Gastrointestinal complications following radical cystectomy (RC) are a common occurrence, with small bowel obstruction (SBO) a known complication. Limited cases have been reported of SBO following RC due to internal herniation of the small intestine around the ureter, ileal conduit, obturator nerve and, as a consequence of retroperitoneal lymphadenectomy, even the abdominal vasculature. We present a rare case in which intestinal herniation beneath the external iliac artery (EIA) resulted in a closed-loop SBO with ischaemia and necrosis. Intra-operative transection of the unrecognised EIA occurred, necessitating primary arterial repair. This case highlights the importance of maintaining a high index of suspicion for complex pathology and anatomical variations in patients following RC and other operations involving retroperitoneal lymphadenectomy. After abdominal surgery, the most common cause of small bowel obstruction (SBO) are adhesions . InternaWe present a case of internal herniation of the small bowel beneath the left external iliac artery (EIA) causing SBO and ischemia following RC and ileal conduit formation, complicated by intra-operative iatrogenic EIA injury. To the author’s knowledge, this is the only reported case of SBO caused by internal hernia associated with major abdominal vessels complicated by iatrogenic injury to the involved vessel.A 75-year-old male presented to our institution 4 months after RC for bladder cancer with acute abdominal pain and vomiting. Vital signs were within normal limits, the abdomen was distended and tender in the left lower quadrant. Significant biochemical derangements with metabolic acidosis and elevated lactate were demonstrated. A computed tomography (CT) scan of the abdomen and pelvis demonstrated a closed-loop SBO in the left lower quadrant with intrabdominal free fluid . The rigEmergent laparotomy revealed an ischaemic segment of ileum in the left lower quadrant and haemorrhagic peritonitis. The closed-loop obstruction was adherent to the pelvic brim with a transition point identified at a firm, narrow, tubular structure that prevented evisceration of the ischaemic segment. This was non-pulsatile and unable to be traced proximally or distally due to the surrounding dilated loops of small bowel. The structure was sharply divided to facilitate mobilisation and resection of the ischaemic bowel. Post-transection it was noted this was a vascular structure, presumed the left EIA, beneath which the small intestine had herniated causing obstruction. Examination demonstrated absence of left femoral and pedal pulses. Intra-operative consultation from Vascular Surgery confirmed an iatrogenic injury to the left EIA. Thrombus was removed from both proximal and distal ends of the EIA which was subsequently primarily repaired with 5–0 prolene suture . The peritoneum was closed over the arterial anastomosis. The necrotic bowel was resected, and a side-to-side functional end-to-end anastomosis was fashioned with an nTLC 75 linear stapler (Ethicon inc.) and the entero-enterostomy was closed with a TX60 stapler (Ethicon inc.). The ileal conduit remained healthy and urine output was noted at the end of the operation.Histopathological examination confirmed ischaemic enteritis with patchy mural necrosis. Post-operative CT demonstrated healthy small bowel and patent left EIA  and 4. TRC is associated with high rates of morbidity and mortality. A total of 29% of complications following surgery are of the gastrointestinal (GI) system with the majority of these being small bowel ileus . SBO comInternal herniation related to the external iliac arteries is an extremely rare pathological process. Fewer than 10 cases have been described following radical lymphadenectomy for testicular, prostate and gynaecological tumours . To our Pre-operative identification of internal hernias would allow for optimal management and planning, however diagnosis of intestinal herniation causing SBO on imaging can be challenging. CT features such as atypical bowel configuration, mesenteric abnormalities  and the position of surrounding viscera raise the index of suspicion of internal herniation . In thisIntra-operative signs of internal herniation related to vascular structures can be atypical. In our patient, the EIA was firm, collapsed and not pulsatile. In most other reported cases the bowel was able to be reduced, a long segment of skeletonised artery was visible or authors were able to identify a pulsation or thrill. Our case highlights that these findings may not always be present. Furthermore, we demonstrate use of sharp rather than diathermy division and early involvement of a Vascular Surgeon for assessment and repair can prevent complications from the injury.We present a unique case in which intestinal herniation beneath the left EIA caused an SBO complicated by intestinal ischaemia. The rarity of this pathological process alongside the atypical radiological and intra-operative findings contributed to an iatrogenic arterial injury occurring. We highlight the importance of considering atypical causes of GI complications and maintaining a high index of suspicion for post-surgical pathologies aside from adhesions in patients who have undergone RC and other operations with retroperitoneal dissection.None declared.None.Data sharing is not applicable to this article as no new data were created or analyzed in this study.


Failure of the bone marrow to maintain adequate blood cell production to match blood metabolic demand incites the production of cell lines outside the bone marrow, which is known as extramedullary hematopoiesis. Herein, we are reporting an 80-year-old male patient who presented with two weeks of worsening headaches and behavioral changes. Labs showed thrombocytosis and imaging showed a large right-sided hemorrhagic brain mass. No evidence of malignancy was seen elsewhere. Brain mass biopsy showed intracranial extramedullary hematopoiesis (IEMH) and bone marrow biopsy confirmed the diagnosis of essential thrombocythemia (ET)/myelofibrosis. This case adds to a few reported cases of IEMH, and to the best of our knowledge, this is the first reported case of IEMH in association with ET. It helps remind clinicians to keep IEMH in the differential diagnosis of those presenting with signs and symptoms of elevated intracranial pressure (ICP) and a newly found brain mass on the background of previously diagnosed or suspected myeloproliferative neoplasms. Essential thrombocythemia (ET) is an uncommon clonal myeloproliferative neoplasm characterized by increased platelet count and platelet dysfunction . Like otAn 80-year-old male patient presented to the emergency department (ED) as a referral from his primary care physician for an abnormal computed tomography (CT) head scan result. The patient was complaining of two weeks of diffuse constant headaches and behavioral changes. It was described that during these two weeks, he had progressive forgetfulness, sleepiness, and somnolence. On multiple occasions, he forgot his way home. No preceding history of recent trauma, fall, or infection was reported. Past medical history was significant for ischemic stroke on aspirin, diabetes type 2, and hypertension. CT scan showed a large, 5.9 x 4.2 x 3.7 cm, peripherally hyperattenuating and internally hypoattenuating irregularly shaped heterogeneous hemorrhagic mass in the right anterior frontal lobe with extensive surrounding vasogenic edema, mass effect on the right lateral ventricle, and 8 mm midline shift to the left. It also showed a separate 1.5 x1.0 x 1.4 cm hemorrhagic lesion in the right thalamus involving the internal capsule with surrounding vasogenic edema  showed stable, similar findings to the CT scan with superimposed enhancement as well as a leptomeningeal enhancement Figure . CT angiEssential thrombocythemia (ET) is an uncommon myeloproliferative disorder with an average age of diagnosis of 58 years . ET has Extramedullary hematopoiesis (EMH) is a process through which the body compensates for long-standing anemia secondary to poor blood cell production by the bone marrow or hemolysis by the proliferation of pluripotent stem cells outside the bone marrow. It is usually seen in hemoglobinopathies, including sickle cell anemia, thalassemia, and hereditary spherocytosis, and myeloproliferative disorders, including myelofibrosis, polycythemia rubra vera, and myeloid metaplasia . HoweverAlthough paraspinal EMH is a well-known condition. There are only a few reported cases of intracranial EMH (IEMH). Current knowledge is based on isolated case reports and hence there is no known epidemiological data. IEMH has been reported to arise from the cranial base close to the sphenoid or ethmoid bones and thus presents initially with progressive visual deterioration . IEMH orIntracranial EMH might be explained by the mesenchymal origin of pluripotent stem cells in the central nervous system (CNS) . In addiSimilar to our case, IEMH can be the initial presentation of myeloproliferative disorder or hemoglobinopathy, although most of the reported cases had an established diagnosis of hemoglobinopathy or myeloproliferative disorder prior to the diagnosis of IEMH . AlthougMultiple cases were reported in the literature citing IEMH, see Table IEMH is an extremely rare entity. It is usually seen in association with chronic hemoglobinopathies and myeloproliferative disorders. Initial presentation is usually with signs and symptoms of elevated ICP. It can be seen in intraparenchymal, meningeal, extra-axial, or choroid plexus locations. This is the first reported case of ET in association with IEMH.


Inguinal herniation of the ureter is a rare entity that occurs either as a complication of renal transplantation or spontaneously. Patients may suffer from obstructive uropathy or groin pain due to the unusual ectopic course of the ureter. This case report highlights the importance of recognizing a ureteroinguinal hernia.  In this case report, we present a 75-year-old man with a surgical history of a right inguinal hernia repair who was referred to our center with burning left inguinal pain that persisted for two weeks. The patient's history and physical examination were consistent with an inguinal hernia. The suspected indirect inguinal hernia was found on preoperative imaging to be a tubular structure distinct from the intestine or adjacent organs. An open exploration of the inguinal canal was performed to prevent further hernia development.  The unusual structure in the inguinal canal turned out to be an ectopic ureter originating from the left upper pole moiety of the left duplex kidney  and containing concentrated urine, as confirmed on a postoperative computerized tomography urogram.  It is crucial to perform a thorough clinical examination and utilize adequate imaging modalities before surgical procedures when encountering unidentified structures. Inguinal hernias affect up to 40% of men and 5% of women during their lifetime and account for about one-third of all hernias , 2. InguA 75-year-old non-smoker man with a surgical history of a right inguinal hernia repair was referred to our center with burning pain in the left inguinal region that persisted for two weeks. He also complained of a left inguinal mass, which was later examined by ultrasound (US). Physical examination revealed a reducible left inguinal mass suggestive of a hernia but with no evidence of strangulation. Furthermore, testicular and abdominopelvic examinations were normal. The first US examination did not reveal a hernia sac but did demonstrate a cystic fluid-filled lesion, so the patient underwent the second US for confirmation. During this time, the patient's inguinal pain was relieved by intramuscular ketorolac 30 mg twice a day. The second US examination revealed a cystic lesion in the inguinal canal, which was believed to be a tortuous vas deferens. The radiologist recommended a pelvic Magnetic Resonance Imaging (MRI) scan to better characterize this unusual structure. MRI showed a large tortuous cystic lesion on the left side of the pelvic cavity, posterior and superior to the urinary bladder, extending to the seminal vesicle, and suggestive of a possible seminal vesicle cyst versus a vas deferens cyst. Since the diagnosis could not be confirmed by MRI, a urologist was consulted to evaluate the hernia and the suspected seminal vesicle cyst. The urologist recommended surgical exploration of the area.The patient underwent surgical exploration of the left inguinal canal. After prepping and draping, a classic incision for hernia repair was made under spinal anesthesia. The skin, fascia, and inguinal canal were opened, then the spermatic cord was identified and kept aside from the field to avoid its damage while exploring the area. Interestingly, no hernia sac was found. A tubular U-shaped structure distinct from the intestine or adjacent organs was identified in the inguinal canal . The U-sThe analysis of the fluid was negative for sperm. It was also culture negative. The biopsy specimen revealed normal ureteral histology with stratified transitional epithelium. Based on the pathology findings and the high creatinine (Cr) value of the aspirated fluid from the U-shaped lesion (Cr = 13.1 mg/dL), the patient's urinary system was restudied with a computerized tomography (CT) urogram. CT urogram demonstrated a duplicated left collecting system . The rigThe patient was referred to a urologist for further evaluation. The urologist believed in the congenital nature of this malformation and that age-related weakness of the surrounding tissue resulted in inadequate support of the ectopic structure, causing it to descend into the inguinal canal. Because of the high risk of surgery at the age of 75 years and the fact that the patient had not suffered renal failure during most of his life  = 89), he was treated only with an appropriate analgesic . At follow-up 6 months later, the patient no longer complained of lower urinary tract pain or symptoms.The summary of the events is depicted in the timeline see .The patient was treated under the latest version of the Declaration of Helsinki of the World Medical Association , and wriInguinal hernias account for nearly 75% of all hernias, 50% of which occur indirectly, often on the right side (7 : 1: ratio of men to women) , can occBased on the accompanying structures, a ureteral hernia is classified as paraperitoneal or extraperitoneal. The former accounts for 80% of cases . Renal tThe diagnosis of ureteroinguinal hernia is often not made preoperatively  and reliSurgical treatment of ureteroinguinal hernias remains controversial , 25. SomIn this study, we present an extremely rare case of an ectopic ureter with no urinary symptoms that herniated from an extraperitoneal origin into the inguinal canal. The final diagnosis was made with the help of the CT urogram, which visualized the ureteral tract with extraordinary precision and showed that the ureter from the upper pole moiety of the duplicated collecting system of the left kidney passed through the inguinal canal, mimicking an inguinal hernia. The course of duplicated left ureters was consistent with the Weigert-Meyer law .The main limitation of this case report was that the urologist was consulted by telephone and was absent during the operation. The unavailability of intraoperative imaging was also an important limitation of this study.Because ureteroinguinal hernia is quite rare, the definitive diagnosis is usually based on imaging and surgical exploration. Imaging methods, such as CT urogram and MRI, are preferred because of their higher diagnostic value. Therefore, we recommend a complete examination of the patient's urinary tract before surgery if urinary symptoms are present or if there is reasonable doubt about congenital abnormalities. This would help to avoid blind intervention and irreparable complications.


A Meckel's diverticulum is one of the most common congenital causes of small bowel obstruction. The lack of a more common gastric-containing tissue and older age of symptom onset can lead to difficulties with preoperative diagnosis. This case demonstrates an adult with chronic abdominal pain with recurrent small bowel obstruction that was found to be a rare ectopic endometrial tissue containing a Meckel's diverticulum following a diagnostic laparotomy. The barriers to diagnostics and factors affecting the age of onset are discussed with a focus on demonstrating the importance of surgical intervention for small bowel obstruction due to a Meckel's diverticulum and on the significance of a rare histological finding. A Meckel's diverticulum  is a congenital malformation resulting from the failed obliteration of the proximal portion of the omphalomesenteric (vitelline) duct . UsuallyA 43-year-old female presented to the emergency department with a 24-hour history of severe upper abdominal pain. The pain was gradual in onset, worsened by food, and associated with nausea and vomiting. The patient denied any alleviating factors, constipation, diarrhea, urinary abnormalities, chest pain, or back pain. She had a history of multiple similar episodes of small bowel obstructions, which resolved without surgical intervention. Despite negative biopsy results, her previous doctor encouraged her to undergo treatment for Crohn’s disease. Her symptoms prompted an evaluation for hereditary angioedema, but the workup was negative. Her past medical history included hypothyroidism and occasional heart palpitations. Her surgical history was significant for a cholecystectomy, C-section, and hysterectomy. Her physical exam revealed a soft abdomen with normal bowel sounds and moderate tenderness in the epigastric and periumbilical areas with no palpable mass.3/uL and a normal lipase of 99 U/L. An abdominal CT scan without contrast demonstrated distention of the stomach and dilated loops of the small bowel without any clear source of obstruction.Laboratory tests were significant for an elevated white blood cell count of 17.72 10The patient was initially treated conservatively symptomatically with adequate hydration and analgesia with bowel decompression. Due to a history of numerous admissions for bowel rest and IV fluids for symptomatic relief, the decision was made to explore surgically. The expected outcome was the common finding of adhesions which would simply require enterolysis. The actual outcome was encountering an inflamed Meckel's ileal diverticulum along with associated inflammatory adhesions that required enterolysis and small bowel resection. Laparoscopic exploration revealed a location of adhesions approximately 60 cm proximal to the ileocecal valve. Extensive enterolysis identified a 3 x 3 x 2.6 cm diverticulum with dilation of the small bowel proximal to this point due to obstruction. No other lesions were identified. The patient had an uncomplicated postoperative recovery, with complete resolution of bowel obstruction, and was discharged one day after surgery. Histologic examination of hematoxylin and eosin-stained sections of the resected bowel revealed that the diverticulum contained endometrial tissue and benign small bowel tissue. The remainder of the resected bowel contained benign small bowel tissue. Due to the adherence of the adjacent small bowel with the diverticulum, a thickened area of smooth muscle can be seen separating normal ileal tissue and heterotopic endometrial tissue in Figure In this case report, we present a 43-year-old female with chronic abdominal pain and recurrent small bowel obstruction due to an etiology less frequently observed in adult populations. In addition, our case revealed ectopic endometrial tissue involving a Meckel’s diverticulum, a finding that is scarcely documented in the literature.The most common clinical presentation of a Meckel's diverticulum in adults is bleeding from ectopic gastric mucosa, while in children it is obstruction due to intussusception . The repWith most cases being asymptomatic, Meckel's diverticula are often found incidentally during laparoscopy or laparotomy when looking for the source of GI bleeding or obstruction . StandarThere are limited data regarding Meckel's diverticulum-associated tumors; however, malignant transformation seems to be uncommon, with reported incidences of 0.5% to 3.2% ,15,17,19A Meckel's diverticulum, despite being a common differential for small bowel obstruction in children, is a rare cause of small bowel obstruction in adults. This case describes recurrent small bowel obstructions secondary to a Meckel's diverticulum that had a rare histopathological finding of ectopic endometrial tissue. Difficulties in diagnosing a Meckel's diverticulum in non-traditional patient populations can lead to unnecessary recurrence and worsening of patient symptoms. Increasing awareness of Meckel's diverticulum as a potential cause of small bowel obstruction in adults and recognizing the limitations of preoperative diagnostics can decrease the time to appropriate treatment.


Low-grade fibromyxoid sarcoma (LGFMS) is an uncommon neoplasm generally affecting muscle tissue. It presents rarely in abdominal viscera and even more rarely occurs in the pancreas. All types of pancreatic sarcomas are uncommon, and LGFMS is a rarer still. We present the case of an LGFMS in the pancreas. Because of its rarity, there are no guidelines for appropriate treatment or summations of the natural course of this illness.We present the case of a 49-year-old female who presented with epigastric pain. She had a prior history of three episodes of acute pancreatitis many years earlier. A CT revealed a pancreatic body mass, which was biopsied. Pathology returned LGFMS. The patient underwent a distal pancreatectomy and splenectomy. She did well after the case and did not require further intervention.Though it is exceedingly rare, cases of pancreatic LGFMS should be reported in order to guide clinical decisions. LGFMS has been shown to have high malignant potential in other tissues, and there is no reason to think pancreatic masses will be different. By building a body of evidence about these rare tumors, patient care will benefit. To date, there are only three cases of pancreatic low-grade fibromyxoid sarcoma (LGFMS) reported in literature. Primary pancreatic tumors are most often epithelial in origin, with adenocarcinoma accounting for roughly 90 percent of tumors. Pancreatic neuroendocrine tumors (PNETs) only account for three percent. Pancreatic sarcomas account for less than 0.1% of pancreatic malignancies and tend to affect individuals in their 4th or 5th decades. Patients present with symptoms similar to other pancreatic masses, such as abdominal pain, nausea, vomiting or painless jaundice . The litLow-grade fibromyxoid sarcoma (LGFMS) is a rare tumor generally arising from soft tissues of the inguinal region, thoracic wall, and shoulder . LGFMS hA 49-year-old female with prior medical history of gastroesophageal reflux disease and 20-pack-year smoking presented to the emergency room with complaints of vague abdominal pain for approximately one month prior. She described the pain as dull to sharp, concentrated in the epigastrium with radiation to the back. The patient had no other complaints. She denied nausea, vomiting, anorexia, weight loss, and changes in bowel function. She also had a history of three episodes of acute pancreatitis. The first was 21 years prior to presenting at the ER and was due to gallstones. A cholecystectomy was performed shortly thereafter. She had two more episodes of acute pancreatitis thereafter, the most recent 13 years prior to presenting to the ER. She denied past or present alcohol use. Imaging from these past admissions was unavailable.A CT at the time of presentation to the emergency room revealed a hypodense pancreatic body mass Fig. . An esopShe was admitted and an open distal pancreatectomy with splenectomy was performed without complications. Due to the rarity of the tumor and malignant potential of pancreatic sarcomas generally, a spleen-preserving procedure was decided against. Six peripancreatic lymph nodes were taken with the specimen, with no further lymph node dissection. Frozen section revealed negative margins. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 5. The patient received post-splenectomy vaccines before discharge, which included haemophilus b conjugate, pneumococcal 23 polyvalent, and meningococcus ACWY.On final pathology, the pancreatic mass was measured to be 2.7 × 3.4 × 3.2 cm and identified as a low-grade spindle cell lesion with a sclerotic background, consistent with fibromyxoid sarcoma (Fig. The patient returned to the office for a two-week follow-up visit and was doing well with no complaints. It was determined that chemotherapy and radiation were not indicated. She was seen at a 4-week follow-up visit complaining of abdominal pain. A CT was done and showed expected postoperative changes, negative for any acute process. At two months post-op, the patient was seen and was doing well. No further follow-up was arranged.Pancreatic LGFMS rarely appears in the literature. Our review revealed only three cases of primary LGFMS of the pancreas Table . One casBecause of its rarity, the guidelines for treatment are not clear. There is presently no standard of care for pancreatic LGFMS as there are so few cases. It is unclear if chemotherapy or radiotherapy are useful adjuncts. Drawing on experience from other types of sarcomas, it is possible that LGFMS has strong malignant potential. Given the propensity of LGFMS to recur, we might have considered surveillance imaging for our patient. But given the lack of guidelines, it was difficult to determine if further surveillance or adjuvant treatment was needed, especially considering we obtained clear margins and no evidence of lymphatic or vascular invasion.Our case involved a 49-year-old female suffering epigastric pain from a LGFMS tumor of the pancreatic body, successfully treated with a distal pancreatectomy. It was possibly associated with her prior episodes of acute pancreatitis, although this is uncertain given the paucity of literature on this subject. Cases of LGFMS should be reported in the future to help determine the features, natural course, and best methods of treatment for these rare and potentially malignant tumors.


Congenital ranula cysts are rare, benign cysts that arise from the obstruction or rupture of the sublingual gland ducts in the oral cavity of newborns. Here, we present a case of a congenital ranula cyst in a newborn, highlighting the clinical presentation, diagnosis, and management of this rare condition. The neonate presented with a smooth, painless, and non-tender mass in the floor of the mouth, which was identified as a sublingual cyst via ultrasonography. The neonate underwent successful surgical excision of the cyst, with no complications or recurrence observed during the follow-up period. Congenital ranula cysts are a rare but treatable condition that can present in the oral cavity of newborns, and early diagnosis and surgical excision are crucial to prevent complications and ensure optimal outcomes. Healthcare providers should consider congenital ranula cysts as a differential diagnosis for any newborn presenting with a mass in the oral cavity. A ranula is a cystic swelling that occurs on the floor of the mouth due to the obstruction of the sublingual gland duct. While ranulas are typically acquired, there are rare instances where they can be present at birth and are known as congenital ranula cysts. The prevalence of congenital ranula is 0.74% . The terA male baby weighing 3 kg was born to a G4P2L2A1 (Gravida 4 Para 2 Live 2 Abortion 1) mother via normal vaginal delivery at 38 weeks of gestation. The baby cried immediately after birth but had mild respiratory distress. On examination, a bluish, translucent swelling was observed on the floor of the mouth. The swelling was approximately 2*2 cm in size, round to oval, and had a regular margin with a smooth surface , can be useful in confirming the diagnosis and identifying any associated anomalies .Surgical excision is the treatment of choice for congenital ranula cysts. The procedure can be performed using a transoral or extraoral approach, depending on the location and size of the cyst. The surgical approach should be carefully planned to minimize the risk of injury to adjacent structures .Congenital ranula cysts are a rare condition that should be considered in the differential diagnosis of neonatal oral swelling. Diagnosis can be confirmed with imaging studies, and surgical excision is the treatment of choice. A careful surgical approach is required to minimize the risk of complications.


Chylopericardium can be due to a variety of secondary causes like trauma, radiation, tumors, following cardiac surgery, etc., or may be idiopathic due to abnormal lymphatic system and mediastinal lymphangiectasia, which is a rare entity. Here, we present a case of a 34-year-old previously healthy male presenting with idiopathic chylopericardium. 2D echocardiography revealed massive pericardial effusion without features of cardiac tamponade. Following pericardiocentesis, a CT scan of the thorax and MR lymphangiogram were done to arrive at a diagnosis of idiopathic chylopericardium. In addition to medical management, surgical treatment included partial pericardiectomy and sclerotherapy of the mediastinal lymphatic sac. The patient had an uneventful post-operative period. Chylous pericardial effusion may occur due to a variety of secondary causes which include trauma, post-cardiac surgery, radiation, or tumors . Rarely,A 34-year-old male patient presented to our hospital with chief complaints of easy fatiguability and shortness of breath for a period of three months. The patient also noticed a painless diffuse swelling on the right side of his neck for the same time period. There was no history of any significant past medical or surgical illness or any history of trauma. On examination, the patient’s vitals were stable. A soft non-tender swelling with an ill-defined margin was found in the right supraclavicular area. On evaluation, the chest x-ray was suggestive of an enlarged cardiac silhouette. The electrocardiograph was normal. A transthoracic 2D echocardiography was done to find out massive pericardial effusion without tamponade Figure . CompletA contrast CT scan of the neck and thorax was done which revealed multiple hypodense fluid attenuating lesions in bilateral supraclavicular regions, anterior and superior mediastinum along with pericardial effusion, suggestive of lymphatic malformation Figure . To confThe patient finally underwent surgery. Under general anesthesia, a partial pericardiectomy was done. Chylous pericardial fluid was drained with the excision of the retrosternal and extra-pericardial lymphatic sac. Additionally, aspiration and sclerotherapy of the right supraclavicular lymphatic sac were done with the installation of Bleomycin under general anesthesia. The patient had an uneventful pre- and post-operative period.Chylopericardium, first described by Hasebrock in 1886, is a rare entity. Chylopericardium can be due to variety of causes like congenital mediastinal lymphangiectasia, iatrogenic after cardiac surgery, gastric signet ring cell carcinoma, Gorham syndrome (osteolysis that results from lymphangiomatosis with adjacent bone resorption), mediastinal malignant tumors like mediastinal dysgerminomas, blunt or penetrating trauma, infection, radiation, congenital anomalies of the lymphatic system, or primary idiopathic . Since tIdiopathic chylopericardium can occur in any age group and affects males and females equally  with chiPericardiocentesis is done to evaluate the characteristics of the pericardial fluid. Usually, whitish or milky chylous fluid is aspirated which has a high concentration of triglycerides and proteins . DiffereApart from CT scan and MRI, chylopericardium can be diagnosed non-invasively by imaging using Tc99m labeled red blood cells and oral administration of 131I-triolein .Once the diagnosis of chylopericardium is established and the cause is found to be idiopathic, the patient is started on treatment with a low-fat diet that is rich in medium-chain triglycerides. Other medical treatments include total parenteral nutrition and subcutaneous octreotide. Unlike in post-traumatic cases, idiopathic chylopericardium rarely responds to conservative treatment alone . SurgicaTo conclude, chylous pericardial effusion due to lymphatic malformation is relatively rare. The diagnostic approach mainly depends on echocardiography and analysis of the pericardial fluid with respect to cytological, biochemical and microbiological parameters. CT scan and MRI serve as necessary investigations to form the proper etiological diagnosis in these cases. Medical management is often unsuccessful in these cases. Therapeutic pericardiocentesis usually relieves symptoms of cardiac tamponade. Definitive surgical treatment which involves pericardiectomy, excision and sclerotherapy of other lymphatic sacs and thoracic duct ligation can be curative in most of the cases.


We report an unusual case of the vulval sinus with persistent seroanguinous discharge in a 59-year-old postmenopausal woman. Examination revealed a 9-cm isolated sinus tract in the right labiocrural fold. This sinus tract was excised under anesthesia. Histological analysis showed skin with a deep dermal sinus tract showing edematous and heavily inflamed granulation tissue. There was no evidence of malignancy or dysplasia. Hidradenitis was ruled out on histology. This case report summarizes the importance of early diagnosis and prompt treatment involving complete excision of the vulval sinus to reduce long-term morbidity and consequences of this rare entity. This article was previously presented as a poster at the BSCCP Annual Scientific Meeting 2023. A wound that fails to heal in six months or more is defined as a sinus . A chronA 59-year-old woman, mother of three was referred to the gynecology outpatients for evaluation of persistent blood-stained vulvovaginal discharge and intense pruritus over 12 months. She is a known smoker and attends colposcopy regularly for HPV-positive smears. There was no significant past medical, surgical, or family history other than three cesarean sections and spina bifida occulta. On clinical examination, a sinus tract was seen lateral to the right labia majora accompanied by a 1/1cm firm and palpable swelling above it. Inflammatory markers were normal, and an MRI pelvis was requested which confirmed a 6-cm long sinus tract running along the right labia major anterosuperior from the skin surface and did not reveal any involvement of deep structures (Figure Ultrasound pelvis showed endometrial thickness of 6mm. Hysteroscopy showed an atrophic endometrial cavity excluding endometrial causes of bleeding Figure .Examination under anesthesia revealed an isolated 9 cm sinus tract in the right labiocrural fold, discharging blood-stained yellowish fluid at two points. There was no inguinal lymphadenopathy. An intraoperative general surgical input was taken to out rule extension or involvement of deeper perineal structures. Sinus tract was not extending to the anus, vagina, or perianal area. The tract was completely excised by the team. There were no other tracts or sinuses seen. A clinical diagnosis of hidradenitis suppurativa was made as the discharge resembled sebum. However, histopathology showed skin with a deep dermal sinus tract showing oedematous and heavily inflamed granulation tissue and focal surviving squamous epithelium. There was no evidence of hidradenitis, dysplasia, or malignancy. The presence of a chronic inflamed sinus tract characterized by the absence of hair follicles and apocrine glands out-ruled differentials confirmed the diagnosis in our case. An informed consent has been obtained from the patient Figure .Outcome and follow-upPostoperative review at eight weeks showed complete closure of the sinus tract and resolution of symptoms. The patient was followed for one year and did not show any recurrence of signs and symptoms related to this condition.A vulval sinus could be a blind end track that extends from the skin to an underlying area or cavity . The symSeeing multiple sinuses at the same or different locations is a common occurrence. Therefore, utmost attention should be given to exploring the number, location, and extent of these sinus tracts along with special attention given to any connection to underlying cavities. A sinus tract should always be assessed using a probe to assess its length, direction, and depth. Clinically, the external opening is often seen as a small, dimpled area draining pus on manual compression . Other A chronic discharging vulval sinus in women requires careful evaluation and appropriate management to alleviate discomfort and prevent complications including chronic discharge and recurrent abscess formation. Early diagnosis can help women affected by this condition receive effective treatment, leading to improved well-being and a better quality of life. It is crucial to prioritize vulval health and engage in proactive healthcare measures to ensure a positive outlook for women facing such challenges.


Patients commonly present to the Emergency Department for the evaluation of soft tissues masses of various etiology. Point-of-care ultrasound (POCUS) can aid in the initial evaluation of these masses to begin narrowing a given differential. Soft tissue sarcomas are a malignant neoplasm that frequently present in an extremity, and require close follow-up for the evaluation of metastasis and possible resection, among other treatment options. Being able to effectively differentiate between infectious, inflammatory, benign, or potentially malignant pathology for undifferentiated soft tissue masses is critical for Emergency Medicine clinicians to ensure patients receive appropriate treatment and referrals for definitive care.Thigh mass, soft tissue mass, sarcoma, point-of-care ultrasound. Soft tissue sarcomas are a type of mesenchymal tumor with over 70 different histological subtypes.An 86-year-old male with no known medical problems presents to the Emergency Department (ED) with one week of pain and swelling of his right posterior upper leg. His family reports that he has had a small lump in the area for a long time, but the size seems to have increased. The patient describes pain in the affected area with ambulation as well as at rest. On physical exam, there is a firm, mildly tender, moderate-sized mass on the right posterior leg without fluctuance or erythema. Distal pulses are intact and his thigh compartments are soft.3/μL).Point-of-care ultrasound (POCUS) demonstrates a large, subcutaneous mass with areas of mixed echogenicity. The mass contains fluid-filled, anechoic areas with internal septations and absent doppler flow. The majority of the mass appears isoechoic to the surrounding tissues with a hyperechoic border. Computed tomography (CT) of his right thigh shows a 16 x 8.1 x 9.5 cm heterogenous, complex mass within his hamstring muscles, inferior to the femur. His lab work was significant for a white blood cell (WBC) of 17.3 (10In the ED, surgical oncology was consulted. After bedside evaluation, the surgical team recommended that the patient should undergo an outpatient CT chest with contrast to look for metastatic spread and have clinic follow-up. About one month after initial presentation, the patient’s thigh mass was surgically removed. Pathology reports confirmed a high-grade pleomorphic sarcoma.Evaluating a patient with a soft tissue mass in the ED is common. While the majority of these will be correctly diagnosed as inflammatory or infectious in etiology, it is important to keep a wide differential diagnosis. Malignant soft tissue masses may present with the appearance of a fluid collection, leading to the potential for a misdiagnosis.7Ultrasound is a useful modality to include in the initial workup of a patient with a soft tissue mass.7Originally, the mainstay of treatment for extremity soft tissue sarcomas was amputation.4This case demonstrates the importance of considering soft tissue sarcomas in the differential diagnosis of patients presenting with soft tissue masses. In addition, utilizing various imaging techniques including bedside ultrasound are helpful in narrowing down the diagnosis while examining for concerning neoplastic features. Additionally, providing appropriate subspecialty care and ensuring timely follow-up is also necessary. A limitation of this case is that the full treatment course and ultimate outcome for the patient is unknown. While a soft tissue sarcoma is not always an emergent diagnosis, failing to recognize a potentially malignant mass may have significant impacts on a patient’s life.


Background: Syncope is a common complaint in clinical practice. The etiologies and mechanisms can be multiple and complex. Syncope caused by a mediastinal mass compressing the vagus nerve is rare.Case Report: We report the case of a patient who presented to the emergency department experiencing recurrent syncope. Imaging revealed a large, calcified mass in the right paratracheal region. After intracranial lesions, cardiac arrhythmias, and orthostatic hypotension were excluded, we suspected that the syncope was related to vagus nerve compression. The patient underwent surgical resection of a mediastinal mass and had complete resolution of syncopal episodes after surgery.Conclusion: This case outcome suggests that recurrent syncope could be the first symptom of an intrathoracic mass. Intrathoracic masses manifesting with recurrent syncope are rare, and the majority of such cases involve the mediastinum with cardiac or pulmonary artery involvement.3Syncope is a common complaint in clinical practice. Many patients have a brief, benign clinical course with spontaneous recovery, with a vasovagal reflex identified as the most common cause of syncope.We report the case of a patient who presented with recurrent syncope and was found to have an intrathoracic paratracheal mass. Because recurrent syncope caused by a paratracheal mass is poorly described in the literature and is believed to be a rare entity, we present our case to augment the literature regarding this complex pathology.A 35-year-old female presented for daily syncopal episodes and dizziness. According to the patient, she had undergone an extensive workup by cardiologists in another state prior to her move to Louisiana. She initially presented to an outside cardiologist 3 years prior to the current presentation and reported daily syncopal episodes. The workup included the SEEQ external cardiac monitoring system (Medtronic), cardiac stress test, and echocardiography. Around this time, she had an episode of severe bradycardia and cardiac arrest. She was believed to have symptomatic sinus bradycardia, which led to placement of a permanent pacemaker. Although her symptoms initially resolved, they recurred during the following month.She reported experiencing a concussion because of her syncopal episodes, without any resulting orthopedic or neurologic injuries. Her medical comorbidities included fibromyalgia, chronic back pain, chronic migraines, endometriosis, and a 4-cm mediastinal mass located superior to the superior vena cava, determined to be histoplasmosis vs endometriosis by a multidisciplinary tumor board review during her previous outside workup. She did not report palpitations, dyspnea on exertion, paroxysmal nocturnal dyspnea, or orthopnea. She did report dizziness during her initial visit and stated that she often “sees stars” and feels a tightness or clenching in the center of her chest just prior to syncopal episodes. However, she reported that syncopal episodes would sometimes occur spontaneously without these prodromal symptoms.Pulmonology consultation raised no concern for superior vena cava obstruction; however, the report suggested that the mass might be compressing the thoracic ganglia and causing autonomic syncope. Since her pacemaker placement, the patient's symptoms had improved, but she continued to have frequent syncopal episodes. Neurology workup with electroencephalography was negative. The patient was referred to otolaryngology to determine if a paradoxical vocal fold motion disorder could be causing vagal episodes. The patient underwent microlaryngoscopy and botulinum injection into the left vocal cord but had no significant improvement in her symptoms. She was referred to cardiothoracic surgery for evaluation of her chest mass; computed tomography showed a heavily calcified mass in the right mediastinum . After aAfter a discussion of the benefits and risks of the planned procedure, including the possibility that the procedure would fail to improve her symptoms, the patient underwent right thoracotomy and resection of the mass in the right mediastinum. Preoperative chest x-rays showed a calcified mass in the right paratracheal area  and 3. EThe patient was seen in the cardiothoracic surgery clinic 3 weeks after surgery. Her incisions were well-healed and she reported resolution of her syncopal episodes. Postoperative chest x-ray showed resolution of the paratracheal mass .1 The pathophysiology is believed to be secondary to cerebral hypoperfusion, and symptoms such as dizziness, lightheadedness, diaphoresis, nausea, and visual disturbances may precede syncopal episodes.4 Syncope accounts for a large number of emergency department visits and hospital admissions yearly in the United States and has varied etiologies, from benign to life-threatening.5 Most syncopal events have a benign cause, with vasovagal reflex being the most common etiology. Vasovagal syncope usually has identifiable triggers and a characteristic prodrome, with diagnosis made on history and physical examination.2 Other causes include orthostatic, neurogenic, postural, situational, and cardiac, with recurrent syncope occurring frequently in elderly individuals with cardiac comorbidities such as arrhythmias or structural abnormalities.5Syncope is defined as a transient loss of consciousness with associated loss of postural tone, followed by spontaneous recovery.6 Syncope is an uncommon symptom of mediastinal masses, with only case reports demonstrating similar presentations. Dúbrava et al reported the case of a mediastinal lymphoma that caused compression of the left atrium and superior vena cava.7 Venkatraman et al reported a vasovagal effect similar to our case, in which an intrathoracic neoplasm (B-cell lymphoma) caused significant compromise of the right internal jugular vein and encased the right internal carotid artery, narrowing its caliber and inducing recurrent syncope.8 A case reported by Koga et al involved a lung cancer directly invading the vagus nerve.9Mediastinal masses are most commonly thymomas, neurogenic tumors, and benign cysts, and they often present with symptoms of cough, chest pain, or shortness of breath.Our patient presented with a symptomatic mediastinal mass. She had repeated episodes of syncope, followed by complete resolution of symptoms after surgical resection of the mass. This outcome suggests that recurrent syncope could be the first symptom of an intrathoracic neoplasm. Although vasovagal syncope is common, in view of this experience, we suggest that intrathoracic mass remain a differential diagnosis if suggested by the patient's history and physical examination.


Perforation peritonitis is one of the most common emergency presentations in Indian hospitals. Stercoral perforations are rare due to increased intraluminal pressure on the gut wall from impacted feces. This is associated with transmural necrosis. We present a 31-year-old pregnant woman who reported abdominal pain and vomiting at 34 weeks of gestation. The diagnosis was unclear from examination and imaging studies, and a provisional diagnosis of acute appendicitis was made. The patient underwent laparotomy and was found to have fecal contamination and multiple stercoral ileal perforations. The bowel segment was resected and exteriorized as a stoma. Stercoral perforations in the gut are usually a rare cause of inflammatory ailments, which augment pressure-induced transmural necrosis due to a fecaloma or impacted fecalith. Stercoral colitis, the most common form of this spectrum, has a mortality rate of 32-57% . In deveA 31-year-old pregnant woman, 34 weeks of gestation, complained of vomiting for the last two days and obstipation for the last five days. A total of six to seven episodes of vomiting per day containing 250 mL of non-blood-stained fluid were experienced. She also complained of abdominal pain for three days, which was diffuse and more in the right lower quadrant of the abdomen. There was no history of medical comorbidities. On examination, she was mildly pale, dehydrated, and afebrile. Her vitals were stable, with a pulse of 82 beats per minute and a blood pressure of 110/70 mmHg. An abdominal examination revealed tenderness in the right iliac fossa with severe guarding and localized rigidity. All other systemic examinations were within normal limits. A rectal examination was normal. Obstetric examination revealed a single fetus in cephalic presentation with a fundal height of 34 weeks and a high floating head.Blood investigations showed mild anemia with a hemoglobin of 9.8 g/dL and normal white blood cell counts. Liver function tests and renal function tests were normal. A chest X-ray showed no air under the diaphragm Figure .Ultrasonography (USG) of the abdomen showed dilated small bowel loops. There was no evidence of collection, growth, or mesenteric lymphadenopathy. The appendix was not visualized. Magnetic resonance imaging (MRI) showed gross dilatations of the small bowel loops with a maximum caliber of 6 cm in the ileum and a mildly distended cecum. Fat stranding around the ileal loop with minimal free fluid in the abdomen was present. There was no evidence of extraluminal free air. Impacted stool in the ileum could not be clearly commented upon when interrogated retrospectively in the postoperative period. There was a single intrauterine fetus. The appendix could not be visualized Figure .With clinical examination and imaging findings, we had three probable differential diagnoses: perforated appendicitis, perforation peritonitis, and intestinal obstruction.Considering these differential diagnoses in mind and acute appendicitis being the most common surgical emergency in pregnant patients, we planned the patient for an emergency laparotomy. There was fecal contamination of the abdominal cavity in the right iliac fossa, around 150-200 mL. Rest of the peritoneal cavity, fecal contamination was not present. Multiple perforations, measuring 0.5 cm x 0.5 cm, are noted nearly 40 cm from the ileocecal junction Figure .The appendix was normal and in a retrocecal position. The segment of the ileum with perforation had hard and impacted stools. Hence, the bowel with multiple perforations was resected, about 30 cm long, and an ileostomy was done. After the resection of the segment of the ileum with multiple perforations, the remaining distal ileum was brought as a distal mucus fistula. Fetal delivery was performed by lower segment cesarean section (LSCS).Post-operative biopsy of the resected specimen showed transmural necrosis and attenuation of the ileal wall, along with an acute inflammatory infiltrate covered with neutrophilic exudate and inflammatory granulation tissue. The inflammatory infiltrate is transmural and reaches the serosal surface. There is no evidence of granulomas, organisms, or parasites in the studied sections. There was no evidence of vessel thrombosis. She was evaluated with the Widal test and cartridge-based nucleic acid amplification test (CBNAAT), which were negative. She was followed up for around one month with no post-surgical complications. Ileal perforations are a common surgical emergency in developing countries. Infectious etiologies have been found to be predominant, with typhoid being the most common, followed by tuberculosis, trauma, and nonspecific enteritis . AccordiStercoral ulceration is the loss of bowel integrity from inspissated feces pressure effects. The risk factors for stercoral perforations include chronic constipation, male sex, older age, nursing facility residence, use of constipating medications, and evidence of fecal impaction . Fecal iMost stercoral perforations are seen in the sigmoid and rectosigmoid, occurring in 77% of cases . This isPerforations typically manifest with abdominal pain, which localizes to the nearest domain of the perforation. They also present with guarding and rigidity, with or without rebound tenderness. Depending on the amount of fecal contamination, a patient with a small bowel perforation can present with completely stable hemodynamics. On the contrary, few patients present with severe septic shock and require ventilator support. Patients with stercoral ulcers may present either way. Our patient presented with abdominal pain and vomiting but with stable vitals. However, pregnancy was a special challenge for us to manage and prevent fetal or maternal mortality.Most patients with ileal perforation peritonitis have just one or two perforations, whereas the presence of patients with multiple perforations suggests the possibility of an immunocompromised state . UncommoThe diagnosis of ileal perforation might be difficult in atypical situations. A simple erect chest X-ray demonstrates the air under the diaphragm, which reveals perforation. However, the perforation site cannot be determined. Air under the diaphragm may also be absent due to a sealed-off perforation. In stercoral ileitis, the perforation might have been sealed off, which made the presentation atypical and therefore required higher investigations for a proper diagnosis. Contrast-enhanced CT of the abdomen is required for diagnosis. CT shows a hyperemic bowel wall, ascites, and extraluminal air in the peritoneal cavity. The absence of intraperitoneal fluid does not rule out bowel perforation . An MRI The extensivity of the intrabdominal fecal contamination, the general condition of the patient, and the location of the ileal perforation are the determining factors for the type of surgical intervention. A diversion ileostomy is an effective option, as patients usually present with abdominal contamination. It is the procedure of choice in cases with delayed presentation (more than one day) after perforation, hemodynamic instability, extensive contamination with severe enteritis, multiple perforations, and signs of impending perforation.Suppose the involved bowel segment shows signs of impending or multiple perforations within a segment. In that case, segment resection is warranted. Following this, the fate of the resected ends is based on the overall clinical scenario. As mentioned above, these ends can be anastomosed or exteriorized as a stoma. In our case, the patient had delayed presentation and multiple perforations. The involved segment was resected with an ileostomy. To our knowledge, stercoral ileal perforation peritonitis has never been reported in the medical literature. Hence, this would help clinicians have a high suspicion of an early entity diagnosis.Stercoral ileal perforations are rare and have never been documented in the literature. This is the first case reported in pregnant women. The clinical picture may mimic acute appendicitis. Imaging studies help with diagnosis; however, sometimes, the findings are more obvious, and diagnosis may be delayed. Such patients will be ideal candidates for diagnostic laparoscopy and will be treated accordingly. Surgical treatment is the only way to reduce mortality, including segmental bowel resection and ileostomy.


Oral squamous papillomas (SPs) are benign masses commonly growing in the tongue, gingiva, uvula, lips, and palate. A case of an asymptomatic pedunculated squamous papilloma at the center of the soft palate is presented. Both surgical management and histopathologic analysis were conducted. The aim of this report is to stress the importance of early diagnosis and management of common benign oral lesions to prevent their transformation into malignancy. Squamous papilloma (SP) is a common neoplasm of the oral cavity. It is a benign proliferation of stratified squamous epithelium that usually presents as a papillary or exophytic overgrowth in the oral cavity . Its patThey occur in one in every 250 persons, most typically between the ages of 30 and 50, and may sometimes be seen in children below 10 years of age. Most investigations found no discernible gender predisposition or modest male predominance . They apComplete surgical excision of the base of the lesion, along with a small area of the surrounding tissue, is the treatment of choice to remove the lesion and prevent its recurrence .Here, we present a case of squamous papilloma located at the center of the soft palate that had been ignored for more than 25 years. The lesion was managed by surgical excision and had a good prognosis based on histopathologic reports and follow-up appointments.A 36-year-old male with a medical history of anal fistula, gastroesophageal reflux, and left eye astigmatism, no known history of drug allergies, and a habit of smoking 25-30 cigarettes daily was referred to the oral and maxillofacial surgery clinic at King Abdulaziz University, School of Dentistry, to evaluate a soft tissue lesion associated with the soft palate. The patient noticed the lesion during childhood at 10 years of age and reported no history of pain, inflammation, or previous infection. Head and neck examination revealed no abnormalities, tenderness, or swelling. Intraoral examination revealed normal hard and soft tissues in the vestibule, buccal mucosa, floor of the mouth, and tongue. However, multiple non-restorable teeth were present. The intraoral image demonstrated a soft tissue lesion in the center of the soft palate  classification, oral squamous papilloma is a benign hyperplastic exophytic localized overgrowth with a verrucous or cauliflower-like appearance with a sessile or pedunculated base . The lesIn our case, the patient presented with a soft lesion in the center of the soft palate. The clinical appearance of the lesion on the soft palate was well-defined, warty, feather-like, white in color, and firm in consistency. These findings match the clinical appearance of squamous papillomas reported in the literature . AlthougSeveral factors, such as tobacco use, alcohol consumption, hormonal changes, and immunosuppression, are associated with the development of oral squamous papilloma. Moreover, certain strains of human papillomavirus, particularly HPV-6 and HPV-11, have been implicated in the development of oral squamous papilloma ,14.Based on the clinical features of the lesion, a differential diagnosis of papillary hyperplasia, verruciform xanthoma, condyloma acuminatum, and focal epithelial hyperplasia was suggested. Although papillary hyperplasia resembles squamous papilloma, no evidence of a soft tissue reaction to chronic irritation or injury was evident in our study, which is a common reason for the development of hyperplasia. Verruciform xanthomas are commonly found in the gingiva and alveolar ridges. Condylomas are large and have a broader base than papillomas with a pink-red color instead of white. Additionally, focal epithelial hyperplasia resembles multiple squamous papillomas instead of solitary lesions, as observed in our study . The finThe presence of epithelial hyperplasia forming finger-like projections gives the lesion a cauliflower-like appearance. These lesions are treated using routine surgical excision or laser ablation . Other tAsymptomatic lesions are a common finding when intraoral evaluation is performed, but in some cases, the lesion shows a malignant resemblance or transformation to oral squamous cell carcinoma . TherefoSquamous papillomas were classified as benign. Although papillomas are usually nonaggressive and asymptomatic, symptomatic squamous papillomas have been reported. Because the lesions may resemble or transform into oral squamous cell carcinoma, a much more aggressive tumor, rigorous histopathologic assessment of these lesions is necessary. Therefore, prompt diagnosis and surgical removal of the lesion will provide comfort to the patient and avoid subsequent complications.


Cavernous hemangioma is a venous malformation and intramuscular hemangioma is a rare type of hemangioma. Most of these cases are reported in masseter and temporalis muscles, and the number of patients with hemangioma involving sternocleidomastoid (SCM) muscle is relatively less. The present study reported a case of intramuscular hemangioma and a literature review regarding hemangioma in the sternocleidomastoid muscle.The present case was a 24-year-old woman with intramuscular hemangioma of the sternocleidomastoid muscle, manifesting a mass in the right supraclavicular region involving the sternocleidomastoid muscle. The woman was treated with surgery and achieved complete treatment. After surgery, the patient was kept under regular follow-up for the last six months without any evidence of recurrence. Intramuscular hemangioma of the sternocleidomastoid muscle is a rare entity that can present as a mass in the neck region. The treatment approach should be considered according to the diagnosis and site of vascular malformation. Cavernous hemangioma is a venous malformation. The International Society for the Study of Vascular Anomalies (ISSVA) classifies cavernous hemangioma as a low-flow venous malformation . CavernoA 24-year-old woman was referred to the ENT service with the presentation of a painless mass in the right supraclavicular region from 2 years ago. The mass had increased in size over that time. The patient had no history of trauma, surgery, inflammation, fever, nocturnal sweating, weight loss, dysphagia, shortness of breath, or hoarseness. Furthermore, there was no history of cutaneous neoplasms, visceral malignancies, or family members with similar presentation. In her past medical history, she had multiple sclerosis and is being treated with rituximab. A physical examination revealed a 3×4 cm firm, semi-mobile, semi-compressible, none tender, round mass in the right supraclavicular region. The skin over the swelling was normal and non-adherent to the underlying mass. There was no abnormal pulsation or bruit. Moreover, no cervical lymphadenopathy was appreciated. The CT scan of the neck with contrast revealed a heterogeneous solid mass measuring 40×25×20 mm infiltrated the most distal part of the right sternocleidomastoid muscle in the base of the neck containing mottled hyperemic foci. The CT scan report was compatible with mesenchymal sarcoma . FNAC shThe pedicle of the mass in the muscle was ligated, and the swelling was excised completely. Furthermore, there was no recurrence of the tumor at the 6-month follow-up. Histopathological examination confirmed the diagnosis of cavernous hemangioma.A macroscopic inspection of the surgically excised specimen showed a well-defined mass lesion 4.3 × 3.2 × 2.5 cm, revealing a brownish-red solid cut surface with a soft consistency. Microscopic inspection showed a benign vascular lesion featuring cavernous hemangioma composed of large dilated vascular channels lined by flat endothelium .Numerous articles have reported intramuscular hemangioma in the head and neck regions. Most of these cases are reported in masseter and temporalis muscles, and the number of patients with hemangioma involving sternocleidomastoid (SCM) muscle is relatively less. As far as we searched, 12 cases of hemangioma with SCM muscle involvement have been reported in studies , 5-15. WThe present case in this study was female; in other studies, the prevalence of hemangioma in the SCM muscle was higher in females. According to published literature, it is more likely to occur on the right side than on the left side, and it was also present on the right side in our patient. The most common form in the studies was the cavernous type, similar to our study .According to the ISSVA  classification, Cavernous hemangioma is a slow-flow venous malformation . AnotherThe venous malformation can occur in any part of the body. Sixty to seventy percent of cavernous hemangioma occurs on the head and neck . The incIntramuscular hemangioma is a rare type of hemangioma that is reported in less than 1% of all. The masseter muscle is the most commonly reported hemangioma. Other muscles in which hemangioma has been reported include the trapezius, temporalis, orbital muscles, and SCM . CavernoThe present study reported a female of intramuscular hemangioma in the sternocleidomastoid muscle. Intramuscular hemangioma is a rare entity that can present as a mass in the neck region. The treatment approach should be considered according to the diagnosis and site of vascular malformation.


Leiomyosarcoma (LMS) accounts for approximately 5-10% of soft tissue sarcomas, with an estimated incidence in the United States (US) of less than one case/200,000 persons, more frequent in women than men. Approximately two-thirds of LMSs are retroperitoneal, abdominal, and mediastinal. Localized, soft tissue LMSs represent a lower percentage, with the lower limbs and trunk being the most frequently involved sites. LMSs larger than 5 cm  are even rarer, and to date have been little reported in the literature. In this paper, we present the case of a giant LMS of the left lower limb in a 73-year-old patient, who had a mass for about two years, and who, after the first diagnostic biopsy, underwent limb amputation. Macroscopic and microscopic examinations confirmed the infiltration of the underlying tibial bone. We briefly discuss eight other cases described in the literature with similar size, pointing out that the parameters with the greatest impact on prognosis proved to be size >5 cm and depth of invasion. Due to the rarity of this neoplasm, little has yet been done in relation to the most suitable therapeutic treatment of such patients, and larger case series are mandated in order to be able to conduct broader-spectrum studies. Leiomyosarcoma (LMS) accounts for 5-10% of soft tissue sarcomas, with an incidence in the United States (US) of less than 1 case/200,000 people , cases h2 was described and a diagnosis of Grade II leiomyosarcoma according to the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) was made. Two months later, the patient was referred for amputation of the distal portion of the lower limb, and the surgical specimen was sent to the pathology department. On macroscopic examination  system ; Tumor Necrosis (microscopic): >/=50%) Figures -2D.Immunohistochemical staining was strongly positive for smooth muscle actin (SMA) and vimentin Figures -3B whileWith the combination of the histological and immunohistochemical picture, a diagnosis of LMS grade III according to FNCLCC was made, and at the three-month follow-up, the patient did not appear to present a disease recurrence.Soft tissue LMS represents a rarer entity than its retroperitoneal/abdominal counterpart and, by virtue of anatomical localization, tends to grow smaller in size ,6. For tTable Of the eight cases reported in the literature, two cases involved the abdominal wall/abdomen ,15, withFurthermore, it is clear from the case reports that the prognostic factors most indicative of an adverse prognosis are the size of the LMS (>5 cm) and the depth of invasion -15. It iThe main differential diagnoses of LMS are both non-pleomorphic spindle cell tumors and other types of pleomorphic sarcomas . PrimariDespite progress and improved therapies, surgery remains the 'gold standard' for cases such as those reported. In particular, some authors have suggested the use of radiotherapy to eradicate any potential residual neoplasm  while chFurther cases with clinicopathological correlations and more case series are mandated to obtain more information on the best diagnostic, therapeutic, and care management of the patient with a rare neoplasm such as soft tissue LMS.Soft tissue leiomyosarcoma, being rarer than its retroperitoneal/abdominal counterpart, is also less studied, and, therefore, case reports, case series, and original articles investigating this entity are much needed. From the case presented by us, it is quite clear that the latency time can be quite long, but cases of very fast development of LMS have not infrequently been described in the literature. The difficulties concerning the correct determination of the muscular compartment from which the soft tissue LMS may originate are very important to emphasize, although this is not helpful for the treatment or staging of LMS, which remains unavoidable.


Sigmoid-rectal intussusception or invagination is an infrequently documented condition in the adult population, with only a handful of cases reported in the medical literature. The underlying pathological mechanism involves impaired peristalsis, often attributed to a malignant tumor.A 78-year-old patient, with a history of abdominal pain and lower gastrointestinal bleeding, sought care at our emergency department with evident symptoms indicative of large bowel obstruction. Abdominal examination revealed distension and rectal examination found a mass mimicking an internal rectal prolapse. Subsequently, imaging studies confirmed the diagnosis of sigmoid-rectal intussusception. The patient underwent an emergency open sigmoid resection with Hartman's procedure. The postoperative course was uneventful. Anatomopathological analysis revealed the presence of stage I adenocarcinoma. A restoration of digestive continuity was scheduled six months later. One-year follow-up assessments showed no indications of local recurrence or distant metastasis.Sigmoid rectal intussusception stands as a unique and infrequently reported medical entity. The absence of distinct clinical symptoms often renders diagnosis a challenging task, with confirmation typically relying on radiological findings. In contrast to the non-surgical approaches employed in pediatric cases, intussusception in adults necessitates surgical intervention due to its predominantly malignant underpinnings.While sigmoid-rectal intussusception is an exceedingly rare occurrence, its manifestation with a multitude of non-specific symptoms can complicate clinical recognition. Nevertheless, it should be duly considered as a potential etiological factor in cases of large bowel obstruction, particularly when suggestive signs are found on rectal examination. •Intussusception is an exceptionally rare occurrence in adults.•Sigmoid-rectal intussusception is the least common subtype of intestinal intussusception.•The majority of adult colonic intussusceptions are of malignant origin.•Sigmoid-rectal intussusception should be considered as a potential cause of large bowel obstruction, warranting a systematic digital rectal examination.•A pre-resection reduction maneuver is mandatory in this intussusception subtype in order to preserve the rectum. While the precise mechanisms underlying this condition remain unclear, advanced theories center around the correlation between impaired peristalsis and bowel lesions. Although relatively common in pediatric cases, it is an exceptionally rare occurrence in adults, constituting 1–5 % of all cases of bowel obstruction . Colorec2A 78-year-old patient, with no medical or surgical history, was admitted to our surgery ward due to symptoms suggestive of a large bowel obstruction that had been progressing over the past 24 h. These symptoms included abdominal pain, important abdominal distension, and complete incapacity to pass stool. Over the course of the last two years, the patient had recurrently experienced pain in the left iliac fossa, often accompanied by constipation and hematochezia. As these symptoms resolved spontaneously, the patient did not seek medical attention.On examination, the patient was conscious and had a blood pressure of 120 / 70 mmHg, a pulse rate of 95 beats per minute, and a respiratory rate of 20 breaths per minute. The abdomen was distended, without signs of abdominal masses or incarcerated hernias. The rectal examination was positive for blood and revealed a circular, painless, prolapsed mass engaged in the lower rectum, 5 to 6 cm from the anal canal. While simulating defecation, the mass became circumferential. Urgent complete blood tests showed anemia with a hemoglobin level of 9 g/dl, and normal white blood cells and platelet counts. No renal function impairment or electrolyte disorders were found. An emergency abdominal US  and CT sAfter a short resuscitation, the patient underwent an urgent laparotomy. Intraoperatively, we discovered a long sigmoid-rectal intussusception a. The su3While it is a routine emergency in pediatric practice, adult intussusception is a rare diagnosis that represents 5–10 % of all intussusceptions combined . The exaAdult intussusception can be classified into four subtypes based on the location of the proximal and distal segments. Among these, sigmoid rectal intussusception stands out as the less frequently encountered subtype, with only a handful of cases documented in comprehensive literature reviews ,8. The mTypically, an abdominal physical examination does not reveal specific signs. In a few reported cases, a mass was found protruding throughout the rectum, thus mimicking complete rectal prolapse . We beliAs for the management of this condition, barium enema is the first line of treatment in pediatric cases. Engaging in this practice with adults is not advised due to heightened concerns surrounding the prevalent malignant etiology associated with adult intussusception . Surgery4Sigmoid-rectal intussusception is an uncommon occurrence in adults. Due to its non-specific symptomatology, arriving at a diagnosis can pose a challenge. Nevertheless, it should consistently be considered as a potential cause of large bowel obstruction, warranting a systematic digital rectal examination. Employing advanced imaging techniques enables a precise and timely diagnosis. While surgery constitutes the fundamental approach to treatment, it is imperative to carefully weigh various critical factors before determining the course of action for the patient.Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval was deemed unnecessary by our institutional ethical committee, as the paper is reporting a single case that emerged during normal practice.Nothing to declare.Anis Hasnaoui: Conceptualization, Writing-Reviewing and Editing. Racem Trigui: writing-Original draft preparation. Mohamed Ben Hassine: Data curation. Ahmed Haggari: Writing-Reviewing. Houda Bellamine: Data curation. All authors read and approved the final manuscript.Anis HasnaouiNot applicable.Nothing to declare.


Traumatic cervical arteriovenous fistulas are rare, accounting for only 4% of all arteriovenous fistulas. They can be caused by penetrating, or rarely, blunt trauma, resulting in high-pressure arterial blood draining directly into a vein, decreasing distal perfusion. They are seldom reported as a complication of a carotid paraganglioma surgical resection. Historically, arteriovenous fistulas were treated initially conservatively, after that, surgically; nowadays, endovascular treatment, when feasible, is the preferred method as it offers advantages over surgery. This case report describes a rare traumatic cervical arteriovenous fistula that developed after a carotid paraganglioma resection and was successfully treated using coils and Onyx embolic agent via endovascular embolization. After successful embolization, the patient had a smooth recovery and remained stable. In conclusion, vascular injury seems to be the only constant in all acquired cervical arteriovenous fistulas independent of the trauma mechanism; and endovascular treatment, when feasible, is preferred over surgery as it offers superior advantages. An arteriovenous fistula (AVF) is an anomalous connection between the arterial and venous systems without an intervening capillary network. AVFs can be caused by iatrogeny, penetrating trauma, or, rarely, blunt trauma, resulting in high-pressure arterial blood draining directly into a vein, decreasing distal perfusion -3.The surgical resection of a carotid paraganglioma can be complicated by dysphagia (10%), facial hemiparesis (6.8%), bleeding (6.8%), hematomas (3.8%), hemiparesis 3.4%), and sinus bradycardia (3.8%); however, an AVF is a rare complication, scarcely reported in the literature [%, and siWe encourage other authors to report more cases like ours to provide further insight into the epidemiology, management, and outcomes of CAVFs, ultimately contributing to the development of evidence-based guidelines and improving patient care.A 54-year-old male presented to the emergency room with painful facial swelling and a pulsatile facial mass. In 2017, the patient had undergone surgery to remove a left carotid paraganglioma requiring the ligation of the middle third of the left external jugular vein. This procedure was complicated by a left vagus nerve injury and ipsilateral vocal cord palsy.On admission, bulging of the left facial vein was identified during the physical examination, accompanied by signs of venous hypertension on the left facial and left temporal vascular territories, corresponding to the facial mass and swelling reported by the patient; hoarseness secondary to vocal cord palsy was also present. The rest of the examination was unremarkable. A head and neck computed tomography angiography suggested a large CAVF from the left facial artery to the left facial vein Figures -1C. Due Therefore, embolization was performed via direct puncture of the dilated left facial vein using a PX SLIM delivery microcatheter  to deploy 16 detachable coils and inject a total of seven vials of Onyx 18 through an Apollo Onyx delivery microcatheter  Figures , 3B. A pCAVFs are rare entities; they account for only 4% of all AVFs, and so far, all the information on its epidemiology is comprised of case reports . AlthougThere are multiple variations for facial vein drainage; according to Dalip et al. in 2018, the facial vein can drain into the internal jugular vein, into the external jugular vein, or into the subclavian vein . In our Historically, AVFs were treated conservatively; later, surgery was the only method of treatment, and nowadays, endovascular treatment, when feasible, is the preferred method as it offers advantages over surgery, like less disability, less bleeding, less post-operative pain, and a faster recovery time ,9. EndovIt is crucial to thoroughly understand the functional vascular anatomy (FVA) of the head and neck to plan an embolization procedure effectively. This concept emphasizes the interconnectedness of adjacent vascular territories , which can serve as potential collateral pathways in the event of vascular occlusion . For exaKnowing the anastomoses between the external and internal carotid arteries is relevant to prevent accidental embolization, which can be a complication of transarterial embolization. Loon et al. in 2017  reportedThis study highlights the importance of recognizing and adequately managing CAVFs, a rare entity that accounts for only 4% of all AVFs. Understanding the FVA of the head and neck is crucial when planning an effective embolization procedure. Endovascular treatment offers several advantages over surgery, including less disability, bleeding, post-operative pain, and faster recovery time. Our case demonstrates the safety and effectiveness of the transvenous approach for select patients with CAVFs, particularly those at risk of iatrogenic embolization with the transarterial approach. Reporting more cases like this case can provide further insight into the epidemiology, management, and outcomes of CAVFs, ultimately contributing to the development of evidence-based guidelines and improving patient care.


Giant greater omental cysts with associated massive hemorrhage are rare. We encountered a 16-month-old boy with a four-day history of acute abdominal pain, distension, and paleness. Physical examination revealed a blood pressure of 74/27 mmHg. No well-defined masses were observed on abdominal palpation. The hemoglobin level on admission was 24 g/L. After initial resuscitation and blood transfusion, a computed tomography (CT) scan was performed, revealing a giant cystic mass with an intracystic hemorrhage. The diagnosis was confirmed via exploratory laparotomy, and the cyst, with the attached partial omentum was removed. Pathological findings revealed a simple cyst originating from the greater omentum. The patient recovered uneventfully and remained well during the two-year follow-up period. We reviewed the literature published over the last 27 years on cases of omental cysts to evaluate demographic characteristics, clinical presentations, complications, diagnostic tool options, and surgical approaches. The estimated incidence is 1 in 20,000 admissions to a pediatric hospital  and amon2.12/L, and hematocrit 7.8%. The white blood cell count was 9.5 × 109/L and the platelet count was 304 × 109/L. Other laboratory parameters, including coagulation screening and serum chemistry, were within normal limits. The patient was immediately fluid resuscitated and received a massive blood transfusion, including 600 mL of concentrated red blood cells and 100 mL of fresh frozen plasma. The patient responded well to therapy and his hemoglobin level reached 92 g/L before surgical intervention. Point-of-care ultrasonography revealed a large anechoic mass with dense debris echoes, suggestive of hemorrhage into the cyst. A chest X-ray before surgery revealed no mass or hydrothorax. Abdominal computed tomography (CT) revealed a cystic unilocular hypodense lesion from the subdiaphragmatic space to the pelvis, measuring 18 × 17 × 10 cm , simple cysts , and inflammatory melanotic cysts . In the present case, the pathological findings revealed a simple unilocular cyst lined with mesothelial cells.Based on the literature review, the results of the pathological diagnosis  revealedClinically, an abdominal mass may mimic an ovarian cyst in female children 16%). Of the 68 reported cases, 27 (39.7%) patients experienced complications, including massive hemorrhage 26.5%), torsion (5.9%), infection, small bowel obstruction, and intestinal perforation. Profound acute anemia is usually associated with massive intracystic hemorrhage    , 22, 32,, 32.4%) , 32, 39,, 32.4%) , have be, 32.4%) , 49.It has been reported that the creation of a low-pressure pneumoperitoneum without compromising the cardiovascular physiology is possible for large intra-abdominal cystic lesions . ControlIn conclusion, omental cysts are rare. The diagnosis may be difficult because of nonspecific symptoms. Complete open or laparoscopic cyst removal is recommended to prevent potential complications and recurrence. We present the case of a toddler with a giant omental cyst complicated by a spontaneous massive hemorrhage leading to profound anemia and shock. Our case study reveals the importance of early recognition and proper management of this potentially fatal complication in patients with giant omental cysts.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical approval was not required for the study involving human samples in accordance with the local legislation and institutional requirements because . Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.FC: Data curation, Methodology, Software, Validation, Writing – original draft, Writing – review & editing. XuX: Data curation, Supervision, Writing – original draft, Writing – review & editing. XL: Data curation, Methodology, Writing – original draft, Writing – review & editing. SS: Data curation, Methodology, Writing – original draft, Writing – review & editing. ZL: Data curation, Methodology, Writing – review & editing. XiX: Data curation, Methodology, Writing – original draft, Writing – review & editing. TF: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. LG: Data curation, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing.


Small bowel mucormycosis is a rare entity with few reports in the literature. Mortality rates secondary to necrosis and perforation remain above 85 %, with an increase in populations at risk noted.This is a case report of a survivor of penetrating trauma who sustained small bowel injuries and was managed with damage control surgery. He required relook laparotomies due to extensive contamination and subsequently developed progressive ischaemia and necrosis of areas of his small bowel – histology confirming mucormycosis. There were no apparent risk factors noted in this case. Early addition of Amphotericin B and prompt surgical management resulted in a positive outcome. The patient was discharged from the hospital successfully. No further complications were noted post-discharge.Small bowel mucormycosis can be a challenging diagnosis and requires a high index of suspicion. The lack of traditional risk factors should not deter a surgeon from considering this diagnosis in trauma patients as the micro-invasive properties of this organism can result in unexpected gastrointestinal ischaemia. Favourable outcomes are associated with prompt surgical debridement, histopathological diagnosis, and appropriate antifungal therapy.Gastrointestinal Mucormycosis is a diagnosis that should be considered in trauma patients with unusual patterns of ischaemia. Prompt therapy can result in positive outcomes. •Small bowel mucormycosis is rare but can occur in trauma patients.•A high index of suspicion and identification of this rare cause is essential.•Prompt surgical debridement and Amphotericin is important for good patient outcomes. Mortali2A 29-year old man presented to our Level 1 Trauma unit in Johannesburg following a penetrating stab injury to the abdomen. He sustained a 10 cm laceration over his left lower back with subsequent bowel evisceration. The bowel was noted to be dusky on arrival, with associated perforation. He came in hypotensive with a blood pressure of 75/55 mmHg and a pulse rate of 109. He was resuscitated in our emergency department as per ATLS®  principlThe small bowel perforations were debrided and primarily repaired. The left ureter was managed, and bleeding from the lumbar vessels was controlled by means of haemostatic sutures. He received a massive transfusion in the form of four units of packed red cells, four units of fresh frozen plasma and one mega-unit of platelets intra-operatively. Due to the patient's ongoing haemodynamic and metabolic instability combined with his coagulopathy, swabs were packed into the retroperitoneal bed of the injury site, and temporary abdominal closure was achieved by means of a vacuum-assisted dressing. He was then transferred for further resuscitation in the Intensive care unit (ICU), and a subsequent relook laparotomy was planned for definitive surgery as part of damage control principles .His goal-directed resuscitation continued in the ICU, where he was weaned off low-dose inotropes  with an improving metabolic acidosis and lactate of 1.5 on Day 1 post-surgery. As per unit protocols, only preoperative prophylactic antibiotics were given. He was noted to have an acute kidney injury (KDIGO Stage 1) without any acute indications for dialysis. Electrolyte imbalances were corrected, and he was then started on enteric feeds via his nasogastric tube.At his planned relook, small bowel repairs remained intact with ongoing contamination noted in the peritoneal cavity due to a missed posterior gastric wall injury (AAST) Grade II. Given the contamination, he was started on empiric broad-spectrum antibiotics (Amoxycillin-Clavulanic acid), an antifungal (Fluconazole), and planned for a further relook and washout in 48 h. He required an additional unit of blood intraoperatively, and his acute kidney injury remained unchanged. His antibiotics were subsequently escalated to empiric Imipenem following positive gram-negative bacillus blood cultures as per unit antibiogram and microbiology recommendation.Suspicious lesions unrelated to his initial injuries were noted on the small bowel at his further relook (done due to extensive contamination at prior relook). The patchy features then progressed at follow-up surgery, where resection of the affected segment of the bowel was carried out , Fig. 2.The patient completed a 21-day course of Amphotericin B as recommended by the infectious disease specialists, with normal renal function on completion. He was discharged from the hospital with normal outpatient follow-up, revealing healthy weight gain and regular bowel habits.3The most common site of GIT mucormycosis is the stomach, followed by the colon, with jejunal involvement being very rare in the literature . MortaliIn immunocompetent hosts, postulated risk factors include burns and nosocomial infections associated with cutaneous mucormycosis. Trauma is another postulated factor, with a study in India showing an up to 22 % association with cutaneous mucormycosis . In thisThe pathologic hallmark of mucormycosis is infarction of host tissue resulting from angioinvasion by hyphae. This gives rise to necrotic ulcers with resultant acute abdominal pain, hematemesis, perforation and peritonitis . Given tKey strategies to avoid this dismal prognosis are early diagnosis, prompt surgical management, and antifungal therapy, as was the case in our patient. Recommendations at large are not specific, however, and there is no recognized optimal course of therapy. The initiation of a polyene therapy  within five days of diagnosis has been associated with survival improvement . While nSurgical debridement of infected tissue thus appears to be a critical component to complete eradication , and giv4Given the global increase in at-risk patients with the steadily rising epidemic of obesity and diabetes mellitus and our population with HIV and tuberculosis, there is a dire need for improved diagnosis and management of mucormycosis . At this5The work has been reported in line with the SCARE criteria .Written consent has been obtained from the patient.Ethics Approval was obtained ON 06/09/2023. Protocol No M230972.No funding was required for this research.Malini Bhana – writing of paper.Naadiyah Laher – writing of paper.Maeyane Moeng - organized the manuscript and revised the paper.Nathan George McGrath – contributed the histology and slides.Prof MS Moeng.N/A.The authors did not require any funding and have no conflicts of interest to declare.


Sclerosing/spindle cell rhabdomyosarcoma (s-scRMS) is a rare variant of striated muscle tumours. It has been recognised as an individual entity, the fourth subtype of rhabdomyosarcoma in the latest WHO classification. In the paediatric population, it occurs more commonly in the paratesticular area, whereas in adults, it occurs more commonly in the head and neck region. It has distinctive characteristics in terms of its histopathological and immunochemistry findings, which help in accurate diagnosis. The mainstay of treatment is a multimodal approach, i.e., surgery, chemotherapy, and radiation therapy. However, no standard care is still being established internationally for adult cases. In adults, this tumour has a poorer prognosis as compared to children. We describe a patient with s-scRMS of the lower limb who has undergone wide local resection of the tumour with surgical reconstruction of the distal tibiofibular joint with autograft and its two-year outcome. Rhabdomyosarcoma (RMS) is a type of soft tissue malignancy that is most commonly seen in children and rarely in adults . It is tA 44-year-old lady with no significant past medical history presented with a one-year history of right ankle swelling that gradually increased in size. There was a history of trauma, where her feet were hit by a steel bar prior to the onset of the swelling. The patient did not seek medical attention initially as the swelling did not affect her activity of daily living. She subsequently started to feel a dull aching pain four months prior to our consultation and ankle stiffness, which was aggravated by prolonged standing and walking.One month prior to the first consultation, she began to have pain at night, which was relieved by hanging her leg to the side of the bed. She did not complain of any constitutional symptoms or pain and swelling elsewhere. On examination, the right ankle swelling was firm, with undefined margins located at the posterolateral aspect of the right leg extending down to the lateral ankle. The swelling was not warm nor tender, and the Tinel sign was negative. The distal neurovascular function was intact. However, the ankle range of motion, particularly dorsiflexion, was limited due to pain. There was no inguinal lymph node palpable.The right tibia-fibula radiograph shows no obvious bone lesions. As shown in Figure The patient underwent six cycles of neoadjuvant chemotherapy of the VAC regime, which consisted of IV vincristine, IV actinomycin, IV cyclophosphamide, and IV doxorubicin. A repeat MRI following neoadjuvant chemotherapy of the right tibia-fibula was obtained and showed stable disease in terms of the tumour response. Three weeks after the completion of her sixth cycle of chemotherapy, she underwent a wide local excision of the tumour.The patient was positioned supine on a radiolucent table under general anaesthesia. A sandbag was placed beneath the ipsilateral buttock to rotate the leg internally. A straight 20-cm longitudinal incision was made in line with the posterior margin of the fibula, starting from proximally. The incision was continued a further 2 cm distally to the tip of the fibula and curved slightly anteriorly. This large incision was done to expose the soft tissue mass that had the encased distal third fibula. A wide local excision was performed, which also included the previous incisional biopsy scar. The encased 15 cm of the distal third fibula was excised using an osteotome and was left with only 3 cm of the tip of the distal fibula. The osteotomy site was decided based on the location of the lesion with a 2-cm margin from the lesion proximally and distally. The 3 cm of the distal fibula was kept, as it served as the attachment of the lateral ankle ligament complex to contribute to the stability of the ankle. The distal tibiofibular joint was reconstructed in the same surgical setting using a tricortical bone graft that was harvested from the patient’s ipsilateral iliac crest, as represented in Figure The patient was discharged one-week post-surgery with no immediate complications. Subsequently, the patient received 25 fractions of radical radiotherapy and, concurrently, three cycles of consolidation chemotherapy with the same VAC regime, which consisted of IV vincristine, IV actinomycin, IV cyclophosphamide, and IV doxorubicin. The histopathological examination of the specimen obtained from the surgery showed cellular fascicles of spindle cells arranged in clusters and cords within a sclerotic collagenous background. The immunohistochemical staining showed that the tumour was positive for desmin and MyoD1 and negative for CD34 and S100.One-year post-surgery, the patient was ambulating with minimal pain and stiffness in the ankle joint. The radiograph showed that the autograft was not united to the tibia bone, as shown in Figure In adults, RMS is a rare malignancy, and it only makes up <5% of all sarcomas. However, cases of adults affected by the new variant of s-scRMS are more uncommon; hence, only minimal data on clinical course, treatment regime, and prognosis are available in the literature. Similar to other soft tissue malignancies, multimodal therapy is required to manage s-scRMS. Internationally, there is no standard treatment described for adult patients. The chemotherapy medications that are typically administered in this type of sarcoma are vincristine, doxorubicin, cyclophosphamide, actinomycin D, ifosfamide, or etoposide . It is kIn our case, the patient had six cycles of neoadjuvant chemotherapy with a VAC regime and showed stable disease after completing her sixth cycle, as evidenced by the MRI findings. Fortunately, our patient’s tumour occurred in her right leg, which allowed a better potential for tumour resection with a clear margin. The tumour encased the distal third of the right fibula. Therefore, it had to be excised with the encased fibula, which left only 3 cm of the distal fibula tip along with the ligaments. The literature proposed that ankle function can generally be preserved when there is a remnant of the distal fibula at least 20 mm above the distal tibiofibular joint. If this is not possible, reconstruction is required because distal fibula resection can cause ankle instability, valgus ankle deformity, and, eventually, secondary osteoarthritis -6. HowevDieckmann et al. reported a case series of wide resection of the entire distal fibula due to malignant bone tumours and employed two techniques of arthrodesis to reconstruct the distal fibula, which were done using screws and retrograde hindfoot nail . In thisThere are also case reports of distal fibula giant cell tumours treated with wide tumour resection, and the skeletal reconstruction technique utilised by the authors was done using a tricortical iliac crest bone autograft ,8. In bos-scRMS is a rare subtype of RMS. There is still no standard care being established internationally for adult s-scRMS and the ideal reconstruction technique of the distal tibiofibular joint due to its rarity and limited literature. The advantage of our technique is that it is easily reproducible, and a stable ankle has been achieved. Additional studies may give us more understanding of its clinical course and response and also the outcomes towards certain treatment modalities.