A 74-year-old Caucasian woman presented with a large mass on her left distal radius, which had previously caused a fracture of the bone at this site and the palmar site that was treated with external fixation a year ago. The patient did not mention tumor-related family history and other neoplasms before the fracture of the distal radius. She noticed that the gradually growing mass had appeared after the fracture treatment. A thorough evaluation of the lesion confirmed the diagnosis of a large benign neurofibroma with distal radius impairment. The diagnostic and therapeutic procedure included the complete excision of the tumor and a six-week cast immobilization of the radius. On the final follow-up two years postoperatively, her clinical situation was satisfactory with no signs of recurrence. Although rare, isolated benign neurofibromas of enormous sizes are associated with bone damage. In our view, immediate surgical excision is crucial and enables total recovery postoperatively. Neurofibromas (NFs) are defined as benign peripheral nerve sheath tumors (PNSTs). PNSTs comprise about 5% and 2% of all tumors of the upper extremity in adults and children, respectively -3. The mFurther, bony involvement is extremely rare, especially in the upper extremities ,7. PatieHere, we report an uncommon case of a huge NF of the left median nerve associated with the destruction of the ipsilateral distal radius. In addition, we describe its clinical manifestation, the diagnostic workup, and the appropriate treatment.A 74-year-old Caucasian woman presented to our hospital with a mass in the left wrist Figure . RegardiThe magnetic resonance imaging (MRI) revealed a 4.5 cm × 6.5 cm × 6.5 cm, well-circumscribed mass with bone damage in both the ulna and the radius. The lesion showed a relatively homogeneous low signal, slightly lower compared to that of the adjacent muscles, on T1-weighted (T1W) images. No edema around the tumor was present, instead, there was a zone of adipose tissue surrounding the tumor Figures , 5. On TWe performed a biopsy before the complete surgical excision. For the final excision, a longitudinal incision centered over the tumor bulk was made, without releasing the transverse ligament of the carpal tunnel. The lesion was revealed in an eccentric position along the median nerve. A marginal tumor excision with preservation of the median nerve was achieved after careful surgical manipulations. After the complete excision of the mass, clear damage to the distal ulna and radius was seen Figures -9. The dThe resected tumor samples (bone and soft tissue) were sent to the pathology department for evaluation and diagnosis. Macroscopically, the specimens were gray in appearance with solid consistency and measured 2.5 × 7 cm with co-resected bones and soft tissues. Histologically, the soft tissue tumor cells were composed of curved and elongated nuclei admixed with fibroblasts in a collagen-rich matrix. The bone did not reveal pathology related to soft tissue tumor cells or other pathology. The final pathology report was consistent with a solitary localized benign neurofibroma Figure .Postoperatively, the patient underwent physiotherapy. On the follow-up X-ray imaging at one year postoperatively Figure , her cliThe precise pathogenetic mechanism underlying the development of NFs in the median nerve has not been fully elucidated ,9. ThereHistological examination remains a crucial step toward the final diagnosis ,7. The rThe size and the infiltration of the surrounding structures determine the precise clinical symptoms . The sigImaging studies are valuable for preoperative assessment. Plain radiographs are an initial step toward the diagnosis. This was also seen in our case as the patient had extended bone damage, which was identified on the radiologic examination. In general, ultrasonography (US) is a useful diagnostic method to differentiate between a benign and a malignant lesion . HoweverA challenging step in the treatment is the complete tumor excision and the simultaneous preservation of nerve function . RegardiOur patient had no complications at the two-year follow-up. Postoperative recovery and good prognosis in such cases depend on surgical skills and lesion patterns .The assessment and diagnosis of NFs remain challenging. The available evidence indicates that imaging features are a debatable topic regarding the diagnostic accuracy of nerve tumors. NFs are soft tissue lesions that cause bone damage on rare occasions. However, clinicians should consider them as a possible cause of bone damage. Finally, we believe that complete surgical excision of such tumors can provide a satisfactory outcome.


Schwannomas are relatively uncommon, benign, slow-growing neoplasms, which are derived from schwann cells that can arise from any cranial, peripheral, or autonomic nerves. The involvement of the palate is a rare presentation and hardly reported in the literature.Here, we report the case of a 39-year-old woman with a history of a foreign body sensation in the throat and difficult swallowing.Oral examination showed a smooth, non-tender, right-sided, soft palate mass. Computed tomography (CT) scan revealed a well-defined, non-enhancing, homogenous pedunculated soft tissue mass arising from the posterior edge of the right side of the soft palate.2 surgical laser. The mass was sent for histologic analysis, which confirmed the diagnosis of a benign schwannoma.The mass was excised completely under local anesthesia in the clinical setting using a COEventually, upon follow-up at six months post excision, no evidence of recurrence was detected. •A 39-year-old woman presented with a two-month history of right sided soft palate mass causing difficult swallowing.•The mass was completely excised in a clinical setting under local anesthesia using a CO2 surgical laser.•Histopathologic analysis confirmed the diagnosis of a benign soft palate Schwannoma.•After six months post excision, no evidence of recurrence was detected. They are derived from schwann cells, which are the sheath cells that cover nerve fibers ,3,4. AppIn this case report, we describe a 39-year-old female patient with a history of a foreign body sensation in the throat and difficult swallowing. She was found to have schwannoma of the soft palate.2A 39-year-old female presented to the outpatient clinic at King Hamad University Hospital in Al Muharraq, Bahrain, complaining of discomfort during swallowing associated with sensation of foreign body in the throat. She first noticed the mass two months prior to presentation. At that time, the mass was painless but gradually increasing in size. She was otherwise healthy and reported no history of smoking or alcohol consumption. No genetic or syndromic abnormalities were reported.2 surgical laser which resulted in no significant bleeding.Clinical examination of the intraoral cavity revealed a solitary, cystic, non-tender soft tissue mass that protruded over the right side of the soft palate . No regiGross histopathological analysis revealed a firm, pinkish tan mass measuring 30 mm in the maximum dimension with intact mucosal surface . MicroscImmunohistochemical (IHC) stains were performed. The neoplastic cells revealed strong immunoreactivity for S-100 protein, vimentin and CD31 . Glial fBased on the morphological and IHC profile findings, a final diagnosis of a benign soft palate schwannoma was made. The patient was completely asymptomatic during follow up appointment in our clinic after six months postoperatively, with healthy mucosa and no evidence of tumor recurrence during intraoral examination .Fig. 6On3Schwannomas (neurilemmomas) are benign nerve sheath neoplasms that can arise from cranial, peripheral, or autonomic nerves that contain schwann cells. They were first described by Verocay in 1908 ,3,4. TheIntraoral and palatal schwannomas are frequently slow-growing, solitary lesions. Multiple nerve schwannomas require further assessment for Von-Reklinghousen disease (neurofibromatosis type 1), while bilateral vestibular schwannomas raise the suspicion of neurofibromatosis type 2 ,12. DespClinically, these benign tumors are easily mistaken for other entities such as mesenchymal tumors  or epithelial tumors (pleomorphic adenoma)  , among oImaging modalities such as CT are useful during the initial assessment to determine the extent of the tumor and narrow down the differential diagnosis. In our case, the CT scan revealed a well circumscribed mass without direct invasion, hemorrhage, or calcification, yet the clinical diagnosis was still suspicious and confounded with other differentials. Similarly, Kun et al. , were abSchwannomas have four major histologic phenotypes: conventional, plexiform, ancient, and cellular variants. The most common type is the conventional schwannoma that shows a biphasic architecture with two main regions: Antoni A and Antoni B. Antoni A regions are more cellular with palisading nuclei surrounded by eosinophilic areas (Verocay bodies), whereas Antoni B regions consist of less cellular areas with a predominant loose and/or myxomatous stroma ,16. In oIHC examination was essential for confirming the diagnosis of schwannoma, and protein S-100 was the first protein to be immunostained during the evaluation of a suspected peripheral nerve tumor. Diffuse staining with CD-34 is rarely seen in schwannomas, as it shows some focal staining in noncellular (Antoni B) regions. Schwannomas also stain positively for Leu-7antigen, GFAP, and vimentin. In our case, using IHC examination with S-100 protein and vimentin revealed intense positivity in the cells of the mass, confirming its neural origin .2 surgical laser under local anesthesia in the clinic. After six months of follow-up, there was no evidence of recurrence (Schwannomas are benign tumors rarely undergoing malignant transformation . Completcurrence .4A proper multi-disciplinary approach is required to provide the best standard of care in case of head and neck tumors. Therefore, combined morphological and immunohistochemical investigations are necessary to attend such tumors and reach a diagnosis of schwannoma, like in our case.Complete surgical excision is the treatment of choice providing unlikely local recurrences.The case report was approved by the institutional review board at King Hamad University Hospital in Al Muharraq, Bahrain.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Alhanouf Alhedaithy: Writing - Original DraftAnwar Alsayed: Writing - Review & EditingKhalid Al-sindi: Writing - Review & EditingWaleed Janahi: Conceptualization, Resources, SupervisionAlhanouf AlhedaithyWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.None.


Cognitive status epilepticus is an uncommon form of focal status epilepticus presenting with a dysfunction of language, thinking or associated higher cortical functions. The absence of ictal manifestations can be misleading and delay a prompt diagnosis. Here we present two patients; one with amnesic and one with aphasic status epilepticus. Through these cases, we aim to highlight the value of EEG performance early in the diagnostic work-up and early antiepileptic drug initiation in cases where an epileptic disorder cannot be excluded. Focal status epilepticus (FSE) with or without an impairment of consciousness can be presented with motor or non-motor symptoms; the latter was formerly known as aura continua ,2. TypicIn the present study, we describe the cases of two patients with cognitive status epilepticus; the first suffering from amnestic and the second from aphasic status epilepticus. These cases address the difficulty of diagnosing such rare clinical entities.A 49-year-old right-handed female patient presented with an amnestic disorder that started upon waking. Three months prior, a similar incident was reported, which lasted for a day and was spontaneously resolved. A neurological examination revealed anterograde and autobiographical amnesia. The patient was afebrile and otherwise cooperative and relatively calm. The emergency brain non-contrast computed tomography (NCCT) was normal. Considering the patient’s personal history, we conducted an emergent scalp EEG, which revealed continuous spike-and-wave complexes 3–3.5 Hz/s over the left hemisphere, which consequently confirmed the diagnosis of amnestic status epilepticus A. No othA 48-year-old right-handed female patient presented with acute onset speech difficulties upon waking. During the previous two weeks, similar episodes with a shorter duration (few minutes) and a spontaneous remission were reported. Her past medical history included a chronic ischemic stroke with mild residual aphasia and right hemiparesis, essential hypertension, hyperhomocysteinemia and hypercholesterolemia. A neurological examination revealed receptive aphasia, right spastic hemiparesis and mild psychomotor agitation. The patient was afebrile. A brain NCCT revealed a hypoattenuation of left temporal lobe in keeping with a chronic stroke. The following day, a scalp EEG was performed to exclude symptomatic epilepsy. No other ictal features were noticed. Continuous periodic epileptiform discharges (PEDs) on the left temporal region were noted, confirming the diagnosis of focal aphasic status epilepticus A. After Based on ILAE epilepsy classification, the term focal status epilepticus (FSE) with or without an impairment of consciousness is used to describe the entity formerly known as partial status epilepticus . The typCognitive FSE presents with a dysfunction of language, thinking or associated higher cortical functions . These sPatient One presented with acute onset memory deficits and underlying focal spike-wave complexes. Amnestic status epilepticus is a rare form of cognitive FSE. The differentiation from transient global amnesia (TGA) can be particularly challenging. TGA presents with an acute onset global (retrograde and anterograde) memory deficit lasting less than 24 h. Other cognitive functions are typically normal. A single, definite etiology has yet to been determined. The underlying pathophysiologic processes that have been proposed include vascular, migraine, epileptic and psychogenic mechanisms. Transient epileptic amnesia (TEA) can be presented as TGA. Typically, TEA episodes are shorter, recurrent and, occasionally, accompanied by ictal manifestations such as oral automatisms or hallucinations . From a Patient Two presented with an acute onset aphasia, which typically can be seen in cerebrovascular events. Rarely, an acute onset aphasia can be the manifestation of epileptic activity. In the absence of typical paroxysmal seizure symptoms, the differential diagnosis solely on a clinical basis can be improbable. Both ictal aphasia and aphasic status epilepticus vary in phenomenology (paraphasia to mutism) and EEG findings . The iniIn conclusion, our cases highlight the difficulties of diagnosing cognitive status epilepticus on a clinical basis and stress the value of performing an EEG early in the diagnostic work-up.


Extracorporeal shock wave lithotripsy has been confirmed as the least invasive and the most widely used treatment for kidney and ureteral stones. However, as with any other type of therapy, potential complications do exist.Herein, we describe a 55-year-old male patient who developed symptoms of acute pancreatitis one day after extracorporeal shock wave lithotripsy for left renal stones. The patient used to manage himself with NSAIDs till he presented to the emergency department with severe epigastric pain and tenderness due to giant pancreatic pseudocyst formation. The pseudocyst was treated by endoscopic cystogastrostomy using metallic stent with uneventful recovery. In addition, we extensively reviewed all available literature studies of pancreatitis and pancreatic pseudocyst occurring after extracorporeal shock wave lithotripsy. We summarized all reported cases and presented them in a comprehensive table.Post ESWL acute pancreatitis is a rare clinical entity with only 11 reported cases. In all cases, abdominal pain was the most common symptom that occurs in less than 24h following ESWL treatment. So it should be considered in the differential diagnosis of acute abdominal pain after ESWL.Although ESWL is generally considered safe and effective treatment; however, major complications have been reported to occur in less than 1% of patients. One of the extremely rare complications is the development of pancreatitis and pancreatic pseudocyst. •ESWL is a safe and effective treatment modality.•Serious complications have been reported in 1% of patients.•Post-ESWL acute pancreatitis is extremely rare.•Only 5 cases of pancreatic pseudocyst after ESWL have been reported.•Endoscopic cystogastrostomy approach is cost-saving, can avoid surgical complications, and offer an early hospital discharge. ESWL isPancreatic pseudocyst (PP) is a peripancreatic fluid collection that usually develops and matures 4–6 weeks after an episode of chronic pancreatitis, acute pancreatitis, or disruption in the pancreatic duct such as blunt, penetrating trauma, or injury during surgeries. It is mainly characterized by a well-defined inflammatory wall with a homogeneous fluid content that rich in amylase enzyme in the absence of tissue necrosis. A pseudocyst with a major diameter equal to 10 cm or more is called a giant pseudocyst .Development of acute pancreatitis after ESWL is an extremely rare condition with only 11 cases reported in our literature, out of which only 5 cases developed into pancreatic pseudocyst 2A 55-year-old male was admitted to our hospital complaining of intermittent left-sided abdominal pain for two weeks. Vital signs were within normal and examination was unremarkable except for mild abdominal tenderness in the left upper quadrant. Urine analysis revealed mild hematuria, and abdominal ultrasound was performed which showed two stones in the lower pole of the left kidney measuring about 4 and 12 mm with an absence of hydronephrosis and normal right kidney. As a treatment for his condition, extracorporeal shock wave lithotripsy (ESWL) was performed with a total of 3,000 shocks were delivered at 15 kv. The patient tolerated the procedure well, and there were no complications during the procedure.One day after ESWL, the patient started complaining of mild to moderate epigastric pain radiating to the back, the pain decreased with ibuprofen administration and the patient didn't seek medical advice. About seven weeks after ESWL, the patient presented to the emergency department with severe epigastric pain associated with nausea, vomiting, and early satiety. The patient had free past medical and surgical history and he is off medication and no history of alcohol consumption. On general examination, he was not icteric or feverish and an abdominal exam revealed epigastric fullness with severe tenderness. Laboratory investigations revealed markedly elevated serum amylase (6320 U/L). Complete blood count (CBC), liver enzymes, serum electrolytes, and lipid profile were within normal limits. An abdominal CT scan with contrast showed a giant multiseptated cyst measuring about 10 × 11 cm occupying the body and the tail of the pancreas . Few smaEndoscopic ultrasound- (EUS-) guided drainage was performed as a therapeutic procedure for giant symptomatic pseudocyst using a Pentax linear echoendoscope (EG-3870UTK 3.8). On the EUS, there was a huge pancreatic pseudocyst with internal septation . The patOn 4 weeks of follow-up, the patient reported disappearance of symptoms. Repeated EUS showed resolution of the pseudocyst and SPAXUS stent was removed without complications  has been widely used for the treatment of upper urinary tract stones since it was first introduced in 1980. Also, it is sometimes used in the treatment of pancreatic and bile duct stones . ESWL isAdjacent organ injury was reported to occur in less than 1% of patients undergoing ESWL procedure with serious complications include perirenal hematoma, urosepsis, pulmonary contusion, new-onset diabetes mellitus, cardiac arrhythmia, rupture of aortic aneurysm, colonic and splenic injury, venous thrombosis, and severe acute pancreatitis that may lead to pancreatic pseudocyst formation .Multiple theories describe how ESWL can cause acute pancreatitis and other tissue damage. One theory proposes that cellular damage caused by cavitation and shear forces produced by the passage of shock waves as they pass through the body may cause pancreatic injury after ESWL. These shock waves may cause hematoma formation and microvascular pancreatic damage . AnotherSome studies suggest that the delivered number and intensity of shock waves could be a possible etiological factor . AccordiAlthough the exact mechanism of pancreatitis after ESWL is still unclear. However, the absence of any of the predisposing factors such as gall stone, alcohol, hypercalcemia, hypertriglyceridemia, and prior abdomen surgery, support that ESWL is the cause of pancreatitis in our case.The course of acute pancreatitis following ESWL is variable, most of the patients resolved with conservative management that includes nasogastric tube insertion, bowel rest, parenteral nutrition, intravenous antibiotics. However, some can develop necrotizing pancreatitis requiring necrosectomy, while others developed pseudocysts as in our case Traditionally, EUS-guided drainage could only be performed using plastic stents like double pigtail stent (DPS) or a fully covered self-expanding metal stent. Recently, a dedicated device, a lumen-apposing metal stent (LAMS), has been developed as an alternative for pancreatic fluid collection. Lumen-apposing metal stents like AXIOS and Niti-S SPAXUS stents with their large diameter, short length, and bi-flanged shape have less risk of stent migration, perforations, leakage, occlusion, and superimposed infection as compared with the plastic stent . MoreoveThe main drawback of LAMS that it was found to be associated with a higher bleeding rate when compared to the plastic stent, including late bleeding at 3–5 weeks after stent insertion which is mainly caused by stent friction to surrounding vasculature around the necrotic cavity promoting pseudoaneurysm formation and subsequent bleeding. This prompted gastroenterologists to change their practice of repeating imaging at 3 weeks to assess the cavity resolution instead of 6 weeks, followed by stent removal if the fluid collection is resolved or placing plastic double pigtail stent inside the LAMS [4ESWL is a safe, effective, and non-invasive procedure; However, serious complications to adjacent organs rarely can occur. Acute pancreatitis should be considered as a differential diagnosis in patients presenting with acute abdominal pain following extracorporeal shock wave lithotripsy, as prompt diagnosis and essential treatment can prevent significant morbidity and death.The study is exempt from ethical approval in our institution.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Hazem A. Ashhab diagnosed and treated the patient. Hussam I. A. Alzeerelhouseini, Yousef S. Abuzneid: Study design and writing the manuscript. Hazem A. Ashhab, Hussam I. A. Alzeerelhouseini: Writing the literature, Review & editing the manuscript.Dr. Hussam I. A. Alzeerelhouseini.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.There is no conflict of interest.


Follicular lymphoma (FL) is one of the most common types of non-Hodgkin lymphoma (NHL). The gastrointestinal tract is the most involved extra-nodal site of NHL. Primary duodenal FL (DFL) is a rare entity with only a few reported cases. It mainly involves the second part of the duodenum and has an excellent prognosis. We report the case of a 74-year-old man who underwent esophagogastroduodenoscopy. Endoscopic findings revealed multiple small whitish mucosal nodules which were detected around the major duodenal papilla. Biopsy of these lesions was compatible with grade I FL. Further investigation failed to demonstrate any evidence of nodal or systemic involvement; thus, the clinical staging was stage I, according to the Lugano staging system. A “watch and wait” policy was chosen. Neither lesion aggregation nor lymphadenopathy was noted during the 5-year follow-up period. In conclusion, this was an uncommon case of DFL with an indolent nature and excellent prognosis. However, further studies are needed to clarify the characteristics, prognosis, and therapeutic approach. Follicular lymphoma (FL) is a neoplasm of germinal center B cells and usually involves the lymph nodes. FL is one of the most common types of non-Hodgkin lymphoma (NHL) with high incidence rates in Europe and the United States. Moreover, it is the second most common type of NHL in Japan , 2. The A 74-year-old male patient underwent esophagogastroduodenoscopy (EGD) for the evaluation of epigastric discomfort. He had no relevant medical history. Physical examination was unremarkable, and there was no evidence of hepatosplenomegaly or superficial lymphadenopathy. All laboratory findings, including lactate dehydrogenase, were within normal ranges. Endoscopically, multiple small whitish mucosal nodules were detected around the major duodenal papilla . Helicobacter pylori was detected by the rapid urease test or histological findings of random gastric biopsy. Colonoscopy revealed no abnormality. A complete enteroscopy, using double-balloon enteroscopy or video capsule endoscopy, was proposed, but it was not performed as the patient refused to undergo the procedure. Computed tomography (CT) of the neck, chest, abdomen, and pelvis along with bone marrow examination were performed but failed to demonstrate any evidence of nodal or systemic involvement. Finally, a diagnosis of primary FL of the duodenum was made. The clinical staging was considered to be stage I, according to the Lugano staging system. After discussion with the patient, a “watch and wait” policy was chosen, and no local or systemic treatment was given. EGD and CT were performed annually. Neither lesion aggregation nor lymphadenopathy was noted during the 5-year follow-up period.Biopsy of these lesions revealed atypical lymphoid aggregation composed of a germinal center of mainly uniform, small cleaved B-lymphoid cells without tingible body macrophages. The tumor cells were immunopositive for CD20, CD10, Bcl-2, and Bcl-6. Ki67 reactivity rate was low. CD23 positive follicular dendritic cells were seen at the periphery of the neoplastic germinal center . FurtherFL is one of the most common types of NHL . HoweverThe most frequently involved sites are the second part of the duodenum 81%), particularly the peri-ampullary area, followed by the jejunum (40%) , 6. Eigh1%, partiPathologically, DFL shows features similar to a nodal lymphoma, which is characterized by several well-circumscribed germinal centers packed together with centrocytes and rare centroblasts with no visible tingible body macrophages and without mantle zones. The sheets of small lymphoid cells with an irregular nuclear contour are usually present outside the follicular structures, and the lymphoma usually involves the mucosa and submucosa. The main differential diagnosis is a reactive germinal center. Unlike reactive germinal centers where the lymphoid follicles are composed of a heterogeneous population of centrocytes, centroblasts, tingible body macrophages and dendritic cells, the normal immunoarchitecture of a germinal center is highlighted by the lack of expression of BCL2 within the germinal center B cells . The neoBCL2) translocation, but the gene expression pattern of DFL shares more similarities with that of H. pylori-associated gastric MALT lymphoma than with that of nodal FL. According to the validation of microarray data by quantitative reverse transcription-polymerase chain reaction for CCL20 and MADCAM1, DFL and MALT lymphoma have increased expressions of CCL20 and MADCAM1, contrary to the low levels expressed in nodal FL. In a study using array comparative genomic hybridization, although a duodenal-type FL is positive for the IGH/BCL2 translocation, it has a lower frequency of other genetic aberrations than nodal FL q32;q21)(IGH/2;q21(IGHnodal FL .In contrast to other extranodal involvements which usually occur in disseminated nodal diseases, DFL seems to share some common characteristics with nodal diseases, such as an indolent nature and excellent prognosis. DFL rareSeveral treatment options for GI-FL have been proposed, such as surgical resection, chemotherapy, and radiation therapy; however, no consensus regarding the choice of treatment for DFL has been established yet. The clinical course of DFL tends to be indolent, and it has an excellent long-term survival rate, even with local recurrence in the intestine, and low risk of progression to a nodal disease . A recenIn conclusion, we present the case of a 74-year-old male patient with primary DFL who had classical endoscopic and histologic results. The patient also underwent staging investigations, including laboratory diagnosis, whole-body CT, and bone marrow biopsy to exclude an involvement of nodal FL, which had already occurred in the advanced stage. No evidence of nodal or systemic involvement was identified. The patient was assigned to a “watch and wait” policy and showed excellent outcomes during the follow-up. However, further studies are needed to clarify the characteristics, prognosis, and therapeutic approach of this rare entity.


Epstein-Barr virus-associated smooth muscle tumors (EBV-SMT) are rare, virally-induced malignancies that occur almost exclusively in immunocompromised individuals. We report a very rare case of a dura-based EBV-SMT with superimposed local cryptococcal infection.An adult male with a history of untreated acquired immunodeficiency syndrome presented to our hospital with worsening headaches, diarrhea, and diffuse myalgias.Staphylococcus aureus and Cryptococcus neoformans serum antigen. Magnetic resonance imaging revealed 2 adjacent enhancing masses in the right temporal lobe, perilesional edema, and mass effect of the right lateral ventricle. Histological examination and immunohistochemical stains of the surgical specimen were consistent with EBV-SMT. Cryptococcus organisms were identified within the neoplasm.Blood cultures were positive for methicillin-resistant The patient underwent complete tumor resection, received an extended course of amphotericin and flucytosine, and was restarted on antiretroviral therapy.The patient was discharged from the hospital with no focal neurological deficits.Epstein-Barr virus associated smooth muscle tumors are rare malignancies that occur in immunocompromised patients. Prognosis is largely dependent on immune reconstitution and treatment of concomitant infections. They are most commonly described in persons infected with human immunodeficiency virus (HIV) or treated with immunosuppressive agents following organ transplant. EBV-SMTs are histologically distinct from classic smooth muscle tumors. In contrast to classic smooth muscle tumors, EBV-SMT histology does not correlate well with clinical outcomes.Opportunistic infections are common in patients with acquired immunodeficiency syndrome (AIDS), but their concomitant incidence with EBV-SMT is not well documented. To our knowledge, we describe the first report of a cryptococcal intracranial infection superimposed on a dural EBV-SMT in an HIV-positive patient.2Staphylococcus aureus (MRSA) and Cryptococcus neoformans serum antigen; therefore, intravenous antibiotics and antifungals were initiated soon after admission.A 42-year old male with a several-year history of AIDS, untreated within the last year, and a new diagnosis of a brain mass 3 months prior presented to our institution with worsening headaches, diarrhea, and diffuse myalgias. Previous workup did not detect infection with Coccidiodes, Histoplasma, Cryptococcus, or Human Polyoma Virus 2. Physical examination did not reveal any focal neurological deficits. On admission, his CD4 count was <40 cells/mL  and viral load was 20,900 copies/mL. Blood culture was positive for methicillin-resistant Magnetic resonance imaging revealed a 5 cm enhancing and necrotic mass in the right temporal lobe with perilesional vasogenic edema causing effacement of the adjacent right hemispheric sulci, mass effect on the right lateral ventricle, and a 5 mm right to left midline shift. An adjacent 1.5 cm lesion was also observed. Given the patient's HIV-associated immunocompromised state and cryptococcemia, the differential for these intracerebral lesions included lymphoma, cryptococcoma, brain abscess, syphilitic gumma, tuberculoma, and toxoplasmosis.The tumor was resected via open craniotomy using standard neurosurgical techniques. A small amount of fluid present in the center of the tumor was cultured. The tumor was microscopically dissected from its tentorial attachment at the transverse sigmoid junction and, after the entire tumor was resected, hemostasis was obtained. Standard closure was performed.Microscopic sections stained with hematoxylin and eosin showed a neoplasm with smooth muscle morphology, featuring a relatively monomorphic population of compact spindle cells arranged in long intersecting fascicles Fig. A. ProlifThe patient awoke from surgery without any neurological deficits, and postoperative imaging demonstrated gross total resection. The patient later complained of persistent headaches. Lumbar puncture was performed on postoperative day (POD) 7, which revealed an opening pressure of 28 mm Hg for which a high-volume tap was performed. Due to continued symptoms of increased intracranial pressure, repeated lumbar punctures were performed on PODs 14 and 20 with opening pressures of 17 mm Hg and 28 mm Hg, respectively. After an unsuccessful attempt at lumbar puncture on POD 25 the patient refused any additional attempts despite continued symptoms.His hospital course was complicated by persistent MRSA bacteremia, femoral osteomyelitis, and acute pyelonephritis secondary to MRSA bacteremia. Amphotericin and vancomycin were continued postoperatively, and flucytosine was added to the regimen on POD 5. Anti-retroviral therapy was held until POD 17 due to concerns regarding the risk of immune reconstitution inflammatory syndrome with active CNS cryptococcal infection. The patient was discharged home on POD 51 and he did not present for further follow-up.3,5 and novel expression of the EBV receptor on smooth muscle cells of AIDS patients has been hypothesized as a likely mechanism for viral entry.EBV-SMTs are rare neoplasms that may arise in a variety of tissues and organs in persons with immunodeficiency, such as HIV-infected individuals, or immunosuppression, such as in transplant patients. Although the mechanism of EBV-induced neoplastic transformation of smooth muscle cells is still under investigation, the observation of small EBV-SMTs occurring around blood vessels has led some authors to suggest a possible viral tropism for vascular smooth muscle  Distinct lesions are thought to represent separate infection events by different EBV clones, rather than metastases of a primary lesion. Because of this multifocal nature, immune reconstitution is highly recommended to reduce further opportunities for EBV-induced neoplastic transformation of smooth muscle tissue.At the time of diagnosis, approximately half of all patients with EBV-SMTs have multiple lesions, which are almost always multifocal. Total resection is recommended in patients with a mass effect, as occurred in our case, or focal deficits. A greater extent of resection is associated with a survival benefit, particularly in those with intracranial invasion, likely due to the relief of the mass effect or cranial nerve dysfunction. Adjunctive treatment options include radiotherapy, which is more often used in HIV/AIDS patients, or chemotherapy, which is typically used in postoperative transplant patients. In our case, intravenous antifungal agents were also used for the treatment of CNS cryptococcal infection and cryptococcemia.In the setting of HIV, EBV-SMT is most frequently found in the CNS and surgical excision is the mainstay of treatment for these tumors.,6 There are few reports of disseminated cryptococcal infection or cryptococcal meningitis occurring concomitantly in a patient with EBV-SMT(s) of the CNS.–9 To our knowledge, there has not been any previously described cases of EBV-SMT with infectious organisms present within the tumor matrix, such as seen in this case.Understanding the natural history of EBV-SMT is complicated by the common occurrence of opportunistic infections in this population. In as many as 90% of patients with EBV-SMT, death is secondary to opportunistic infections rather than tumor burden.4We report a case of a dura-based EBV-SMT with superimposed local cryptococcal infection, which, to our knowledge, has not been previously described in the literature. Despite the relatively indolent course of extracranial EBV-SMT, surgical intervention with an attempt for maximal total resection is recommended for individuals with mass effect or focal CNS deficits. Immune reconstitution and aggressive treatment for concomitant infections are paramount. Despite its rarity, EBV-SMT should be considered in immunodeficient or immunosuppressed patients presenting with CNS mass.The authors  organized the order of the visits of this patient and interpreted the results. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.Conceptualization: Sam Tavakoli, Michael McGinity, Andrea Gilbert.Data curation: Sam Tavakoli.Investigation: Sam Tavakoli.Project administration: Michael McGinity, Andrea Gilbert.Supervision: Michael McGinity.Writing – original draft: Kaylyn Rose Barrett.Writing – review & editing: Kaylyn Rose Barrett, Sam Tavakoli, Andrea Gilbert.


The exact incidence of small bowel obstruction (SBO) due to congenital adhesions remains unclear. Herein, we report a 59-year-old male who appeared in the emergency department with diffuse abdominal pain associated with vomiting. The patient reported no previous medical or surgical history. Clinical examination revealed a soft, distended abdomen and diffuse tenderness. Computed tomography indicated a close loop obstruction. A congenital band extending from mesentery to ileum and causing an internal hernia was identified via a midline incision. The band was ligated and divided. There is no difference in the clinical presentation, and the initial work-up of SBO on account of congenital adhesions was compared to other bowel obstruction causes. Surgical exploration is crucial for the diagnosis and treatment of congenital adhesions. Although laparotomy is considered the cornerstone of surgical management, laparoscopy has emerged as a feasible and safe alternative for the diagnosis and treatment of these congenital bands.  Congenital adhesions are infrequent in children and is rare in adults. Ileum is the commonest site of congenital bands, followed by colon, mesentery, omentum, peritoneum, jejunum as well as every site of the gastrointestinal tract, including the abdominal organs and peritoneum .There are no differences in the clinical manifestation and initial work-up of small bowel obstruction (SBO) due to congenital bands when compared to other causes of SBO . PhysicaTo the best of our knowledge, 57 cases of SBO due to congenital bands in adults have been reported in the literature until now. Here, we report the case of a 59-year-old male who was diagnosed with SBO due to a congenital adhesion.A 59-year-old-male visited the emergency department with a history of diffuse abdominal pain in the previous 6 h. The pain was described as colicky, and it was associated with vomiting. The patient reported no previous medical or surgical history. Abdominal examination revealed a soft, distended abdomen, tympanic on percussion, diffuse tenderness on palpation and positive bowel sounds. No rebound pain or muscle guarding were revealed by the physical examination.Vital signs were as follows: blood pressure (BP): 163/93 mmHg, heart rate (HR): 80/min, respiratory rate (RR): 14/min, SO2: 99% and temperature (T): 36.5°C. Laboratory studies were unremarkable. A contrast-enhanced CT of the abdomen was performed, and it showed distended jejunal and ileum loops with a transition point in the right iliac fossa after which ileal loops, as well as the large bowel, were collapsed. The small bowel feces sign was also observed. The CT of the abdomen corroborated the diagnosis of SBO and indicated a close loop obstruction .The patient was then transferred to the operating room for exploratory laparotomy via a midline incision. A congenital band obstructing the ileum was observed. This anomalous band extending from mesentery to ileum caused a small window through which internal herniation of the small bowel and obstruction occurred. No signs of bowel ischemia or peritonitis were noted. The band was ligated and divided. The patient recovered uneventfully, and he was discharged after 3 days.Adhesive SBO is a frequent clinical problem worldwide that results in hospitalization and, quite often, in surgical exploration . TouloukDespite being infrequently in children  and rareAdhesive SBO manifests the clinical symptoms and signs of SBO regardless of the etiology. Occlusion occurs either from the small bowel’s compression due to these bands or trapping of the small bowel loops between the band and the mesentery . The cliLaboratory studies that might indicate peritonitis include elevated white blood cell count and c-reactive protein, though these tests’ sensitivity and specificity are relatively low. Plain X-rays are non-specific, with a sensitivity of 70% in the diagnosis of SBO. Typical features encompass the distention of small bowel loops, multiple air-fluid levels and gas absence in the colon. Plain X-rays can also detect pneumoperitoneum secondary to bowel perforation , 9. CT sSurgical exploration is the cornerstone of the management of congenital adhesions causing SBO as it is the only way to establish the final diagnosis and treatment . In receInclusion criteria for laparoscopic approach encompass mild abdominal distention, a proximal obstruction, a partial obstruction and an anticipated single-band obstruction . The pre


We aim to report a patient with vertebral brown tumor in the context of a primary hyperparathyroidism presented by shoulder pain. This is the first report of C5 brown tumor involvement in a primary hyperparathyroid patient and emphasizes the consideration of cervical vertebral evaluation in patients with persistent shoulder pain. This study emphasizes the consideration of cervical pathologies in patients with shoulder complaints. Cervical brown tumor is a rare entity but can be easily treated if diagnosed early. The prevalence of brown tumor is up to 5% in primary and 13% in secondary hyperparathyroidism.2A 46‐year‐old man was referred to our clinic complaining of neck pain for 8 months. Early in the course of the disease, his cervical plain X‐ray was normal. At that time, he also had a normal cervical MRI report and rheumatologic workup. Incidentally, a high level of calcium  and low level of phosphate  was detected. Upon further workup, it was determined that he had a high level of parathyroid hormone , normal range 14.5–87.1 pg/ml) and serum alkaline phosphatase , normal range 80–360 U/L). He underwent a neck ultrasound that showed a lesion in favor of parathyroid adenoma (lower pole of left parathyroid lobe). His parathyroid adenoma was resected. He was recommended to undergo neck physiotherapy. Our patient experienced exacerbation of his neck pain and radiation of the pain to his left shoulder after starting physiotherapy. He was visited by a shoulder surgeon. A cervical plain X‐ray and CT scan was performed. The neck X‐ray revealed a collapse in the C5 vertebrae . Regarding previous reports of spinal brown tumor, the most frequent neurologic finding was sensory (pain or paresthesia) in primary hyperparathyroidism and motor weakness in secondary hyperparathyroidism. Similarly, the main complaint of our case having primary hyperparathyroidism was neck and shoulder pain. It merits attention that the lesion may also present itself with signs and symptoms of hypercalcemia due to the underlying hyperparathyroidism including the classis tetrad “kidney stone, painful bones, abdominal groans, psychic moans”, polyuria, and urolithiasis.The lesion is associated with increased parathyroid hormone, increased level of calcium and alkaline phosphatase, and decreased level of blood phosphate. However, as previous papers reported, the level of calcium may be normal in known cases of brown tumor due to accompanied vitamin D deficiency.In plain X‐ray and CT scan, brown tumor is found as a lytic lesion. In the magnetic resonance imaging (MRI), it has low signal intensity on T1 and high/low signal intensity on T2‐weighted MRI images.Occasional episodes of hemorrhage within the brown tumor and its rich vascularity give the lesion its characteristic brown appearance. Tissue biopsy of the lesion reveals peritrabecular fibrosis, hemosiderin deposits, and multinucleated giant cells. Evidence of atypia or anaplastic cells in the biopsy rules out the diagnosis of osteoclastoma.Besides osteoclastoma, giant cell tumor and aneurismal bone cyst should be considered as a differential diagnosis in single lytic bone lesions and Paget's disease, multiple myeloma/metastasis in multiple lytic bone lesions. The giant cells have a more even distribution in giant cell tumor compared with the osteoclastoma. Also, hemosiderin deposits in the tissue biopsy and increased level of PTH are in favor of osteoclastoma. The aneurysmal bone cyst has a cystic nature with a possible fluid–fluid level in radiography. Aneurysmal bone cyst affects younger individuals (10–20 years of age).Treatment of hyperparathyroidism causes the brown tumor to regress and remineralize. However, as noted in our patient, spinal brown tumors if associated with vertebral fracture or neurologic symptoms will need an emergent spinal decompression in addition of treating the hyperparathyroidism. After spinal decompression, instrumentation and spinal fusion are performed in cases of large lesions affecting at least two vertebrae or those complicated with vertebral fracture.As brown tumor is rarely reported to involve cervical spine, this report on a complicated missed case of cervical brown tumor highlights the importance of early diagnosis and treatable nature of the lesion. However, higher level of evidence may be still needed to define its best management.4Brown tumor rarely affects the spinal column. However, as this clinical entity is preventable and treatable by diagnosing and managing hyperparathyroidism, it merits to be considered whenever a lytic vertebral lesion in encountered. This case report emphasizes the possibility of dangerous neurologic condition when a spinal brown tumor is missed and mismanaged.“The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.”B.M conducted the surgery and supervised preparing the manuscript. F.V literature reviewed and wrote the manuscript. S.B edited the manuscript and collected the patient's data. S.H.S edited the manuscript.The Ethics Committee Board of Tehran University of Medical. Sciences (TUMS) declared no ethical concern in this study.The authors are accountable for all aspects of the work in ensuring that questions related to accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures in studies involving human participants were in accordance of ethical standards of the institutional and/or national research committees and with Helsinki declaration (as revised in 2013). Written informed consent was obtained from the patient for publishing the case report and any accompanying images.


Multiparametric MRI (mpMRI) of the scrotum has been established as a useful second‐line diagnostic tool for the investigation of scrotal diseases. Recently, recommendations on clinical indications for scrotal MRI were issued by the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology.To update current research on when to ask for an MRI of the scrotum.PubMed database was searched for original articles and reviews published during 2010–2021.Eighty‐three articles fulfilled the search criteria. Scrotal MRI is mainly recommended after inconclusive US findings or inconsistent with the clinical examination and should be asked in the following cases: differentiation between intratesticular and paratesticular lesions (in rare cases of uncertain US findings), characterization of paratesticular and intratesticular lesions (when US findings are indeterminate), discrimination between germ cell and sex cord‐stromal testicular tumors, local staging of testicular malignancies (in patients planned for testis‐sparing surgery), differentiation between seminomas and non‐seminomatous tumors (when immediate chemotherapy is planned and orchiectomy is delayed), assessment of acute scrotum and scrotal trauma  and detection and localization of undescended testes (in cases of inconlusive US findings). Although preliminary data show promising results in the evaluation of male infertility, no established role for mpMRI still exists.Multiparametric MRI of the scrotum, by assessing morphologic and functional data represents a valuable problem‐solving tool, helping to improve our understanding on the nature of scrotal pathology and the process of spermatogenesis. The technique may improve patient care and reduce the number of unnecessary surgical procedures. An accurate differentiation of the nature of scrotal lesions, especially lesions of small size is not always possible, based on sonographic features.Multiparametric MRI (mpMRI) of the scrotum has emerged as a valuable supplemental technique for the investigation of scrotal pathology.Recently, the Scrotal and Penile Imaging Working Group (SPIWG) appointed by the board of the European Society of Urogenital Radiology (ESUR) has produced recommendations on clinical indications for scrotal MRI, based on literature published before 2016 and combined expertise of the group.In this review, we summarize current research on when to ask for an MRI of the scrotum.2Starting in January 2021, a structured search using PubMed database was performed and included all relevant original articles and reviews, published in and after 2010. The search used the following key word combinations: [(SCROTUM) OR (SCROTAL) OR (TESTICLE) OR (TESTICULAR) OR (PARATESTICULAR)] AND [(MRI) OR (Magnetic Resonance Imaging)] combined, depending on the specific domain of interest, with [(TUMOR) OR (TUMORAL) OR (CANCER) OR (MASS) OR (NEOPLASM)]; [(TRAUMA) OR (ACUTE) OR (TORSION) OR (EMERGENCY)]; [(CONGENITAL) OR (UNDESCENDED) OR (DESCENT) OR (NONPALPABLE)]; [(INFERTILITY) OR (FERTILITY) OR (STERILITY) OR (INFECUNDITY) OR (IMPOTENCE)]. Data extraction was independently performed by two reviewers (M.D. and G.E.), and any disagreement was discussed with a third reviewer (L.M.).All papers published on human subjects were included. Citations and references of the retrieved studies were used as additional sources. Case reports, editorial comments, conference abstracts, and short communications were excluded.3n = 584; acute scrotum, n = 193; undescended testes, n = 178; and infertility, n = 151). Ultimately, 83 articles were deemed relevant and used as the literature basis of this review .The literature search found a total of 1106 articles , and positive predictive value (PPV) of 100%, each, in a study including 84 patients with suspected scrotal masses.Paratesticular solid tumors are rare and more often benign, with an incidence of malignancy approximately of 3%. Accurate characterization of the nature of paratesticular lesions is of outmost importance to allow planning of a conservative treatment in benign lesions, such as surveillance, excision, or TSS. The US characteristics of paratesticular tumors are usually overlapping, and therefore, scrotal MRI is strongly recommended as a valuable supplemental technique, to define lesion location and extent and to suggest a possible histologic diagnosis.Although the sonographic diagnosis of an epididymal cyst or a tunica albuginea cyst is often straightforward, concerns may arise in the presence of complex cysts. In these cases, absence of enhancement on MRI confirms an avascular mass and the diagnosis of benignity. MRI with multiplanar imaging also helps in suggesting lesion location.When differentiation between an adenomatoid tumor and a peripheral intratesticular mass is ambiguous on US, scrotal MRI is highly recommended to suggest paratesticular origin. Surgery in paratesticular adenomatoid tumors includes intraoperative frozen section biopsy and local resection, whereas in intratesticular adenomatoid tumors, TSS is planned.MRI is helpful to suggest the paratesticular location and the benign nature of fibrous pseudotumor. Sonographic findings of this benign lesion are usually non‐specific and may guide to an unnecessary radical orchiectomy. Lesion hypointensity on both T1WI and T2WI, with slow but persistent enhancement, characteristics for the presence of fibrous tissue allows for an accurate diagnosis. Local excision and frozen section confirmation may be recommended, following scrotal MRI.US is not always suggestive of the diagnosis of paratesticular lipoma, as a hyperchoic appearance cannot be easily differentiated from other paratesticular lesions, including lymphadenopathy, inguinal hernia, or liposarcoma. Moreover, lipomas may appear with variable echogenicity on sonography. MRI provides a specific diagnosis, as the lesion shows fat signal characteristics, with lack of enhancement. The presence of chemical shift artifact within or at the margins of the lesion can be used to confirm lipomatous content. MRI also helps in confirming the paratesticular location of large‐sized lipomas.MRI is extremely helpful in suggesting the pre‐operative diagnosis of a paratesticular sarcoma and in evaluating the local extent of the disease. Paratesticular sarcomas are usually ill‐defined, heterogeneous solid masses, strongly and inhomogeneously enhancing, with areas of restricted diffusion.MRI characteristics may suggest the histologic nature of other extremely rare paratesticular tumors.MRI performs better than US in the identification of the contents of an inguinal hernia and also in the detection of symptomatic hernias, which are impalpable. Fat‐containing hernias appear as elongated masses arising from the inguinal canal, with signal intensity similar to that of subcutaneous fat.MRI is recommended to confirm the presence of polyorchidism, in cases of indeterminate US findings, and to provide additional information in complicated cases, including cryptorchidism and testicular neoplasms. MRI shows a rounded or oval lesion, with signal characteristics and enhancement patterns often similar to normal testis. The detection of the tunica albuginea, as a hypointense T2 rim surrounding the supernumerary testis, confirms the diagnosis. Occasionally, the mediastinum testis, supernumerary epididymis, and bridging vessels between the normal testis and the extra‐testicle may be seen.The great majority of solid intratesticular lesions are malignancies, with TGCNs representing approximately 95% of testicular carcinomas.The sonographic findings of testicular cysts and TERT are usually typical, and therefore, MRI is rarely needed. However, it is recommended when differential diagnosis from cystic neoplasms, including cystic teratomas and papillary adenocarcinomas of the rete testis is difficult.The sonographic diagnosis of testicular fibrosis is usually difficult. MRI is recommended as a confirmatory study. The low T1 and T2 signal of fibrous tissue and the slow, progressive contrast enhancement are highly suggestive findings.Hypoechoic intratesticular hematomas, especially in cases of uncertain history of trauma may be difficult to differentiate from malignant tumors. Even in the absence of lesion vascularity on CDUS, the diagnosis of an underlying malignancy cannot be excluded. MRI confirms the presence of a hematoma, when a prompt diagnosis is needed, by showing lesion hyperintensity on T1WI in the subacute phase, with lack of enhancement. A T2 hypointense rim may be detected on chronic hematomas, due to hemosiderin deposition.MRI is highly accurate in establishing the diagnosis of STI, mainly recommended in cases with indeterminate sonographic findings, such as those of a rounded, ill‐defined hypoechoic intratesticular lesion, with uncertain vascularity. MRI findings include an avascular lesion, mainly of low T2 signal, and a markedly enhancing rim surrounding the mass. Occasionally, intralesional hyperintense T1 foci may coexist, due to hemorrhagic elements.Although intratesticular lipomas are typically hyperechoic on US, their histologic complexity may result in variable echogenicity. In these cases, MRI findings are diagnostic, as lipoma follows the signal intensity characteristics of fat on all sequences, with lack of contrast enhancement. Scrotal MRI by depicting multiple, small hyperintense intratesticular foci on T1WI, with drop of signal of fat‐saturated T1WI confirms the diagnosis of testicular lipomatosis, a rare entity, seen in patients with Cowden disease.Scrotal MRI is recommended for the diagnosis of Leydig's cell hyperplasia. The detection of multiple, bilateral small intratesticular lesions, of few millimeters in diameter, hypointense on T2WI, with mild contrast enhancement combined with the appropriate clinical history and laboratory data, is strongly suggestive of the diagnosis of this benign entity. Compared to sonography, MRI may demonstrate more lesions and confirm bilaterality.MRI is helpful for the diagnosis of testicular adrenal rest tumors, strongly recommended in candidates for TSS. These lesions are often bilateral, involve the mediastinum testis, of low T2 signal, variably enhancing after gadolinium administration. MRI surpasses US, by assessing the extent of the disease. Lesion size and margins are clearly delineated and differentiation between different small‐sized contiguous foci and one, large lobular lesion is possible.Based on the recent WHO classification, testicular epidermoid cyst (EC) is considered a subtype of teratoma of prepubertal type, included in the group of TGCNs unrelated to germ cell neoplasia in situ.The minimum requirements of scrotal MRI protocol include the addition of DWI and DCE‐MRI.−3 mm2/s has been reported reliable for the characterization of intratesticular lesions, with a sensitivity of 93.3%, specificity of 90%, PPV of 87.5%, and NPV of 94.7%.DWI by assessing the microscopic diffusion movements of water molecules in testicular tissue, greatly improves the diagnostic efficiency of MRI in the detection and characterization of intratesticular lesions.By manually segmenting the whole testicular lesion on the ADC map, volumetric ADC histogram analysis was used to characterize 61 pathologically confirmed intratesticular lesions. An increase in energy, total energy, and range of ADC and a decrease in minimum ADC and 10th percentile ADC was observed in testicular neoplasms, compared to benign intratesticular lesions. The minimum ADC had the highest diagnostic performance in characterizing testicular lesions, with an area under the curve (AUC) of 0.822, sensitivity of 81.40%, and specificity of 77.78%.Moreover, intratesticular lesions have increased anisotropy, when compared to normal testicular parenchyma. This was proved in a recent preliminary study, using diffusion tensor imaging (DTI) to characterize testicular mass lesions and reporting high fractional anisotropy (FA) values in both TGCNs and benign lesions.The patterns of contrast enhancement on dynamic imaging represent an adjunct parameter in differentiation of intratesticular lesions.Although published data are limited, preliminary observations on other MRI techniques, including magnetization transfer imaging (MTI), proton MR spectroscopy (1H‐MRS), and texture analysis report useful results in the characterization of the nature of intratesticular lesions.Recently, texture analysis was used to characterize testicular lesions. Specifically, histogram analysis and intra‐perinodular textural transition (Ipris) were applied, after manually segmenting testicular lesions on T2WI. Twelve significantly different features were found between benign and malignant tumors, of which the most robust were Energy, Total Energy, and Ipris_shell1_id_std with AUC of 0.807, 0.808, and 0.708, respectively.The increased use of scrotal US has resulted in a high incidence of small, impalpable solid testicular mass lesions, detected as incidental findings. Histologic diagnosis is benign in approximately 80% of these cases, and LCTs represent the commonest pathology.Although no established imaging criteria exist, mpMRI may help in the characterization of LCTs and in the differentiation from TGCNs, and especially testicular seminomas.Semiquantitative and quantitative DCE‐MRI parameters have been reported useful in the characterization of small, impalpable solid testicular tumors.Radical inguinal orchiectomy, with removal of the entire testis containing tumor along with the spermatic cord to the level of the internal inguinal ring, is the treatment of choice for testicular malignancies and should be performed within a week of initial diagnosis.MRI provides valuable information regarding local staging of testicular malignancies, such as tumor dimensions, possible invasion of the rete testis, the testicular tunicae, the paratesticular structures, and/or the spermatic cord.−3 mm2/s is reliable in differentiating seminomas from non‐seminomatous tumors.Multiparametric MRI features closely correlate with the histologic characteristics of TGCNs.Recently, whole‐lesion ADC histogram analysis and T2WI‐based radiomics provided promising results in the characterization of the histologic type of TGCNs.Characterization of the histologic type of TGCNs is rarely needed, in patients diagnosed with disseminated disease and/or life‐threatening metastases, in whom immediate chemotherapy is given. In these cases, MRI is strongly recommended.3.1.2CDUS remains the first imaging technique for the investigation of acute scrotum, and specifically for the differentiation between testicular torsion and acute epididymoorchitis.Testicular torsion represents a real surgical emergency. The detection of testicular blood flow on CDUS may be limited in some cases, depending on operator expertise and US machine sensitivity, and this is problematic, especially in prepubertal testes.Recently, MRI has been reported helpful in the diagnosis of bell clapper deformity (BCD), an important risk factor for testicular torsion. The detection of BCD may also help in diagnosing intermittent testicular torsion. The “split sign” has been described as useful in diagnosing BCD, detected as a hyperintense T2 area placed between the posterior aspect of the epididymis and the scrotal wall.Multiparametric MRI may complement the sonographic evaluation in patients with acute scrotal pain due to testicular torsion, as a confirmatory examination, helping to determine when and how to perform surgical intervention.Scrotal MRI is also helpful in the diagnosis of incomplete testicular torsion or delayed torsion. Both entities usually have misleading characteristics, on clinical and US evaluation.MRI may be used as a second‐line imaging examination in the assessment of complicated scrotal infections and inflammations. Scrotal MRI provides a reliable map, regarding the extent of the disease, especially when there is concern for Fournier's gangrene, helping in planning percutaneous drainage or surgical debridement.MRI limitations in the assessment of acute scrotum should be acknowledged, including limited availability of an urgent MRI study and possible need for anesthesia in young patients.MRI is rarely needed in cases of scrotal trauma, as sonography is often diagnostic.However, in cases equivocal for the diagnosis of testicular rupture at US, MRI represents a valuable adjunct tool. Multiplanar T2WI greatly assesses the integrity of the tunica albuginea, in patients with blunt scrotal trauma.MRI may be proposed for the differentiation between a post‐traumatic hematoma and a TGCN, considering that testicular malignancies represent an incidental US finding in 15% of men presenting with scrotal trauma. Lack of enhancement confirms benignity in these cases, allowing the distinction from hypovascular tumors.3.1.3US and MRI have similar accuracy in the identification of undescended testes, although the sensitivity of MRI has been reported superior to that of sonography.DWI and T2WI with fat saturation increase the diagnostic performance of MRI in the detection and localization of impalpable, undescended testes.Interestingly, a fetal MRI study investigating the time course of testicular descent in utero according to gestational age, highlighted the importance of assessing male sexual development and early diagnosis of congenital anomalies, such as cryptorchidism.3.1.4Recently, scrotal MRI has focused on the evaluation of deranged spermatogenesis. Although reported data are still preliminary and heterogeneous, mainly based on small sample size, various MRI parameters, including ADC, FA, MTR, and testicular metabolites have been described as possible non‐invasive fingerprints of male infertility.MRI may provide useful information regarding the early damage of spermatogenesis in testes with varicocele, possibly helping clinicians to plan appropriate treatment in men who will benefit from varicocele repair.Promising results have been reported regarding the potential role of functional MRI techniques, including DWI and MTI in the evaluation of male infertility. An increase in testicular ADC and a decrease in MTR have been reported in states of defective spermatogenesis.Biochemical alterations in NOA testes might also be used as non‐invasive prognostic parameters for successful sperm retrieval.Testicular lipids represent the most useful discriminating metabolite in the characterization of the histologic subtype of NOA. Increase in lipid peaks is seen in NOA testes with presence of foci of advanced spermatogenesis up to the haploid gamete stage.Furthermore, recently testicular fat deposition was measured using the fat fraction map of mDIXON Quant sequence in middle‐aged overweight patients, including infertile and normal population.4Although CDUS remains the primary modality for the investigation of scrotal pathologies, mpMRI may be used as a valuable diagnostic adjunct. The technique represents a tool of high diagnostic performance, providing morphologic and functional information. The main goal in scrotal imaging is to reduce the number of unnecessary radical surgical explorations. MRI greatly helps by improving scrotal lesion characterization.Based on recommendations published by the SPIWG and review of the recent literature, scrotal MRI should be asked for the following: (1) discrimination between intratesticular and paratesticular lesions (rarely needed), (2) characterization of paratesticular and intratesticular lesions, in case of ambiguous US findings, (3) differentiation between germ cell and sex cord‐stromal testicular neoplasms, especially in case of small, non‐palpable testicular tumors, incidentally found on US, (4) pre‐operative local staging of testicular germ cell neoplasms, in candidates for testis‐sparing surgery, (5) differentiation between seminomas and non‐seminomas, when immediate chemotherapy is needed, (6) assessment of acute scrotum and scrotal trauma , and (7) detection and localization of undescended testes, following uncertain US findings. Although reported preliminary data are promising, the potential role of mpMRI in the assessment of impaired spermatogenesis in infertile men is still under investigation. New and specialized MRI techniques have recently been added in the MRI protocol of the scrotum, helping us to improve our knowledge on the nature of scrotal masses and the extremely complex process of spermatogenesis.None.AT and LM conceived and designed the study. MD and GE contributed equally in the definition of the search keys, in the critical evaluation of the articles, and in the writing of the draft. AT and LM wrote the manuscript. MA and CC revised the article. AT and LM provided the final approval of the completed article.


Chondroblastoma is one of the uncommon benign bone tumors, particularly when located in the mandibular condyle. Such a location makes its diagnosis difficult when based on only its clinical presentation and radiographic features. Herein the current report presents a case of chondroblastoma of the mandibular condyle: its clinical presentation, radiographic features, and immediate condylar reconstruction after resection. Additionally, the relevant literature is discussed to provide clinical recommendations for its diagnosis and treatment. Chondroblastoma has been reported so infrequently in the temporomandibular joint (TMJ), more common entities should first be considered in the differential diagnosis of masses in this location. Osteochondroma is the most frequent bone neoplasm in the TMJ. Since a correct diagnosis is difficult, additional tools, such as magnetic resonance imaging (MRI) and immunohistochemical analyses, should be used for diagnostics and surgical planning. PrimaryHerein the authors present a case of chondroblastoma located in the mandibular condyle for which the patient underwent immediate condylar reconstruction after resection. This article will discuss the clinical presentation, radiographic features, histological analysis, surgical treatment, and long-term follow-up for this case.22 × 4.0 cm2 expansive neoplasm located in the right TMJ region , tender swelling in the right TMJ area, progressive hearing impairment in the right ear, and slight crepitation on auscultation of the right TMJ. A physical examination revealed a round, subcutaneous mass with clear boundaries located on the right preauricular site; the mass was approximately 30 mm in diameter, moderately hard, immobile, and painful with condylar movement. There was no abnormal occlusal relationship or facial paralysis. Hematological and biochemical examinations were normal. A computed tomography (CT) scan showed a 3.5 cmAfter preparation of the patient for surgery, excision of the lesion was carried out using a preauricular approach under general anesthesia. During surgery, a dark red neoplasm, measuring 4 cm in diameter with a hard but elastic consistency, was found. Additionally, the mandibular condyle and disc were surrounded and being eroded by the neoplasm (The reconstruction technique was the same as we have described in previous literatures ,12. BefoThe patient provided an informed consent to the whole treatment procedure. Further, informed consent was obtained from the patient for the publication of this case report and any accompanying images.3Chondroblastoma is an unusual benign neoplasm of the bone. It was first reported by Codman in 1931 as a chondromatous giant cell tumor and was renamed benign chondroblastoma by Jaffe and Lichtenstein in 1942 ,13. ClasThe radiological appearance of chondroblastoma has been described as an osteolytic process with sharply defined sclerotic margins on radiographs. In this case, the enhanced CT scan findings revealed an irregularly lobulated expansile mass with bony destruction. Although commonly reported in the literature , calcifiA histopathological examination of chondroblastoma is generally characterized by sheets of polygonal, mononucleated, and neoplastic chondroblasts with thick and sharply defined cell membranes, eosinophilic cytoplasm, and round-to-indented nuclei. Interspersed within the chondroblasts are scattered collections of osteoclast-type giant cells. Also, chondroblastoma typically presents with a pink chondroid matrix and shows a distinctive pericellular deposition of calcium, which creates a “chicken-wire” formation . There wChondroblastoma of the bone is presumed to arise from the epiphyseal cartilage prior to complete ossification because of its usual presentation in the second decade . HoweverThe treatment strategies for chondroblastoma in previous cases included total en bloc excision, curettage, irradiation, and surgery combined with radiation. The most effective modality appears to be total excision with or without radiation . The con4Chondroblastoma has been reported so infrequently in the TMJ, more common entities should first be considered in the differential diagnosis of masses in this location. Osteochondroma is the most frequent bone neoplasm in the TMJ. Chondroblastoma is often misdiagnosed as granulation tissue or a giant cell tumor. Additional tools, such as MRI and immunohistochemical analyses, should be used for diagnostic and surgical planning. Because of its high recurrence after surgical curettage, complete surgical excision and long-term follow-up are recommended as the treatment for chondroblastoma.TMJtemporomandibular jointCTcomputed tomographyMRImagnetic resonance imaging


Head and neck osteosarcomas (HNOS) account for less than 1% of all head and neck cancers and makeup 6-10% of all primary osteosarcomas. Mandibular osteosarcomas are the second most common subtype of HNOS. They demonstrate higher recurrence rates; however, are amenable to surgery. An 18-year-old male presented with a 2 cm x 3 cm x 2 cm intraoral mass for two months. Biopsy revealed chondroblastic osteosarcoma. Computed tomography revealed extension into the left internal jugular vein. Composite resection of the left mandible, floor of the mouth, ventral tongue, submandibular gland, and modified radical neck dissection with fibular flap repair was performed. Adjuvant chemotherapy and palliative radiotherapy were added. Unfortunately, progressive metastasis to the contralateral mandible and entire spinal cord ensued. We report the first case of head and neck osteosarcoma with intravascular invasion into the internal jugular vein. Osteosarcoma (OS), the most common primary bone malignancy, generally arises in the long bones of the extremities with a reported incidence varying with age: 4.0 - 5.0 per million per year from 0 to 19 years old . It is rMandibular Osteosarcoma (MOS), the second most common anatomic location of HNOS, tends to carry the best overall prognosis out of all HNOS subsites, with local recurrence rates of 56%, and a lower likelihood of metastasis to pulmonary and non-pulmonary sites -4,7. In An 18-year-old African American male presented to the oral and maxillofacial surgery clinic with a two-month history of an expansile osteolytic mass of the left mandible, requiring biopsy. Associated symptoms included: localized pain, halitosis, worsening ability to chew solid foods, 10-pound weight loss, night sweats, mouth ulceration, and tooth abnormalities. He denied motor dysfunction of the tongue, dyspnea, dysphagia, odynophagia, or local paresthesia. He denied prior use of tobacco products, had no pertinent family medical history, and showed no improvement after a short course of oral amoxicillin. Per the patient, from the time of initial biopsy to the authors' evaluation, the lesion increased dramatically in size. Oral exam revealed a 2 cm x 3 cm x 2 cm exophytic mass emanating inferior to teeth 18 and 19 with extension to left parasymphysis and multiple submucosal nodules along the buccal and lingual aspect of the left mandibular body and parasymphysis as seen in Figure Subsequent pathology was consistent with chondroblastic osteosarcoma and immunohistochemistry of the sample was positive for CD99 and vimentin, but negative for schwannian-100 (S100), anti-muscle actin antibody HHF35), cytokeratin, and epithelial membrane antigen (EMA). A computed tomography scan (CT), seen in Figure 5, cytokeThree weeks later, the patient presented for resection of the tumor, which was noted to have doubled in size since surgical planning. He underwent composite resection of the mandible from right parasymphysis to left ramus, the floor of the mouth, ventral tongue, submandibular gland, left internal jugular vein, and modified radical neck dissection, sparing the spinal accessory nerve and sternocleidomastoid muscle, shown in Figure Three weeks later, he began chemotherapy following the Children’s Oncology Group protocol AOST0331, which consisted of 29 weeks of methotrexate, cisplatin, and adriamycin. As seen commonly with both radiotherapy and chemotherapy, obliteration of microvasculature delayed angiogenesis, and local tissue fibrosis can lead to reconstructive complications, so after extended tumor-board discussion, adjuvant radiotherapy was not considered at that time. Approximately three months into his chemotherapy treatment, the patient began to note superficial exposure over his left hemi-mandible, leading to significant oral-cutaneous communication as seen in Figure Approximately eight months later the patient developed left upper extremity weakness and left-sided lymphadenopathy. A left-sided parasymphyseal orocutaneous fistula had developed with exposed hardware. CT Figure  and MRI He elected for external beam radiotherapy for cervical metastasis, which resulted in some improvement in left upper extremity function. Hospice was discussed at this time but was declined by the patient and his mother. Denosumab and sorafenib were initiated for palliative therapy, but the progression of local disease proceeded, and the biologics were stopped due to worsening side effects. A follow-up MRI Figure  revealedOne month later the patient reported to the emergency room due to worsening paresthesia of bilateral lower extremities and MRI revealed extensive bony metastases involving the entire sacrum and bilateral ilium with right S1-S3 neural foramina tumor extension and posterior epidural invasion at T10-L1 producing spinal stenosis and cord compression Figure . NeurosuClear surgical margins have been reported to be the most significant positive prognostic factor for overall survival, local control, and disease-free survival in MOS ,11,12. OHistorically, surgical resection of HNOS with wide margins is the mainstay of treatment, but the anatomic complexity of the head and neck can prevent adequate margins ,5,13-15.Highlighted in the case above, the patient did benefit symptomatically from palliative radiotherapy, but it is unlikely that adjuvant radiotherapy after his composite resection would have prevented the further distant progression of his disease. The patient in the case above initially presented with a histopathologically confirmed intravascular invasion of the internal jugular vein (IJV), suggesting a more severely advanced lesion at the onset, likely leading to his poor outcome. Overall, evidence of adjunct radiotherapy in HNOS treatment is lacking. Thariat and colleagues failed to demonstrate the benefit of radiotherapy in HNOS but noted a small sample size as a limiting factor of the study . AnotherBoth adjuvant and neoadjuvant chemotherapy are other HNOS treatment options that lack high-grade evidence ,13,15,16Lastly, within the literature, there have been a handful of case reports describing intravascular metastasis of osteosarcoma, but none involving HNOS. One noted case study described intravascular embolic metastases to pulmonary vasculature from primary OS lesion in his right femur ,19. AnotAfter an extensive literature review, no reported cases were discovered reporting HNOS with an intravascular extension of tumor into any major blood vessels. Early identification and surgical excision with wide margins are the most viable treatment in MOS, but with early vascular invasion, excision alone is not always feasible. There appears to be a role for radiotherapy and chemotherapy, but unfortunately, it is not well defined in HNOS literature. The authors hope that this report could provide insight to providers on the identification and treatment of intravascular HNOS invasion and prevent further morbidity and mortality in this patient population.


Congenital melanotic macule of the tongue (CMMT) is a rare and underestimated benign entity with few cases reported in the literature . ClinicaOther diseases presenting oral mucous hyperpigmentation, such as pigmented fungiform papillae, lingua nigra villosa, Laugier Hunziker syndrome, and Peutz–Jeghers syndrome, can easily be excluded based on clinical grounds alone. Oral congenital melanocytic nevi are exceptionally rare, with only 6 cases reported in the literature, in all cases the tongue was not involved . AlthougThe cause of CMMT is unclear. Congenital lesions might represent a hamartoma of melanocytes with localized functional change in melanin production. No predisposing or causative factors occurring during gestation have been linked to CMMT.To exclude malignancy, some authors suggest performing a tongue biopsy. Others argue that follow-up alone is justified, since CMMT clinical features are distinctive, congenital melanocytic nevus of the tongue is an extremely rare disorder, and congenital melanoma has never been reported in the oral cavity. If significant changes occur, a biopsy should be considered.A 5-month-old boy, born at term, skin phototype III, was referred for evaluation of congenital, asymptomatic pigmented lesions on the tongue that had enlarged proportionally to the infant’s growth. Our patient’s follow-up, with photographic documentation from the first medical evaluation at 5 months until 5 years of age, is one of the longest reported in the literature. Additionally, this is the first dermoscopy report in a case of CMMT. Although this entity is more common in people with dark phototypes , our case reports CMMT in a phototype III child.It is important to raise awareness on this underreported entity to avoid unnecessary aggressive surgical approaches in children. Clinical follow-up alone is warranted due to the extremely rare occurrence of oral congenital melanocytic nevi and the unreported childhood congenital melanoma of the oral cavity.


A hernia is an abnormal protrusion of an organ or tissue from its containing cavity. Inguinal hernia is the most common type of abdominal hernias. The presence of the appendix within the inguinal hernial sac is a rare occurrence. We present the case of a 41-year-old man, with no previous surgical history, who presented to the emergency department with a right-sided painful groin swelling. The swelling was associated with nausea, vomiting, anorexia, and fever. Initial laboratory investigation revealed leukocytosis and elevated C-reactive protein and erythrocyte sedimentation rate. A computed tomography (CT) scan demonstrated the presence of an inflamed appendix with an inguinal hernia. The patient underwent laparoscopic repair of the hernia with appendectomy. The patient tolerated the procedure without any complications. Amyand hernia with acute appendicitis is a very rare surgical condition. Clinicians should have a high index of suspicion for Amyand hernia with appendicitis when they encounter a patient with groin mass with laboratory markers indicating an inflammatory process. A hernia is an abnormal protrusion of an organ or tissue from its containing cavity. Inguinal hernia repair remains one of the most commonly performed surgeries worldwide. It accounts for 80% of the abdominal wall hernias. The lifetime prevalence of inguinal hernia reaches over 25% . SurgicaWe present the case of a 41-year-old man who presented to the emergency department complaining of swelling in his right groin for two weeks’ duration. He reported that the swelling became painful and non-reducible for the last two days. The pain was associated with decreased appetite and subjective fever. The patient reported having nausea and recurrent episodes of vomiting in the last 24 hours. The patient did not undergo any previous surgeries. His past medical history was remarkable for well-controlled asthma. He was a non-smoker and never drinks alcohol. The patient worked as a school teacher. He has a significant family history of sickle cell disease.Upon examination, the patient appeared in distress due to the pain. His vital signs were as follows: a temperature of 38°C, a pulse rate of 110 beats per minute, blood pressure of 118/95 mmHg, and respiratory rate of 14 breaths per minute. There was a swelling in the right inguinal region, measuring 4 x 6 cm. It was oval in shape and had a smooth surface with an evident expansile cough impulse. The swelling was non-reducible with slightly erythematous and warm overlying skin.In view of the clinical features, the diagnosis of incarcerated inguinal hernia was established. The patient underwent a pre-operative laboratory investigation, which revealed leukocytosis with neutrophilia and left shift, elevated erythrocyte sedimentation rate and C-reactive protein, and normal renal and hepatic profiles Table . The patThe patient was prepared for an emergency laparoscopy operation for the reduction of the inguinal hernia. The patient was administered general anesthesia and was placed in a supine position. Pneumoperitoneum was established. The diagnostic evaluation revealed a right inguinal hernia containing an inflamed appendix. An appendectomy was performed, and the appendix was removed in a sterile bag. The hernia was repaired using the totally extraperitoneal approach with mesh repair. No complications were encountered during the operation. The estimated blood loss was 5 mL and the total operative time was 120 minutes. The patient had an uneventful recovery and was discharged on the fifth postoperative day. The histopathological examination of the appendix confirmed the diagnosis of acute appendicitis.We described the case of a middle-aged man with an Amyand hernia and acute appendicitis that was managed successfully via a laparoscopic approach. The occurrence of the appendix within the sac of inguinal hernia is very rare. It was first described by Claudius Amyand in 1736 who successfully performed appendectomy in a young child with a right inguinal hernia . Amyand In the present case, the appendix was found to be inflamed as per the CT findings. The presence of appendicitis within the hernia sac has essential surgical implications. For instance, the surgeon needs to perform an appendectomy instead of a simple hernia repair in the case of Amyand hernia with acute appendicitis. It should be noted that the Amyand hernia may contain a normal or an inflamed appendix. However, the herniated appendix is at a higher risk of developing an infection. It is postulated that the narrow hernial neck causes restricted blood flow, leading to edema and inflammation .In contrast to the present case, Amyand hernia is three times more prevalent among children than adults. However, it may occur at any age and has been reported in patients ranging from neonates to the elderly . It is mEarly diagnosis and management of Amyand hernia are crucial. The reported mortality rate from Amyand hernia may reach up to 30% . HoweverThere are controversies about the optimal surgical approach . SeveralAmyand hernia with acute appendicitis is a very rare surgical condition. Clinicians should have a high index of suspicion for Amyand hernia with appendicitis when they encounter a patient with groin mass with laboratory markers indicating an inflammatory process. A CT scan is essential in making the preoperative diagnosis. The laparoscopic approach is feasible and safe for the repair of the Amyand hernia with acute appendicitis.


Aspergillus fumigatus with associated sphenoid sinus osteomyelitis. We postulate that the presentation was related to the patient’s previous radiotherapy for nasopharyngeal carcinoma. To the best of our knowledge, this is the only report of such a case.Cerebral mycosis is extremely rare in immunocompetent patients. A 61-year-old male presented with a 3-month history of worsening left-sided headaches and 3-week history of left-sided upper lip paraesthesia. Magnetic resonance imaging revealed an enhancing lesion in the left temporal lobe. Histopathology of this lesion revealed what initially resembled a zygomycete but additional cultures obtained on further surgical debridement revealed the infection to be  Cerebral mycosis is extremely rare in immunocompetent patients. It normally afflicts those who are compromised due to immunosuppressants, solid organ and hematological malignancies, or infections such as human immunodeficiency virus . MortaliA 61-year-old Chinese male presented with a 3-month history of worsening left-sided headaches and 3-week history of left-sided upper lip paresthesia. He had these symptoms intermittently over the course of the year, but they had recently worsened. Due to his past medical history of migraines, previous presentations to hospital were dismissed as sumatriptan overuse. In 2001, he had been diagnosed with nasopharyngeal carcinoma (WHO Type III) in the left fossa of Rosenmüller. The nasopharynx and base of skull were treated with 70 Gy 35 fractions, while the neck received 60 Gy 30 fractions. Follow-up over 5 years showed no residual or recurrent tumor.At presentation, neurological exam was normal aside from a known left-sided blindness since childhood and on-going paresthesia of V2 region of cranial nerve V. The patient was afebrile and all other observations were within normal limits.Brain magnetic resonance imaging (MRI) study with contrast revealed an irregular enhancing mass within the left temporal lobe measuring 3 × 2.6 × 2cm with significant surrounding parenchymal oedema . In addiThe patient underwent a left-sided temporal lobectomy to excise the lesion but, due to the proximity to the cavernous sinus, the lesion was not followed beyond the dural attachment on the middle fossa floor. Unexpectedly, the histopathology revealed hyphae resembling a zygomycete, with broad (5–12 μm) hyphae without septae and branching angles between 45° and 90° . LiposomAspergillus fumigatus and histology was consistent with this diagnosis, demonstrating narrow, septated hyphae with branching angles around 45°. The lateral wall of the sphenoid sinus revealed signs of osteomyelitis from chronic Aspergillus infection. There was no evidence of mucormycosis from any culture. Following sensitivity reports, the antifungal agent was changed to voriconazole due to acute kidney injury from liposomal amphotericin B.The patient underwent further endoscopic re-resection a week following his initial operation. The sphenoid sinus appeared necrotic and a frank collection of fungal matter was observed in the space. Fungal culture from this repeat surgery grew Further surgical debridement was undertaken due to concerns on MRI of intracerebral abscess formation. The appearance at theatre was that of a hematoma, and bacterial cultures yielded no growth.Investigations for auto-immune conditions, hematological malignancies, diabetes mellitus and other immuno-compromising conditions were negative. At time of discharge, the patient was clinically stable.Due to liver function derangement from voriconazole, the antifungal agent was changed to posaconazole. The patient completed a total of 12 months antifungal therapy. Subsequent serial MRI imaging showed good response to therapy with no further recurrence.Aspergillus cerebral abscess with associated osteomyelitis. This has a poor prognosis with a crude mortality rate of 25%. The sphenoid sinus may have been more susceptible to infection due to destruction following treatment of previous nasopharyngeal carcinoma [Fungal cultures confirmed that our patient had an arcinoma . Given dAspergillus infections [Invasive aspergillosis of the immunocompetent patient is extremely rare. Best outcome is observed with extensive surgical resection followed by long-term antifungal therapy , 6. Our fections . The corfections , 10. Thifections  and it hInvasive fungal sinusitis can be broadly divided into acute, chronic and granulomatous types . PatientIn addition to these symptoms, imaging can help with early diagnosis. In the immunocompromised, lesions appear thick and irregular with heterogenous ring-like enhancement on MRI due to abscess cavity . HoweverA. fumigatus with associated sphenoid sinus osteomyelitis following previous radiotherapy. Although invasive fungal infections in the immunocompetent are rare, our case demonstrates the importance of considering it in the differential diagnosis of a cerebral lesion in the presence of relevant risk factors. With radiotherapy frequently used in the treatment of nasopharyngeal malignancies, this potential complication needs to be recognized.We present the first case of an immunocompetent patient with cerebral invasion of The authors report no conflict of interest or any funding.None.