles chemo- or radiotherapy may have in management. Further work needs to be done but given the rare nature of this pathology, head-to-head studies are unlikely. As previously mentioned, serum molecular markers have been unreliable for diagnosis, but several genetic abnormalities have been identified that may provide targets for molecular therapy for related gall bladder cancers. Loss of activity of TP53 and overactivation of COX2 have been implicated in carcinogenesis in gall bladder cancers and may provide appropriate targets for advanced therapies.In conclusion, we present a case of carcinosarcoma of the hepatobiliary system that presented with multiple extra-hepatic lesions. This previously unreported presentation had features such as positive cultures from the fluid drained from the lesions, which delayed appropriate diagnosis, but, ultimately did not change the management of the patient. Given the rare nature of this malignancy, more study is required to identify at-risk patients and optimal treatment modalities.Informed consent from next of kin was not required due to institutional policies on the publication of de-identified patient information. Official certification of de-identification was obtained prior to publication.


Despite the prevalence of intestinal malformation in Childs, late-onset during adulthood is rare and usually diagnosed incidentally. It may be present as subtle or vague abdominal pain following mid-gut volvulus. Computerized tomography may help diagnosis, but surgery remains the gold standard of diagnosis and treatment.We presented a 24-year-old woman who complained of chronic intermittent abdominal pain, progressive food intolerance, and severe weight loss. Magnetic resonance enterography revealed dilated jejunum and collapsed ileum with slight bowel rotation around its mesentery (whirlpool sign), which was suggestive for mal-rotation of the intestine complicated by midgut volvulus, then the diagnosis was confirmed by laparotomy. During six months of follow-up after surgery, the patient's appetite improved significantly with eight kilograms of weight gain and resolution of abdominal pain.It may be a rationale to consider intestinal malformation as a differential diagnosis in a patient who complained of chronic abdominal pain with progressive weight loss, anorexia, and recurrent bowel obstructive symptoms. Intestinal anomalies including malrotation with concomitant atresia is rare. Intestinal malrotation defines as the failure of the fetal intestine to complete rotation around the superior mesenteric axis (SMA) . Fifty-fHerein, we report a 24-year-old woman who complained of chronic abdominal pain, intermittent bloating, nausea and vomiting, progressive food intolerance, severe weight loss after her first vaginal delivery, and inconclusive referrals to different clinical specialties.A 24-year-old household woman was admitted to our hospital with complaints of chronic abdominal pain, nausea and vomiting, and progressive food intolerance. The patient mentioned that her symptoms began since her childhood and was exacerbated after her first vaginal delivery five years ago. Her symptoms had gotten worse during the past three months. She described an intermittent colicky pain in the periumbilical area which got worse by eating and getting a little better with defecation. She had intermittent nausea and vomiting especially post-prandial, containing food materials that got worse during the past three months. She mentioned progressive anorexia and food intolerance, which led to around 35 kilograms of weight loss during the past five years. She also mentioned an intermittent period of diarrhea and constipation in the past five years. During these years, she underwent upper gastroscopy, which revealed severe bile reflux gastritis  with patClinical finding: Initial physical examinations were blood pressure of 120/80 mmHg without orthostatic hypotension, pulse rate of 95 beats per minute, respiratory rate of 20 per minute, and temperature of 36.8 ◦C. There was no abnormality in head, neck, and chest examination. Abdominal examination revealed upper abdominal distention with mild tenderness in the periumbilical and epigastric area without guarding or rebound tenderness. Diagnostic assessment: Initial Laboratory evaluations were normal except for mild anemia (hemoglobin of 11.7 mg/dl) and serum Na of 130 mmol/l . Plasma levels of IgA, anti-Tissue transglutaminase Ab (IgG), anti-Tissue transglutaminase Ab (IgA), anti-Endomysial Ab (IgA), and anti-Endomysial Ab (IgG) were all in the normal range. So, no further evaluation was needed because of low clinical suspicion for celiac disease.Magnetic resonance enterography was requested and revealed dilated jejunum and collapsed ileum with mid-small bowel rotating around its mesentery  and supeTherapeutic intervention: During diagnostic laparoscopy, jejunal dilatation and ileal loop collapse, with segmental stenosis in the mid-portion of the small intestine distal to the jejunum was apparent, then the operation was converted to open laparotomy. There was 15-centimeter length spiral segment of the intestine with stenosis at the jejunoileal junction (apple peel sign) with volvulus of dilated, thickened wall, proximal segment around its mesentery and collapsed loop in the distal part suggestive for type 1 jejunoileal junction atresia accompanied by volvulus of proximal midgut (l midgut . The mesentery of the affected segment was short and narrow, with enlarged lymph nodes and ecstatic lymphatic vessels . Due to Follow-up and outcomes: During six months of follow-up, the patient's appetite improved significantly with eight kilograms of weight gain, and abdominal pain resolved.Incomplete intestine atresia accompanied with chronic midgut volvulus rarely presents in late adulthood -14. PatiDespite the rare occurrence of midgut volvulus in adults as a late presentation of intestinal anomalies, it should be considered a differential diagnosis for chronic abdominal pain with non-specific symptoms. Appropriate diagnostic measures like abdominal CT scan with contrast or magnetic resonance enterography may be helpful to confirm the diagnosis. Still, surgery remains the gold standard for both diagnosis and treatment.


Hibernoma is a benign soft tissue tumor; it is extremely low in incidence, slow-growing and painless and is often mistaken for lipoma or liposarcoma. Diagnosis requires imaging and pathological analysis. Complete resection is the treatment of choice. We analyzed a case of lipoma from imaging and pathology perspectives and reviewed the relevant literature.  Hibernomas, also known as brown adipose tumors, are benign tumors originating from brown adipose cells. They are characterized by slow growth and painlessness, often going unnoticed. The incidence rate of hibernomas among adipose cell tumors is ~1.1% [The patient was admitted to the hospital due to the discovery of an inguinal mass that had been present for 1 year. The patient initially noticed swelling in the groin area a year ago. Over time, it gradually increased in size and caused localized discomfort. During the examination, a mass the size of a hen’s egg was felt in the right inguinal region. It had limited mobility and was not tender. No significant abnormalities were found in the motion or sensation of the right lower limb. Ultrasonography showed an isoechoic mass within the muscle tissue of the left inguinal region. Unenhanced and enhanced magnetic resonance imaging (MRI) scans suggested a well-defined intermuscular mass at the root of the right thigh. The mass showed low signal intensity on diffusion-weighted imaging and isointense-to-slightly hyperintense signal post-enhancement . The patHibernomas are rare adipocytic tumors that primarily affect individuals aged 30–40 years old. They are commonly found in regions rich in brown adipose tissue, such as axillary fossae, necks and interscapular areas. Cases have also been reported in abdominal regions, thighs and buttocks. Hibernomas rarely undergo malignant transformation, with only a minority of cases recurring due to incomplete excision . ClinicaDue to the high metabolic activity and abundance of mitochondria in brown adipomas, they exhibit elevated FDG uptake on PET scans. Simultaneous CT scans show fatty masses without infiltration into surrounding tissues. PET/CT can aid in differentiating hibernomas from liposarcomas to some extent. Nevertheless, definitive diagnosis still requires histopathological confirmation. Direct observation of brown adipomas revealed irregularly lobulated, well-demarcated and pliable oily masses with diameters typically ranging from 5 to 10 cm. The cut surfaces appeared yellow-to-reddish-brown with occasional hemorrhagic areas. Under the microscope, encapsulated structures consisting of multivacuolated and univacuolated cells were observed. Immunophenotypically, brown adipoma cells were positive for Vimentin and S-100, but do not express CD34. Molecular markers such as MDM-2, CDK-4 and p-16 may provide additional diagnostic support for brown adipomas [In summary, brown adipomas are a rare benign lipoma subtype that is often misdiagnosed as conventional lipomas or liposarcomas based on clinical and radiological findings. Accurate diagnosis relies on pathological analysis.None declared.None.


Bone pain in pediatric patients is exceedingly common, with etiologies ranging from benign lesions such as fibrous dysplasia and enchondromas to potentially devastating, life-threatening malignancies such as Ewing's sarcoma or osteosarcoma. Given the low yield of physical examination and routine laboratory workup, pediatric patients with bone pain or an inability to ambulate warrant further workup. The initial workup should consist of imaging with radiography. A large majority of patients will have a resolution of symptoms without intervention and will have normal imaging. When radiographic imaging has suspicious findings, expert consultation is warranted because differentiating between benign and malignant processes on imaging can be challenging. Here we present a case of a six-year-old male with progressive worsening leg pain who was found to have a rare aneurysmal bone cyst with an associated pathologic fracture requiring open reduction and internal fixation. Bone cysts are benign lesions most commonly found in the pediatric population during the second decade of life. These lytic lesions can be subclassified as unicameral or aneurysmal. Aneurysmal bone cysts (ABCs) are exceptionally rare, at a rate of 0.14 per 100,00 per year. Morphologically, aneurysmal bone cysts are expansive and hemorrhagic indeterminate bone tumors of intermediate malignancy, typically located at the metaphysis of long bones. On radiographic imaging, ABCs appear as eccentric, radiolucent, and expansile lesions containing cystic cavities that cause cortical bone bulges. Primary lesions have a genetic rearrangement of the USP6 oncogene on chromosome 17, but ABCs can be secondary to other bone lesions. A biopsy is essential to differentiate from telangiectatic osteosarcoma. Treatment includes wide resection to cure and prevent reoccurrences, osteosynthesis with graft, and cement or bone substitute for fragilization or pathological fracture.A six-year-old male began having left leg pain in July 2022. His pediatrician took a radiograph of his knee and lower leg, which did not reveal any fracture or deformity. Over the span of a few months, his pain worsened to a limp when he attempted to play football, and he could no longer bear weight. In October 2022, the patient returned to his pediatrician due to his inability to ambulate. A repeat radiograph of the hip revealed an ill-defined lytic lesion with pseudotrabeculation involving the proximal left femoral diaphysis extending into the femoral. Along with this, there was a lucency involving the inferior portion of the neck of the femur, which likely represents a pathologic fracture Figure . Given tOrthopedic surgery recommended magnetic resonance imaging to further characterize the lesion Figure .Pediatric orthopedic surgery biopsied the cystic lesion, and pathology revealed benign-appearing cystic tissue. An open reduction and internal fixation with pins and a plate were completed for stabilization of the pathologic fracture Figure .Curettage of the cyst was performed, and the cystic space was filled with an injectable inductive graft and crushed cancellous bone. Physical therapy and occupational therapy provided education for ambulation with a walker upon discharge post-operative day one. Hematology/oncology followed the permanent pathology report, which ultimately diagnosed an aneurysmal bone cyst. Pediatricians often encounter patients with lower extremity pain in their practice. When a child presents with lower extremity pain, the initial assessment begins with a history and physical examination to evaluate the nature and timing of the pain, its impact on ambulation, and if any associated symptoms ensued in the same period. The physician assesses the joints for a range of motion, signs of infection, deformity, and gait, along with a neurovascular exam. The further investigation includes basic screening labs to screen for infectious etiology and radiographs of the affected site . In our Young, well-appearing children with acute gait disturbance often self-resolve. In a study of 1- to 5-year-old outpatient children that presented for acute gait disturbance, radiographic studies appeared normal 96% of the time. In follow-up observations, 81% returned to their pediatrician within 4-28 months, all of which showed spontaneous resolution . AdditioEvaluation of a patient with a physical exam revealing moderate-to-severe pain and pinpoint tenderness over the anterior thigh should prompt initial imaging with radiography and consultation with orthopedic surgery if a suspicious lesion is found. When followed in the outpatient setting, the large majority of pediatric patients presenting with acute gait abnormalities will have normal imaging, and nearly all patients will have a resolution of symptoms. Regardless, key signs and symptoms such as pain or an inability to ambulate should prompt imaging and a referral to a specialist. Here we present a case of an aneurysmal bone cyst with an associated pathological fracture in a patient with an inability to ambulate.


Orbital lymphangioma is a rare benign lymphatic and vascular malformation, which is distinguished by its abnormal endothelial ducts and can cause proptosis in the patients. Radiological imaging is essential in confirming the diagnosis. Sclerotherapy is an alternative treatment option if surgery is not an option or is too risky. This report presents a rare case of a 4-year-old girl who had complained of bulging her right eye since she was 3 years old. Because surgery can be challenging to the surrounding vital orbital structure, the patient underwent several sclerotherapy sessions which yielded good results on the patient. Lymphangioma is a localized multi-cystic malformation of the lymphatic and vascular systems that most commonly affects children' heads and necks. Lymphangioma accounts for 0.3%-4% of all orbital tumors and it is not considered hamartoma as the orbit does not typically contain lymphatic vessels A 4-year-old girl came to our hospital with chief complaint of bulging right eye, which was often accompanied with yellowish pus discharge since she was 3 years old. The patient also experienced a dry cough, runny nose, decreased appetite, and weight loss. Upon examination, the patient was cranky, weak, and sleepy. On her right eye, there was a 3 × 2 × 2 cm ocular mass covered by conjunctiva . The masOrbital MRI showed an inhomogeneous lesion in the right retrobulbar that infiltrated the right intraconal and extraconal fat, right nerve optic, and right superior-medial-anterior recti; with the distance between the anterior margin of the right ocular bulb and right interzygomatic line was 2.36 cm . The lesDue to the possibility of destruction of the surrounding mass, the patient was scheduled for sclerotherapy instead of surgery. The patient then underwent 3 sclerotherapy sessions with interventional radiologists using bleomycin. After the first sclerotherapy session, there was still a bulging right eye with yellowish discharge and the patient was still unable to see. The patient then underwent the second sclerotherapy session in the next month, and the mass looked reduced in size, however, the patient was still unable to see.The third sclerotherapy session took place 1 month after the second one, and the proptosis was reduced significantly after the treatment . A folloLymphangioma is also known as lymphatic malformations. Lymphangioma is a multicystic, localized malformation that involves the lymphatic and vascular systems. The prevalence of lymphangioma has been estimated to be 1.1-5.3 cases per 10,000 live births. Lymphangioma accounts for 4% of all vascular tumors and roughly 25% of pediatric benign vascular tumors. Lymphangioma of the orbit is considered rare as it makes up about 1%-4% of all orbital lesions Ptosis and proptosis are the most common features of orbital lymphangioma, with the majority of cases appearing in the first decade of life. Traditionally, these lesions are not clinically recognized until bleeding into the lesion causes acute axial or nonaxial proptosis. This is common in infants as they become more active and prone to minor trauma. In the presence of an upper respiratory tract infection, lesions frequently appear acutely swollen. Occasionally, the lesion will cause progressive proptosis and ocular motility restriction. In rare cases, focal lesions may remain asymptomatic and be discovered by chance during neuroradiological imaging. Lesions can cause a mass effect, resulting in compressive optic neuropathy, most commonly after acute bleeding into the lesion. These potentially amblyogenic factors are significant findings because patients frequently present before full visual maturation, which may dictate the need for surgical intervention Lymphangioma develops as a result of either congenital or acquired lymphatic system disorders. The congenital form is caused by an improper connection of the lymphatic ducts to the main lymphatic drainage duct and usually occurs before a patient reaches 5 years old. Acquired lymphangioma may develop from surgery, trauma, cancer, or radiation therapy. The failure of the lymphatic system to connect with or separate from the venous system, abnormal budding of lymphatic tissue from the cardinal veins, and obstruction of the efferent lymphatic vessels are causes of lymphangioma development. It can also be triggered by trauma, infection, chronic inflammation, and obstruction during embryonic development ,8. HistoCT scans of a lymphangioma reveal a cyst-like mass with varying degrees of elevation and an increased cyst margin with bleeding. MRI reveals areas of acute and chronic bleeding within the mass and has been shown to identify feeder vessels that CT scans may not. The presence of such feeder vessels distinguishes this lesion from a lymphangioma. Angiographic studies show that the lesion is isolated from the arterial and venous circulations. Noninvasive dynamic MR angiography with contrast kinetics imaging, diffusion-weighted MRI, and ultrasonography have all been described as imaging modalities that can help differentiate lymphangioma from other vascular lesions. Lesions were found to branch into surrounding structures with all imaging modalities, causing image distortion without invading these structures Lymphatic venous malformations are difficult to manage as they cause structural and functional disorders depending on their location, size, and relationship to adjacent tissues. Although conservative observation is often appropriate for asymptomatic lesions, because lymphatic venous malformations tend to develop with age, early intervention may be considered. Treatment for vision-threatening lesions will be more urgent. There were 2 types of treatment strategies: surgical and nonsurgical Sclerotherapy is a preferred treatment method for cystic lesions, involving injection of agents with ultrasound guidance, resulting in scar formation and reduced cyst and lesion size. OK-432 (Picibanil), sodium tetradecyl sulfate, doxycycline, ethanol, pingyangmycin, and bleomycin are some of the specific agents used in orbital lymphangioma. The sclerosing effect is achieved by stimulating neutrophils and macrophages to produce cytokines such as IL-1, IL-2, IL-6, g-interferon, and TNF which increase endothelial permeability and activate neutrophils, macrophages, natural killer T cells, and lymphatic endothelial apoptosis, resulting in increased lymph fluid clearance and lesion resolution or shrinkage Orbital lymphangioma is a rare multicystic lymphatic and vascular malformation that most commonly affects children in the head and neck region. Radiological imaging is important in confirming the diagnosis by identifying and evaluating the orbital mass. Orbital lymphangioma may be a challenging case to manage due to high risk of adjacent vital orbital structures destruction if surgery is performed. Sclerotherapy, as a less invasive intervention, is an effective alternative treatment for orbital lymphangioma with favorable result.Written informed consent for publication of their case was obtained from our patient's parent.


Acute abdomen in pregnancy presents many diagnostic challenges. Non-specific symptoms, anatomical and physiological changes and diagnostic imaging limitations lead to diagnostic uncertainty and delayed diagnosis and treatment. Meckel’s diverticulitis in pregnancy is extremely rare with only 27 cases reported in literature, only 11 of which are found to be perforated intraoperatively. We present a rare case of a patient in third trimester of pregnancy with perforated Meckel’s diverticulitis. Acute abdomen in pregnancy occurs in 1:500 cases [Meckel’s diverticulum is the most common congenital malformation of the gastrointestinal tract. It results from the incomplete obliteration of the vitello-intestinal duct leading to the formation of a true diverticulum of the small intestine, involving all three layers . The truPresentations with symptomatic Meckel’s diverticulum during pregnancy are extremely rare. Only 27 case reports of Meckel’s diverticulum can be found in a search of the English literature in the last 30 years [A 23-year-old primigravid woman presented at 34 weeks of gestation with sudden onset, severe, right iliac fossa pain that woke her from sleep. It was sharp in nature, did not radiate and was worse with movement. The pain was associated with nausea and vomiting and bowels had not opened for four days. She was admitted to the MFAU where the foetus was confirmed to be healthy. Pre-term labour and ovarian torsion were excluded by the obstetric team.At the time of the surgical consultant review, the pain was increasingly severe (9/10) despite opioid analgesia. The patient was afebrile with a heart rate of 110 bpm  with tenderness and guarding in the right iliac fossa and flank.9/L) with a neutrophilia and further increased to 20.8 preoperatively. C-reactive protein was normal 2.60 mg/L (reference <30.0 mg/L) and increased to 7.6 mg/L preoperatively.The results of the initial haematological investigations showed the white cell count was raised at 16.0  × 10Urgent pelvic ultrasound was performed which described a 19 mm blind ending tubular structure with surrounding hyperaemia, echogenic fat and focal tenderness, which was marked by the sonographer in the right upper quadrant and deemed compatible with acute appendicitis .Further investigation with CT was considered after discussion with the Obstetric team, given the atypical presentation of appendicitis; however, given the progressive pain and peritonism, and the unequivocal ultrasound findings, the decision was made to proceed to surgery for presumed appendicitis.in situ.The patient was commenced on intravenous antibiotics and proceeded to theatre to have an open exploratory laparotomy via a transverse incision in the right upper quadrant. Intraoperatively, an approximately 7 cm inflamed Meckel’s diverticulum with a thickened mass at the tip and evidence of perforation just proximal to this was evident . Both thPostoperative ileus gradually improved, diet was gradually upgraded as tolerated and the patient was discharged home on postoperative Day 6.The histopathology confirmed Meckel’s diverticulum with diverticulitis. Heterotopic gastric mucosa and associated fibrinopurulent serositis was noted; however, there was no dysplasia or malignancy and the lymph nodes were all reactive.There were no obstetrics concerns postoperatively. The patient was admitted to MFAU at 40 + 2 weeks gestation, in early labour and had vaginal delivery with smooth postnatal recovery.It is well known that ultrasound scan (USS) is the preferred imaging modality for investigating the aetiology of acute abdominal pain in pregnancy due to its availability and its lack of ionizing radiation. When USS is inconclusive, magnetic resonance imaging (without intravenous Gadolinium) is recommended as it provides excellent soft tissue views with multiplanar imaging and is safe in any trimester . However5 is less than the recommended maternal dose (50 mGy) below which foetal teratogenesis should not occur [When considering the CT of the abdomen and pelvis in a pregnant patient, a risk-benefit assessment should be performed. Although there is strong evidence that exposure to ionizing radiation in pregnancy increases the risk of teratogenesis and childhood haematological malignancies, the radiation exposure of 20–50 mGyOnce the decision is made to operate the next consideration is whether to perform laparoscopy versus laparotomy. This is based on the pathology, the size of the gravid uterus, available resources and surgeon preference. We chose an open approach because of the location of the pain in the right upper quadrant, the gravid uterus measuring more than 34 weeks and suspected perforation with clinical peritonitis. In this particular case, we found perforated Meckel’s diverticulum and we were able to resect and washout via the open approach. However, laparoscopy is considered to be safe during any trimester without any increased risk to mother or foetus and the benefits include less postoperative pain, decreased risk of foetal respiratory depression secondary to opioid analgesia, less wound complications, less postoperative ileus and decreased length of stay .Meckel’s diverticulitis is an important consideration in pregnant patients presenting with acute abdomen and can often be misdiagnosed as appendicitis. Ultrasound should be used for initial diagnostic imaging; however, MRI without gadolinium contrast and CT can be considered if available and if there is diagnostic uncertainty. The treatment of Meckel’s diverticulitis is always surgical intervention, which can be performed both open or laparoscopically, depending on the fundal height and surgeon’s expert opinion.


Spinal meningiomas represent 25%–45% of intradural spinal tumors and are commonly seen in the thoracic spine. Ventral midline spinal meningiomas in the thoracic spine are challenging lesions to resect given their location in relation to the spinal cord. Resection for symptomatic or growing lesions requires adequate bone removal to limit retraction of the spinal cord. Surgical adjuncts such as intraoperative navigation, robotics, and ultrasound can improve the efficiency of and safety for resection of these lesions. The authors present a case of a complete resection of a ventral thoracic meningioma using a T12 transpedicular approach with robot-assisted navigated pediculectomy and intraoperative ultrasonography. She had intermittent low-back pain with mild gait imbalance. She had no weakness or numbness in her lower limbs or new bowel or bladder dysfunction. Physical examination demonstrated full strength in upper and lower extremities except for right ankle, which had limited movement due to prior foot surgery. Patient had intact sensation throughout. She did not exhibit hyperreflexia or clonus in her lower extremities.Preoperative sagittal T2-weighted MRI showed a ventral T2 isointense intradural extramedullary lesion with cord compression at T12 as well as faint intramedullary T2 hyperintensity. The axial T2 image showed that the spinal cord was rotated toward the left and the lesion was in the midline but eccentric to the right side.Sagittal and axial contrasted MRI of the thoracic spine showed homogeneous enhancement within the ventral intradural extramedullary T12 lesion.Noncontrasted CT scan of the thoracic spine showed that the ventral T12 lesion was calcified. Imaging of the rest of her neuraxis did not show any additional lesions.Given the degree of cord compression, intramedullary signal change, and symptoms of mild thoracic myelopathy, we recommended surgical resection of this lesion. The surgical plan was a T11–12 laminectomy with a right T12 robot-assisted pediculectomy and resection of ventral intradural extramedullary mass. Given that the calcified tumor was visualized on the preoperative navigation CT, the surgical robotic system was used for presurgical planning as well as to perform the pediculectomy. We also performed a T10–L2 robot-assisted pedicle screw fixation and posterolateral fusion. We elected to perform fusion to prevent postsurgical thoracolumbar instability. We also planned to utilize intraoperative ultrasound, neuromonitoring, and microscope for microsurgical dissection.The patient was placed in a prone position on a Jackson table. Fluoroscopy was used to identify the T12 pedicle and a midline incision from T10 to L2 was made. Next, a subperiosteal dissection was performed, and a clamp was placed on the transverse process of T12. A right iliac crest pin was then used to anchor the surgical robot, and fluoroscopy was used to register the presurgical CT to the patient’s anatomy.This presurgical planning CT shows the screw trajectories for the T10–L2 fusion.7The calcified ventral lesion is visible on the axial image at T12. The right T12 screw was planned to visualize the trajectory of the pediculectomy that needed to be performed at that level. Using the robotic navigation and arm, the pedicle was drilled and tapped up to the posterior edge of the vertebral body. This facilitated a more efficient and safer pediculectomy to access the tumor.This image shows the results of pediculectomy.Laminectomy with facetectomy and pediculectomy was performed to access the tumor. Intraoperative ultrasound confirmed adequate bone removal, and the entire tumor was visualized. This ultrasound image is showing the hyperechoic rim of the ventral intradural extramedullary lesion with the spinal cord draped over it.The dura is being opened off midline to the right. The arachnoid is being opened separately and tacked up with vascular mini clips.The partially calcified tumor is visible displacing the cord dorsally and the nerve roots laterally. The roots around the tumor are being moved to develop the plane between tumor and spinal cord. The dentate ligament is being sharply dissected to prevent traction on the spinal cord during surgery. The superior and inferior poles of the tumor are being identified.The tumor capsule is being opened. At this stage, specimens were sent for permanent pathology. The tumor is being internally debulked using the ultrasonic aspirator.Arachnoid adhesions at the poles were cut to mobilize the tumor. Ventral dural attachment was sharply dissected. All visible tumor was resected, and the ventral dura was coagulated. Ultrasound was performed in addition to visual inspection and did not reveal any residual lesion There was no change in the baseline SSEPs or MEPs throughout the case.Dura was repaired with 5-0 Prolene in a watertight fashion. The wound was irrigated with antibiotic irrigation. At this point, we performed an ultrasound once more. This ultrasound image shows no signs of residual tumor or intradural hematoma. After this, the facet joints and transverse processes were decorticated. Autograft and morselized allograft was placed for posterolateral arthrodesis. The wound was then closed in layers.The patient had no new neurological deficits after surgery. She experienced a transient postoperative ileus that resolved prior to discharge home. At her last follow-up visit approximately 6 months after surgery, she reported no new neurological deficits and improving presurgical symptoms. Postoperative T2-weighted and contrasted T1-weighted MRIs showing improved position of the spinal cord within the canal and no residual tumor.CT scan of the thoracolumbar spine shows the laminectomy defect and removal of the ventral calcified lesion as well as evidence of the right T12 pediculectomy.Postoperative thoracolumbar x-ray shows the T10–L2 fusion hardware to be in stable position.Final pathology showed that the lesion was a WHO grade 1 meningioma with abundant calcified psammoma bodies and extremely rare mitotic figures.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Primary surgeon: Vedantam. Assistant surgeon: Truong. Editing and drafting the video and abstract: Vedantam, Rahman. Critically revising the work: Vedantam, Rahman. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Vedantam. Supervision: Vedantam.The necessary patient informed consent was obtained in this study.


Ectopic adrenocorticotropic hormone syndrome (EAS) is a condition of hypercortisolism caused by non-pituitary tumors that secrete adrenocorticotropic hormone (ACTH). A rare occurrence of this syndrome is due to an ACTH-producing neuroendocrine tumor that originates from the gallbladder. One patient with severe hypokalemia and alkalosis was admitted to our hospital. Clinical presentations and radiographic findings confirmed the diagnosis of an aggressive ACTH-producing gallbladder malignancy with multiple liver metastases. The diagnosis was verified by pathological and immunohistochemical measurements from a biopsy of the hepatic metastasis. A literature review identified only four similar cases had been reported. Despite being rare and having a poor prognosis, hormone-producing neuroendocrine tumors that derive from the gallbladder should be considered in the differential diagnosis of ectopic ACTH syndrome. Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors originating from neuroendocrine cells and are able to secrete amines or peptides as their neurotransmitters, such as 5-hydroxytryptamine, vasoactive polypeptide, insulin, growth hormone, adrenocorticotropic hormone, gastrin, somatostatin pancreatic polypeptide, and calcitonin. Ectopic adrenocorticotropic hormone syndrome (EAS) develops as a result of neuroendocrine tumors outside of the pituitary gland, which secrete either adrenocorticotropic hormone (ACTH) and/or corticotropin-releasing hormone, leading to a clinical presentation that resembles Cushing disease, characterized by hirsutism, muscular wasting, truncal-central obesity, hypertension, diabetes mellitus, and osteoporosis . The mosWe reported a case of severe hypokalemia and alkalosis caused by an aggressive ACTH-secreting gallbladder malignancy with numerous liver metastases. Only four comparable cases have been reported –6, accorA 65-year-old man was admitted to our hospital with complaints of progressive weakness and anorexia that had persisted for ten days. Prior to this, the patient had been in a normal state. His condition began to deteriorate rapidly, as he claimed to have experienced accelerated fatigue, decreased appetite, and a weight loss of 1 kg. The patient denied experiencing any abdominal pain or diarrhea. His previous medical history included hypertension for the past 8 years and type 2 diabetes mellitus for the past 5 years. Glycemia was well controlled with insulin Aspart30 during the past two years, but it has deteriorated in the last month. Additionally, he underwent a bladder mass resection surgery in 2015, but the pathology of the mass could not be traced. He had a history of smoking for over 20 years and alcohol consumption for 30 years (100 ml per day). There was also a positive family history of hypertension and diabetes mellitus. Physical examination indicated that the patient had facial blushing, central obesity with thin extremities, and proximal muscle wasting. Pitting edema was also observed in both lower limbs. Skin hyperpigmentation was not obvious. His height measured at 159 cm, weight at 64 kg, and his blood pressure at 162/102 mmHg.9/L. Liver function manifested slightly elevated GGT (81.2 U/L) and total bilirubin (31.3 μmol/L). Hypoproteinemia was observed . HbA1c was 7.5%, indicating that blood glucose levels had not been well controlled for the past 3 months. Notable analysis revealed a hypokalemia of 1.98 mmol/L and metabolic alkalosis. Urinary potassium excretion (138.53 mmol/24 h) markedly increased. Additional tests revealed that the patient had disrupted circadian biorhythms of plasma ACTH and cortisol  and 134 mmol of potassium. This eventually helped to maintain the serum potassium level at 3.7 mmol/L. Radical resection of gallbladder malignancy and hepatic metastases was unattainable on account of the patient’s delicate condition. Chemotherapy, molecular targeted therapy, somatostatin analogues, and peptide receptor radionuclide therapy were openly discussed with the patient and his family members. The patient initially declined these therapeutic measures. He died of advanced gallbladder malignancy, liver function failure, malnutrition, and chronic gastrointestinal bleeding, hypoxemia after one month.Literature review found that 4 cases of gallbladder EAS were reported. Three patients had gallbladder malignancy, and one patient had cholangiocarcinoma. The main clinical characteristics are listed in In this patient, elevated ACTH and serum cortisol levels supported the diagnosis of ACTH-dependent Cushing syndrome. The next challenge is to identify the tumor responsible for producing ACTH. High doses of dexamethasone may partially or completely suppress ACTH secretion for most pituitary corticotrophin tumors but not for most ectopic ACTH-secreting tumors . However2 and Ki-67 >20% (often associated with a Ki-67 >55%). The carcinomas are further subtyped as small cell and large cell neuroendocrine carcinomas based on cytomorphological characteristics  are defined as >10 mitoses per 2 mmeristics . In thisMedical management of EAS is a complex matter. The aim is to reduce excessive cortisol levels and eliminate neuroendocrine tumors. The optimal treatment strategy is complete surgical resection of the tumor. However, most patients are at a late stage of disease when they get a final diagnosis, and only 10–30% of them have a chance for curative resection of the tumors. A combination of active chemotherapy, radiotherapy, targeted therapy, somatostatin analogues, and other multimodal treatments should be considered to minimize tumor size and prolong survival time . When thWe systematically reviewed the previous reports on ACTH-secreting gallbladder endocrine tumors. Four cases had been reported at present –6. All wIn conclusion, ACTH-producing neuroendocrine carcinomas located in the gallbladder are rare. We present a case of a male patient with a gallbladder NEC that secretes ACTH. The disease advanced rapidly and had a poor prognosis. Recognition of its clinical condition by laboratory measurements, radiological and immunohistochemical examinations may benefit in an earlier diagnosis and a better chance of life-saving management.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The studies involving humans were approved by the ethics committee of Shaoxing People’s Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XZ and DH are co-first authors of this case report. XZ conducted the writing and literature search. DH performed the acquisition, analysis and interpretation. XP and QS carried out the medical practice. QY is the corresponding author supervising this work. All authors contributed to the article and have approved the submitted version.


A 76-year-old female consulted her general practitioner because of new-onset leg oedema and dyspnoea. Medical records revealed a history of smoking and hypertension. The diagnosis of chronic obstructive pulmonary disease was considered, and a chest X‑ray was performed, which showed a broadened mediastinum. Computed tomography angiography revealed a supracoronary aorta aneurysm of 10.1 cm in diameter reaching to the brachiocephalic trunk (Fig. An isolated supracoronary aorta aneurysm larger than 10 cm is rare [Video 1 Three-dimensional reconstruction of thoracic and abdominal aorta


MDM2 gene locus amplification. Subsequent laser ablation of the tumor bed was conducted with no recurrences noted to date. Proper histologic identification, alongside adjunctive cytogenetic and molecular diagnostics, followed by definitive surgical resection and extended follow-up, are emphasized as critical in optimizing outcomes for this disease. A review of the existing English-language medical literature relating to esophageal liposarcoma was performed and summarized.Liposarcomas are extremely rare occurrences in the esophagus. Here, we present an unusual case of esophageal liposarcoma that contributed to a long history of dysphagia before a definitive diagnosis was reached. The case is that of a 61-year-old woman who complained of dysphagia and foreign body sensation in her throat and was found to have a large filling defect within the cervical esophagus on barium esophagogram. She underwent endoscopic resection of the mass and was diagnosed with a five-centimeter long, well-differentiated esophageal liposarcoma, confirmed with fluorescence in situ hybridization for  MDM2 gene locus amplification remain critical for diagnosis  me," and "block[s] my airway.” She also reported difficulty swallowing solids, liquids, and especially pills. She had multiple esophagogastroduodenoscopies (EGDs) with empiric dilation eight years ago, but no diagnosis prior to being evaluated at our center.At the time of the current presentation, the patient denied any other symptoms, including fever, chills, weight loss, or hemoptysis. Physical exam was unremarkable with the exception of slight dysphonia, consistent with the patient’s prior history. Head and neck exam was normal, including upper airway evaluation with nasopharyngoscopy.A barium esophagogram was obtained for further evaluation. A long smooth tubular filling defect within the proximal esophagus, approximately 9 cm in length, was observed beginning at the level of the cricopharyngeus muscle Figure . This waThe patient underwent rigid esophagoscopy with a Slimline scope to expose the mass. A zero-degree telescope was used to visualize the mass from the left hypopharyngeal wall, and suction cups were used to pull the elongated mass from the esophagus. Next, an approximately 6 cm mass was truncated using cupped forceps and Sonicision  at the left hypopharyngeal wall and retrieved transorally without mucosal tear. The mass was sent for permanent section to pathology. The patient tolerated the procedure well with no complications and was discharged from the hospital on the same day.in situ hybridization (FISH) analysis using a dual-color MDM2/CEN12 probe set was performed to detect MDM2 gene amplification and was positive . COA CT scan of the neck and chest with contrast was obtained following the operation and revealed no residual disease or evidence of local, regional, or distant metastases.On follow-up visit one month after re-excision, the patient reported complete resolution of dysphagia and dysphonia. Six months after re-excision, the patient reported intermittent solid food dysphagia. The patient underwent repeat esophagoscopy in the OR, and there was no tumor noted on examination. A small left-sided esophageal web was again visualized, and this area was successfully dilated to 84 Fr with a balloon.The patient denied dysphagia during follow-up visits at nine and 12 months, respectively, following balloon dilation of the small esophageal web. Head and neck exam at each of these visits was normal, including upper airway evaluation with nasopharyngoscopy. She continues to do well and has been instructed to follow up on an as-needed basis.MDM2 gene locus, an inhibitor of p53, which can be identified either by immunohistochemistry or FISH as a diagnostic test [Liposarcomas are a class of malignant tumor derived from adipose tissues . They artic test . The usetic test . This isLiposarcomas commonly arise in the sixth to seventh decades of life and usually involve the retroperitoneum or extremities . Among wA search in PubMed was performed using the following search string:  and (Liposarcoma) or  or . All English-language articles and articles from 1983 (first case report) to May 2023 were included. A total of 76 cases of esophageal liposarcoma were identified in the English-language medical literature: 66 from two reviews ,8 and 11Given the rarity of esophageal liposarcomas, no guidelines exist on the optimal management of this tumor. In this case, given the favorable size and location of the tumor, endoscopic resection was pursued and was successful. In other cases reviewed in the literature, more invasive surgical approaches have also been utilized, usually secondary to unfavorable tumor characteristics, such as size, location, or an intramural tumor, as opposed to an intraluminal pedunculated mass that is readily excisable at the level of a stalk. In such cases, the added morbidity associated with a more invasive approach, as well as the increased length of the recovery period and cost, may be justifiable in the pursuit of a complete resection. However, in cases similar to the one presented here, serious consideration should be given to an endoscopic approach to minimize the aforementioned factors while still achieving excellent outcomes.The probability of recurrence is difficult to establish in esophageal liposarcoma, given the relative lack of data in the literature, which is almost exclusively comprised of single case reports with limited long-term follow-up, as well as the heterogeneity in clinical behavior of different subtypes of liposarcoma. Given that esophageal liposarcoma has been known to recur as late as 25 years post-initial resection, the need for long-term follow-up is emphasized . The proMDM2 gene amplification by immunohistochemistry or FISH. Resection is indicated and can be pursued either by invasive surgical approaches or alternatively by endoscopy when tumor morphologic characteristics are favorable. They can recur following resection, underscoring the need for negative tumor margins and extended follow-up.Esophageal liposarcoma are an exceedingly rare clinical entity that nevertheless should be considered in the evaluation of an esophageal mass. Definitive diagnosis requires histology, and the diagnosis of the well-differentiated subtype is greatly aided by the identification of


Cauda equina neuroendocrine tumors (CENET) are rare neoplastic processes that develop in the cauda equina or filum terminale region of the spinal cord, which in previous incarnations of the World Health Organization (WHO) classification of the central nervous system (CNS) tumors were designated as paragangliomas. The change of terminology was carried out due to the rarity of the condition, its specific place of origin, the non-specific clinical and imaging characteristics with which the tumors present, and differences in biological properties (secretion and progression) as well as some minor differences in immunohistochemical protein expression patterns. Herein, we present a case of a male patient in his sixties who presented to us for a histopathological consultation of a previously excised tumor, which was grossly well-demarcated and connected to a nerve root in the cauda equina region. The tumor presented with histomorphological features of a sharply demarcated, non-infiltrative tumor growing in a nested to pseudopapillary pattern with a highly vascularized, intersecting stroma. Tumor cells were mildly atypical ovoid ones, with eosinophilic cytoplasm, central hyperchromatic nuclei, some with nucleoli, and salt and pepper chromatin. Intersecting stroma was rich in reticulin fibers, and the cell did not express epithelial membrane antigen, excluding the diagnosis of ependymoma as well as glial markers, excluding glial origin. Pan-cytokeratin was focally positive, neuroendocrine markers were diffusely positive, and the proliferative index was low. As such, the diagnosis of CENET, WHO CNS grade 1 was established, and the patient was referred back to the institution at which the surgery was performed for follow-up and further management. Cauda equina neuroendocrine tumor (CENET), previously referred to as paraganglioma, is a rare central nervous system (CNS) tumor that typically develops as per its name in the cauda equina region or the spinal nerve roots. It is a rare and probably underdiagnosed entry, with medical literature reporting only around 300 cases since the nosological entry was initially described back in the 1970s ,3.Patients affected are typically in their fourth to sixth decades, although cases have been described in nearly all age groups ,4. MalesClinical and presenting symptoms are widely unspecific and include lower back pain, numbness, and paresthesia, with manifest cauda equina syndrome being exceedingly rare ,6. FunctNeuroradiological findings are again non-specific for the tumor entry with high similarity to significantly more common tumors such as ependymoma and schwannoma ,8. TumorHistopathological diagnosis requires these tumors to be located in the cauda equina region, be sharply demarcated, and have Zellballen architecture or tumor nests separated by vascular stroma; tumor cells must express neuroendocrine differentiation markers ,10. The Herein, we present a histopathological case report of a male patient in his early sixties who presented to our team for a histopathological consultation of an excised spinal tumor. Previous medical history was unremarkable except for mild hypertension under adequate medication control for the past two decades. The initial presenting symptoms of the patient were lower back pain, abdominal pain, and difficulties in defecation. The patient was consulted by an outpatient gastroenterologist, with abdominal ultrasound being unremarkable except for ballooning of the large intestine and mild prostate hyperplasia. The patient was then referred to an outpatient urologist and subsequently scheduled for intestinal endoscopy. Prostate-specific antigen came back within reference values, and the patient was referred for abdominal radiology, with computed tomography revealing a tumor formation at the level of the third and fourth lumbar vertebrae. Subsequent magnetic resonance imaging confirmed the tumor formation in the same area as an isointense tumor, sharply demarcated and suspected to be attached to a nerve root and with a diameter of 1.5 cm. The patient was referred to a neurosurgeon, with the neurological status being unremarkable; however, due to the tumor formation on imaging modalities, the patient was scheduled for spinal surgery.Intraoperatively, a firm, purple-pink, well-demarcated tumor, which was attached to a nerve root with a diameter of 1.3 cm, was visualized at the level of the third and fourth lumbar vertebrae and completely extirpated. Histopathology revealed a non-infiltrative tumor with nested to pseudopapillary growth but did not place a diagnosis, instead offering differentials such as schwannoma, meningioma, and spinal ependymoma.After surgery, the patient's clinical symptoms resolved completely within a couple of days, and the postoperative period was uneventful.Histopathology revealed a sharply demarcated, non-infiltrative tumor Figure . On highA classical differential in a tumor with the described morphology is predominantly that of ependymoma; however, based on the extramedullary location, this diagnosis seemed unlikely. Reticulin staining revealed significant fiber deposits intersecting the nests, where the epithelial membrane antigen (EMA), a highly specific marker expressed in ependymoma, did not show positivity, even in a dot-like pattern Figure  and 2B. The lack of EMA reaction, the pattern of reticulin fiber deposition, and the specifics of the S100 reaction excluded the diagnosis of ependymoma, with glial fibrillary acidic protein reaction coming back negative Figure  and exclAs per the morphology of the tumor and the spectrum of reaction on special stains and the immunohistochemical profile, the tumor was interpreted as a CENET, specified to be designated in the previous classification as a paraganglioma. As per the World Health Organization (WHO) classification of CNS tumors, the neoplasm was designated a WHO CNS grade 1. The patient was referred to the institution where the surgical procedure was performed for future management.As mentioned previously, CENET are rare neoplasms. Our case and other similar reports and series show that the principal histopathological differential diagnosis is ependymoma . DespiteClinical history can also suggest the neuroendocrine origin of the tumor in the rare cases when the tumors are secreting. In these instances, intraoperatively, typically, there is a surge in catecholamine excretion from the tumors, and a rapid and significant increase in systemic blood pressure generally is well-recorded .As per the designated WHO CNS grade of 1, CENET are clinically indolent tumors. However, several more extensive series and reports have depicted cases with recurrence and metastatic potential of these rare neoplasms . In casuOther, although acceptably rare, cases that may pose a differential diagnosis conundrum are secreting CENET, where the patient presents with catecholamine or other endocrine-related symptoms and the only site detectable is the cauda equina region ,17. In sAs the tumors are designated as WHO CNS grade 1, CENET are typically benevolent tumors, rarely progressing or recurring, except in cases of incomplete excision. Progression with metastatic dissemination is a casuistic feature of these exceedingly rare primary CNS tumors .Case report limitationsDue to the nature of the presented case, mainly the initial symptom analysis and imaging modalities being carried out in an outpatient setting and the surgical procedure, initial histopathological analysis of the tumor, the patient follow-up, and treatment after definitive histopathological diagnosis, our report has several weaknesses. Among these are the lack of correlation between the symptoms and the tumor's location, correlation with the imaging findings on computed tomography and magnetic resonance imaging to the exact location, imaging to gross size, and the comparison of the imaging characteristics and the gross appearance of the tumor itself. As such, the report's primary focus is on the histopathological findings, differential diagnosis, and approach to it. Furthermore, due to the unavailability of direct data from the surgical procedure, its type, possible complications, etc., and the follow-up of the patient at another institution, we cannot provide detailed data on patient recovery parameters and functional outcomes.CENET, previously referred to as paragangliomas, are rare primary CNS tumors with neuroendocrine differentiation occurring in the cauda equina and filum terminale region of the spinal cord. The tumors present with non-specific clinical symptoms, and imaging modalities typically offer little specific findings to differentiate them from other tumors common in this area. Histopathological diagnosis is challenging, with the principal differential diagnosis being that of ependymoma and paragangliomas metastatic to this region. As underlined by our case's histopathological findings, a careful approach must be carried out in tumors with such morphology so as to exclude other tumors with similar histopathological findings and apply a detailed panel to confirm nosological origin.


Primary diffuse large B-cell lymphoma of the orbit is a rare diagnosis that accounts for less than 1% of all non-Hodgkin's lymphoma (NHL) cases. We present here the case of a middle-aged woman with a past medical history of intellectual delay and hypothyroidism who presented with a large diffusely infiltrating mass of the left orbit. A biopsy of the lesion during the patient's hospitalization confirmed a diagnosis of diffuse, large B-cell lymphoma. Due to extensive local invasion, she was deemed a poor surgical candidate. While inpatient, she was started on systemic chemotherapy and discharged with close follow-up planned with the oncologic and surgical teams. Primary orbital lymphoma (POL) is a rare type of non-Hodgkin lymphoma that originates in the orbit or surrounding tissues. Non-Hodgkin's lymphoma (NHL) is a cancer that begins in the lymphatic system and commonly involves the lymph nodes; however, in about 40% of individuals, the primary lesion involves extranodal sites. Extranodal NHL typically presents as a constellation of primary organ pathologies with the most common of these sites being the gastrointestinal tract followed by the integumentary system and soft tissues .When considering the broad classification of NHL, diffuse large B-cell lymphoma (DLBCL) is the most common. As with other lymphomas, DLBCL has a predilection for the lymphatic system with the primary lesions of the orbit being exceptionally rare, accounting for less than 1% of all NHL cases . OrbitalA 56-year-old female with a past medical history of intellectual delay, mutism, and hypothyroidism presented to the emergency department (ED) with her mother for evaluation of left eye swelling. The patient was unable to communicate; therefore, medical history was obtained from the patient’s mother. The patient’s mother stated that for one year, she noticed gradual enlargement of what initially began as a small nodule over the medial aspect of the patient’s left eye. The patient’s mother stated that the lesion had recently started draining purulent fluid, which prompted her to bring the patient to the ED.In the ED, the patient’s vital signs were within normal limits and the laboratory analysis was unremarkable. Physical exam at this time was significant for a nonverbal, middle-aged female with an erosive, ulcerating mass to the left eye that had overlying erythema, edema, excoriations, and purulence Figure . The ophComputed tomography (CT) of the head in the ED demonstrated an infiltrative mass lesion originating in the orbit, measuring 8.7 cm x 6.0 cm x 9.0 cm with diffuse bony erosion of the walls of the left maxillary sinus through the left nasal cavity into the bilateral ethmoid air cells and the bilateral sphenoid sinus. The lesion was noted to be invading and eroding the adjacent skull base as well as the left carotid canal and the cribriform plate Figure . Out of Upon admission, the ophthalmology, oral and maxillofacial surgery, neurosurgery, and oncological teams were consulted and further imaging was obtained. MRI of the brain detailed epidural expansion of the lesion along the floor of the anterior cranial fossa (left more than right) with abutment of bilateral inferior frontal lobes. There was also epidural extension into the left middle cranial fossa inseparable from the underlying anterior frontal lobe Figures -5.Consulting teams recommended a punch biopsy of the lesion, which resulted in an atypical lymphoid infiltrate consistent with diffuse large B-cell lymphoma (DLBCL) (CD20: positive) Figure . FluoresStaphylococcus aureus, and the patient was committed to six weeks of IV antibiotics.Due to the expansion of the DLBCL into the epidural space, a lumbar puncture was performed, which resulted in an unremarkable CSF fluid analysis. A bone marrow biopsy performed during hospitalization had unremarkable flow cytometry and surgical pathology. Mycobacterial cultures of the lesion grew The extensive invasion of the patient's malignancy into her cranium made her a poor surgical candidate and, after an extensive multidisciplinary discussion, a decision was made to offer the patient chemotherapy. The patient's mother, the healthcare surrogate, was amenable to the plan, and the patient was started on a combination of cyclophosphamide doxorubicin, vincristine, solumedrol, and rituximab (R-CHOP). The patient tolerated two cycles of chemotherapy well while inpatient and was discharged with plans to follow up with oncology and ophthalmology.Unfortunately, according to hospital records, the patient missed multiple follow-up appointments and was reported to have passed away two months after the presented hospitalization. Outside medical records were obtained and did not detail any recent admissions or visits with providers at other institutions.Primary orbital lymphomas are a diverse group of tumors that are commonly characterized by their low-grade classification, with only about 16% being high-grade lymphomas. The most common type of primary orbital lymphomas are mucosa-associated lymphoid tissue (MALT) followed by follicular lymphomas, diffuse large B-cell lymphomas (DLCL), and mantle cell lymphomas . When coThe diagnosis of orbital lymphomas may be challenging, as the malignancy does not present with classic findings. On computerized tomography, these malignancies are typically characterized by a heterogeneous soft tissue density, which may have areas of calcifications and/or phleboliths. Advanced imaging with magnetic resonance commonly demonstrates an isointense T1 signal, bright T2 signal, and dark internal septations . AlthougIn the presented case, histological analysis of the orbital lymphoma resulted in DLBCL (CD20: positive). This POL subtype is one of the most commonly diagnosed and is associated with the most outcomes. A large cohort study, published in 2022, focused on determining the prognostic characteristics of DBCL. These researchers discovered that older age at the time of diagnosis and stage IV malignancies were two main characteristics that confer the worst outcomes [In a recent multicenter study evaluating treatment modalities in DLBCL POL, and resultant outcomes, it was found that there is notable intracenter and intercenter variability. Despite this, the most commonly utilized treatment modality was reported to be external beam radiation therapy (EBRT) followed by R-CHOP . In thisDiffuse large B-cell lymphoma is one of the most prevalent types of primary orbital lymphoma with limited case reports detailing this malignancy’s potential for local invasion into the central nervous system. This case emphasizes multiple diagnostic challenges of orbital lymphomas and why this may delay early diagnoses. In the presented case, as with many other cases of orbital lymphomas, the malignancy was not recognized promptly due to nonspecific symptoms. Another teaching point that this case reinforces is the importance of providing medical care for individuals with intellectual or developmental disabilities. This care requires a comprehensive and patient-centered approach tailored to the patient’s specific needs and circumstances in collaboration with the primary caregiver. We hope, through the presentation of this case, to emphasize this rare entity and the serious complications that can result.