Intraspinal extradural synovial cysts are a rare occurrence at the spinal cord level and thus a rare cause of myelopathy. Synovial cysts usually present in the more mobile lumbar and cervical parts of the spine; however, they may also arise in the thoracic spine. We present a case of a 59-year-old male with a left upper thoracic synovial cyst at T2-3 causing disabling, progressive myelopathy, and an incomplete spinal cord injury syndrome with inability to ambulate. An urgent decompressive laminectomy with bilateral facetectomies, cyst excision, and posterior fusion was performed. Subsequently, the patient recovered full function. Synovial cysts should be considered in the differential diagnosis of progressive thoracic myelopathy. This is only the sixth reported case of a synovial cyst of this kind occurring between the levels of T1 and T7. Urgent surgical decompression is the recommended treatment. Intraspinal extradural synovial cysts are a rare cause of myelopathy, and when they occur, they most commonly present in the lumbar and cervical spine. Such cysts can also appear in the thoracic spine, although such cases are rare. We present a case of a 59-year-old male with a left-sided intraspinal, extradural synovial cyst at the T2-T3 levels on the left resulting in an inability to ambulate and paresthesia in bilateral lower extremities. A laminectomy and excision of the cyst with fusion from T2-T4 was performed resulting in complete resolution of symptoms. There are only 5 reported cases of synovial cysts in the upper thoracic spine. Laminectomy, with cyst excision, is the treatment of choice, although steroid injections and percutaneous drainage have been described in the literature.Patient is a 59-year-old male who sustained a minor impact to his back one month prior to presentation. He was evaluated by a pain management specialist for chief complaint of back pain and ambulatory dysfunction. An MRI of the lumbar spine was performed which demonstrated mild, multilevel spondylosis. He was referred for physical therapy of the lumbar spine and was prescribed NSAIDs and muscle relaxers. He was reevaluated and reported worsening gait and an improvement in pain. He was referred for a lumbar epidural injection. He was reevaluated again two weeks after the epidural . At that time, he was completely wheelchair bound. He endorsed difficulty with bladder control for two days. He was referred to the emergency department for an immediate evaluation. At that time, he reported mild (3/10) pain in the lumbar spine. He denied neck pain, thoracic pain, arm pain, or leg pain. He denied numbness or paresthesia in any distribution including the chest wall.The patient's physical examination revealed 2/5 strength in the left iliopsoas, quadriceps, tibialis anterior, EHL, and gastrocnemius. His right lower extremity strength was 4/5 in the left iliopsoas, quadriceps, tibialis anterior, EHL, and gastrocnemius. He had decreased sensation below the nipple line bilaterally. He had normal digital rectal tone. He had no sensory loss in the perineal region. He had no clonus or Babinski sign. He had 1+ reflexes in all distributions.A CT scan of the thoracic spine was ordered and found to be negative for any acute pathologic process. An MRI of the thoracic spine demonstrated a large high T2 intensity, low T1 intensity, heterogenous, and extradural round mass at the level of T2-T3 on the left side. There was no contrast enhancement. There was severe cord compression. There was acute cord signal change at the T2 level .The patient was admitted to the intensive care unit, and intravenous steroids were administered with no significant improvement prompting surgical management.The patient was taken to the operating room for surgical intervention. Due to the location of cyst, as noted on preoperative imaging, a full laminectomy of T3 was performed first to define a normal region of dura. During the approach, the T3-4 interspinous ligament was resected. A midline laminectomy and decompression of T1, T2, and T3 was performed followed by complete excision of a large 3 cm × 1.5 cm synovial cyst . The cysImmediately after surgery, the patient was at his preoperative baseline level. He had an uneventful postoperative course. He was discharged to an inpatient rehabilitation facility and eventually home. Final pathology report resulted in a diagnosis of a benign synovial cyst. The patient was evaluated at 2, 6, and 10 weeks postoperatively. At his two-week follow-up, his strength had substantially improved to at least four out of five in all distributions. By the sixth week postoperatively, patient's strength was fully restored to five out of five strength bilaterally in all distributions with no remaining paresthesia. At the patients tenth week postoperatively, his strength had remained full with no recurrence of symptoms and complete resolution of symptoms. A follow-up MRI was obtained three months postoperatively and revealed persistently adequate decompression of the spinal cord with no cyst recurrence as compared to preoperatively .We present a case of a relatively young male in the setting of a thoracic synovial cyst. Synovial cysts in themselves are rare in the spine; however, when they are identified, they typically arise in the lumbar spine –4. When Patients are typically treated conservatively initially with analgesics, immobilization, and occasionally CT-guided aspiration with, or without, steroid injection , 10. GraJuxtafacet synovial cysts are rare, but the rate of diagnosis has increased due to the use of MRI. This pathology is exceedingly rare in the thoracic spine, and upper thoracic presentation is even more infrequent. In patients who develop ambulatory dysfunction, a thorough workup for thoracic pathology should be conducted even in the absence of thoracic pain. The presence of a synovial cyst should prompt continued evaluation as the cyst can increase in size leading to progressive myelopathy. Synovial cysts do not necessarily illicit axial back pain. In the case presented, it is hypothesized that the minor trauma the patient experienced caused inflammation that may have lead to the synovial cyst expansion. Nonsurgical management has been described; however, surgical excision is recommended as symptoms commonly persist with nonoperative management. This patient had an incomplete Brown-Sequard presentation, which typically have a good clinical prognosis. Facetectomy with posterior spinal fusion after cyst excision should be determined on a case by case basis but should be considered to help prevent cyst recurrence. When ambulatory dysfunction is present, operative intervention should be urgently completed to optimize patients' chance of improvement.


Tuberculous (TB) disease remains an endemic pathology in Tunisia. the ileocecal region is the predominant site of involvement while gastroduodenal tuberculosis is very rare, this form is often presenting as one of the complications, mainly upper gastrointestinal stenosis or exceptionally as a perforation.We describe a case of female patient aged 33 years-old presented with a 2-day history of acute abdominal pain, with a tenderness of the right hypochondrium and the epigastrium, ultrasound of the abdomen revealed gallbladder distension with a wall thickening.The diagnosis of acute cholecystitis was suspected and the patient had an exploratory laparoscopy that revealed the presence of a perforated duodenal ulcer which was blocked by the gallbladder and several peri-duodenal lymph nodes. Cholecystectomy was performed and the edges of the ulcer were resected and the ulcer was sutured. Histological examination revealed duodenal tuberculosis and the patient was referred to the TB eradication program. •The primary duodenal tuberculosis is very rare.•The perforation is an exceptional complication its described for the second time in literature.•The diagnosis is difficult with no clinical and endoscopic features.•Surgical approach is recommended in complicated forms with antituberculos treatment. Laboratory analysis revealed a white blood cell count of 12,000/mm3 and microcytic hypochromic anemia. The chest x-ray was normal.Ultrasound of the abdomen revealed gallbladder distension with a wall thickening and peri-cholecystic fluid.In view of these data the diagnosis of acute cholecystitis was suspected and the patient had an exploratory laparoscopy that revealed an attachment between the gallbladder and the duodenal bulb, several peri-duodenal lymph nodes, the largest of which was 2cm, Because of technical difficulties, a conversion to open surgery was decided. Then a careful dissection showed the presence of a perforated duodenal ulcer which was blocked by the gallbladder . CholecyThe postoperative follow-up was simple and the patient was discharged on day 5.Helicobacter pylori or dysplasia. Examination of the peri-duodenal lymph node and the gallbladder lymph node showed caseating necrosis  was started and given subsequently for 6 months. The patient is doing well on follow-up with no recurrence.3Intestinal tuberculosis is the second most common form of gastrointestinal tuberculosis . The sitThe diagnosis is often difficult due to the paucity of symptoms. Rao et al. in a review of 23 consecutive cases of gastroduodenal tuberculosis noted that vomiting (60.8%) and epigastric pain (56.5%) are the most common presenting symptoms .With the absence of pathognomonic clinical or endoscopic features, complications are usually the most common cause of diagnosis, dominated by gastric outlet obstruction and gastrointestinal bleeding , while pOur case report is the second one to document this type of complication due to the rarity of the form of duodenal tuberculosis and the difficulty of diagnosis.In the early stages, there are no pathognomic features, endoscopy may reveal duodenal bulb deformity and biopsy has a poor yield even in ulcerated lesions, it rarely reveals granulomas and often shows non-specific inflammatory lesion, Guilinsky et al. in a review of 27 patient who underwent endoscopic biopsies of duodenal tuberculosis, 20 had nonspecific lesions and granulomas were found in only 7 patients . Koch baA chest x-ray may show evidence of pulmonary TB in up to 20% of cases, in our patient the x-ray was normal.The CT-scan may show a thickening of the gastric or duodenal wall, associated with enlarged local lymph nodes, it may be the only clue to diagnosis .The predominant complication is obstruction and perforation is rare because of the surrounding inflammatory fibrosis induced by the ulcer.This difficulty of diagnosis and the absence of specificity of endoscopic and radiological features may explain why most patients must undergo surgery before confirming the disease. However, surgery is not indicated as a first-choice procedure in chronic, uncomplicated cases, because intestinal tuberculous lesions often regress or disappear under appropriate antituberculous medication.In the case of our patient, the duodenal perforation was blocked by the gallbladder that explains the absence of peritonitis like in the case reported by Berney et al. , but the4Although it is uncommon, duodenal tuberculosis should be considered in patients with gastric symptoms or lesions of unknown etiology, and it should be kept in mind even in the case of negative biopsies. Patients presenting a diagnostic dilemma or with complications require surgery.No sources of funding.There is no ethical committee in our country (Not applicable for this Manuscript).Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All authors contributed to the study design.All authors read and approved the final manuscript.This is not a research it's a cases report.Atri Souhaib.Not commissioned, externally peer reviewed.All authors declare that they have no any conflicts of interest.


Inflammatory pseudotumors of the kidney are an infrequent entity. More frequently described in the lung, the genitourinary tract location is rare. Commonly described in the bladder, the kidney damage remains exceptional. Herein, we report the case of 60 years old man with a history of flank pain, initially diagnosed with a locally advanced left renal carcinoma invading the left colon. Then, after performing a laparoscopic radical nephrectomy, the histopathological diagnosis of inflammatory pseudotumor of the left kidney has been made. Inflammatory pseudotumors of the kidney are a rare entity. More frequently described in the lung, the genitourinary tract location is rare . CommonlA 60-year-old man has been presented with a year history of apyretic left flank pain. The clinical exam was normal, and the urine was clear. The first computerized tomography has shown a pelvic and caliceal dilatation associated with an aerial content and a hydroaeric level in the left renal pelvis. Moreover, the excretory phase of the uro-CT shows a contrast medium not only in the renal pelvis but also in the left colic angle extending to the transverse colon. These findings confirmed the diagnosis of a left renocolic fistula Figures .To certify the confirmed etiology of the fistula and to understand its genesis, we performed a magnetic resonance urography. It has revealed a 41 × 38 × 41 mm lower pole left renal mass, rounded with irregular contours, and low signal intensity in T2-weighted spin-echo images. Outwards, the renal mass invaded the left colic angle noting the gadolinium flow to the colic lumen certifying the renocolic fistula. Inner, it infiltrates the proximal ureter what is causing 37 mm hydronephrosis. Backward, the mass is closely adhering to the psoas muscle Figures .A 6 mm unique regional lymph node has also been demonstrated. The thoracic computed tomography did not reveal any metastasis. The tumor is then classified as a T4N1M0. We decided to perform a laparoscopic radical nephrectomy with a segmental colic resection.After bowel preparation, we performed a left lateral and segmental colonic resection. We firstly proceed on lowering the left colon by performing an extensive dissection of the left colon and transverse to the tail of the pancreas medially and the spleen and stomach above. Then, we completed the resection by a total left nephrectomy extending to the perirenal fat and preserving the left adrenal .The histopathologic study of the specimen using the Hemalin-Eosine coloration showed an inflammatory pseudotumor of the kidney. The inflammatory infiltrate is composed of lymphocytes, plasma cells, and fibrous backgrounds. The process invades the colic mucosa .The intestinal transit resumption was effective on the second day after surgery, and the postoperative renal function was normal. The patient did not receive any specific treatment considering the histopathological diagnosis. An enhanced computed tomography has been performed after a month and shown an empty renal lodge without recurrence. We planned to perform an enhanced computed tomography once a year for five years.Renal inflammatory pseudotumor (RIPT) is an exceptional benign condition. It is also known as inflammatory myofibroblastic tumors, plasma cell granuloma, or myofibroblastoma. Inflammatory pseudotumors appear in the WHO classification as a distinct borderline lesion . DiffereThe disease occurs at all ages, predominately in children and young adults; both sexes are affected with a slight male predominance . The patThe etiology of these tumors also remains to be discovered. Different theories have been suggested, including Epstein-Barr and hepatitis B virus infections, and traumatic, vascular, and autoimmune causes, among others. In addition, Schweckendiek et al. also raised the possibility of arrangements of the ALK gene (Anaplastic Lymphoma Kinase), which plays an essential role in the genesis of these tumors .Our patient presented with left lumbar pain without irradiation. The clinical presentation is atypical. Symptoms could be localized pain in the lumbar region like our patient and also renal colic related to hydronephrosis due to ureteral or pelvic compression. However, hematuria is the most frequently described clinical sign in the literature. It can be micro or macroscopic, concomitant, or not with the painful symptoms. It should also be noted that inflammatory pseudotumors can be completely asymptomatic and therefore discovered fortuitously.Imaging of inflammatory pseudotumors is also nonspecific. This fact explains why in almost all the writings on this subject, the diagnosis is only made on a piece of enlarged nephrectomy. In addition, the radiological signs are misleading, and the diagnosis of a malignant renal tumor is most often difficult to rule out due to the heterogeneous characteristics of the mass. Some characteristics have nevertheless been mentioned in the literature. On ultrasound, the lesion appears rather hypoechoic and heterogeneous, mimicking an atypical cyst. On CT, the lesion is rather hypodense and appears as T2 hypointense on MRI .There is currently no consensus on the management and the follow-up of inflammatory pseudotumors. Due to the rarity of renal involvement, there are no prospective studies on this subject to date. The published articles relate only to case reports.An atypical presentation for a renal tumor should attract the attention of clinicians, especially in cases of a unique kidney, to avoid unnecessary radical nephrectomies.Inflammatory pseudotumors or inflammatory myofibroblastic kidney tumors remain rare, often confused with malignant kidney tumors. Larger-scale studies are needed to have more answers concerning the etiology and pathogenesis of this entity and establish diagnostic criteria in order to limit the number of unnecessary nephrectomies. The rarity of renal involvement, the heterogeneity of the clinical presentation, and the nonspecificity of the radiological signs make it a significant diagnostic and therapeutic challenge and a diagnostic pitfall to be avoided. The laparoscopic approach that we also lift allows a less invasive approach for these lesions whose neoplastic origin has not yet been demonstrated.


A mucocele is a cystic and expansive lesion of the sinus cavities. It is uncommon in the sphenoid sinus and its management is quite challenging especially in low to middle income countries like Cameroon. A 43-years-old female was referred to us by a neurologist for chronic headache and visual disturbances. The pain was unresponsive to analgesics. Physical examination was non-remarkable and a head CT scan realized showed a cyst-like lesion in the sphenoid sinus cavity. Surgical endoscopic treatment was proposed and realized with basic endoscopic instruments, consisting of opening the cavity with drainage of the mucocele. A large opening was made on the anterior wall of the sphenoid sinus, in order to ensure continuous drainage and prevent a recurrence. Sphenoid sinus mucocele is a rare condition, and its diagnosis can be difficult. Confirmation requires specific imaging and treatment is presently well established, but it can be managed with basic tools. A mucocele is defined as a benign expansive pseudo-cyst of the sinus cavities. It is a rare condition made up of a wall consisting of a modified mucosal lining and a viscous liquid content that is generally aseptic . This lePatient information: a 43-year-old female, with no relevant past medical history, was addressed to our service by a neurologist for an opinion on chronic severe retro-orbital headache and blurred vision ongoing for about seven months, she also complained of chronic intermittent rhinorrhoea. The headache was unresponsive to chronic non-opioid analgesic use.Clinical findings: physical examination done at our unit showed stable vital signs , and a normal nasal cavity examination. Flexible nasopharyngoscopy was normal. The rest of the ear-nose-throat and head and neck examination was non-remarkable.Diagnosis assessment: a head CT-Scan was requested and identified a roundish isodense lesion occupying both sinus cavities with absence of the intersinus septum. The lesion eroded the walls of the sphenoid sinus, with partial lysis of the superior wall of the cavity , reducing the risk of recurrence . This prThe prognosis of sinus cavity mucoceles is generally good when diagnosis and management are prompt. Neurological symptoms mostly regress when treatment is timelyThe sphenoid sinus mucocele is a rare condition for which diagnosis can be challenging, especially in resource-limited settings. A CT-scan is sufficient enough in the presence of suggestive clinical signs and symptoms to make the diagnosis. The management may only require basic tools of functional endoscopic surgery in our context.


Acromegaly is, in most cases, caused by growth hormone secreting pituitary adenomas. Those patients often develop different pathologies of the thyroid gland, however, the occurrence of Grave´s disease is quite a rare situation. We report a case of a 64-year-old female patient who presented with signs of hyperthyroidism and imbalance of her diabetes mellitus. On physical examination, she had facial features of acromegaly. Biochemical testing confirmed the suspicion of acromegaly and Grave´s disease, with an elevated insulin-like growth factor-1 and a suppressed thyroid stimulation hormone (TSH) with positive TSH-receptor antibodies. A pituitary Magnetic Resonance Imaging (MRI) was performed, revealing a macro-adenoma and an empty sella. The patient successfully underwent a transsphenoidal surgery and obtained a remission of her hyperthyroidism under anti-thyroid drugs. Acromegaly is a systemic disorder caused by an excessive secretion of the growth hormone (GH). It is caused by a pituitary adenoma (PA) in most cases . The assA 64-year-old female patient was referred to the endocrinology department for investigation of recent diabetes mellitus imbalance and symptoms of hyperthyroidism. For her personal medical history, she has been treated for hypertension and sleep apnea for 17 years now, and was operated on gonarthrosis and carpal tunnel syndrome in both hands 15 years ago. Regarding her family history, her first daughter was diagnosed with GD and the second daughter was followed for hyperprolactinemia caused by an empty pituitary sella. Clinically, she was complaining of thermophobia, trembling, polyuro-polydipsic syndrome and weight loss. On examination, she had facial features of acromegaly with enlargement of her hands and feet and a goiter. Her blood pressure was often high. She did not present with specific skin lesions or bones deformations. Biochemical testing revealed an elevated insulin-like growth factor-1 (IGF1) and a suppressed thyroid stimulation hormone (TSH) with positive TSH-receptor (TSHR) antibodies. The prolactin level was normal and corticotropic insufficiency was ruled out with a normal level of cortisol after 1μg Synacthen test . A pituiet al. found in his study that GH-producing microadenomas with ES account for 20% of all growth hormone microadenoma cases [et al. suggested that the growth pattern of GH-secreting pituitary tumors and accompanying sellar floor remodeling may induce the morphological ES aspect in patients with acromegaly [et al. about an ES associated with an ectopic secretion of growth hormone releasing hormone by a pancreatic neuroendocrine tumor [Association between ES and acromegaly was described for the first time in the 1960s . Many rema cases . Mainly ma cases . Secondlromegaly . Furtherne tumor . Finallyne tumor , 13.et al. studied the impact of ES on transsphenoidal surgery in such patients and he concluded that they might encounter a higher risk for non curative resection in surgical treatment and they may also present with more frequent intra-operative cerebrospinal fluid leakage [et al. studied the role GH and IGF1 play in influencing the production of auto-antibodies directed against the TSH receptor (TSHR), therefore, exacerbating TSHR-induced Graves´ thyrotoxicosis [As for our patient, she did not present with any history of pituitary apoplexy nor did she suffer from any hormonal hyposecretion. Therefore, the second theory would probably be the case. Sasagawa  leakage . Our pat leakage . As for oxicosis . As a maoxicosis . Secondloxicosis .In conclusion, the present case illustrates the uncommon occurrence of acromegaly, empty sella and Grave´s disease. Hyperthyroidism in our patient was probably due to an auto-immune background with the multiple effects of GH and IGF1 on the thyroid and the immune system. As for the ES, it has been described in multiple studies and they all concluded to tumor-induced local bone remodeling processes or an episode of apoplexy.


Megalencephalic leukoencephalopathy (MLC) with subcortical cysts is a very rare white matter disorder characterized predominantly by motor developmental delay and seizures in a child with macrocephaly. Extrapyramidal symptoms, ataxia and mental retardation may also occur. Only a few cases of the disease have been reported worldwide with most of them showing an autosomal recessive pattern of inheritance. In India, most cases have been reported in Agrawal community. Here, we present an interesting case of MLC in a child born in non-Agrawal community to a non-consanguineous marriage. By reporting this case we intend to increase the research horizon and increase the published literature for atypical cases of MLC. The credit for identifying MLC goes to Dutch pediatric neurologist Marjo S Van der Knaap and hence, the disease is often referred to as Van der Knaap disease. In 1995, she studied brain imaging in children with macrocenphaly and leukoencephalopathy who presented with motor developmental delay, seizure and other symptoms like ataxia. She described the imaging characteristics of the disease as peripheral and subcortical white matter involvement which is diffuse, homogenous and supratentorial with sparing of grey matter and central white matter. Subcortical cysts involving bilateral anterior temporal region and sometimes frontoparietal region are also noted . Even thMLC is mostly inherited as an autosomal recessive disorder (MLC1 and MLC2A), and a small proportion as autosomal dominant (MLC2B). Underlying defects are noted in MLC1 and HEPACAM genes, thus affecting the astrocytes at blood-brain barrier causing abnormal extracellular potassium dynamics, swelling and vacuolation of white matter -7. PhenoWe present a case of a three-year-old female child born to parents from a non-Agrawal community, who had a non-consanguineous marriage. The child had macrocephaly and later developed seizures during infancy which were controlled with medication. Developmental milestones were delayed; as she started walking with support around 15 months and without support only after two years, she still had difficulty running or walking on stairs after three years. Mild lag was also present in social and language domains; she was unable to construct phrases or sentences and had a vocabulary of 10-15 words. Birth history was normal; she was born by normal vaginal delivery at term and there was no history of birth asphyxia. Family history did not suggest any similar features in close relatives. The general physical examination was normal. Routine blood profile and electrolytes were normal. Patient was clinically diagnosed with global developmental delay with seizures and was referred to our radiology department for MRI brain. MRI showed multiple ill-defined discrete and confluent T2 hyperintensities in subcortical and peripheral white matter with corresponding hypointensities on T1W images and no inversion on fluid-attenuated inversion recovery (FLAIR) Figures .No diffusion restriction or blood products were noted on DWI and GRE respectively. No abnormal post-contrast enhancement was noted. Subcortical cystic change was noted in bilateral anterior temporal region Figures , 5.No abnormal NAA peak was noted on spectroscopy. Deep white matter and basal ganglia were normal Figure .Combining the clinical profile with typical imaging findings the diagnosis of megalencephalic leukoencephalopathy with subcortical cysts was made. Due to non-availability of any specific treatment, parents were properly counselled. Physical and speech therapy was advised andantiepileptic treatment was continued.Here we report an atypical case of a very rare disease. MLC is mostly inherited as an autosomal recessive disorder in predisposed populations i.e. Turks, Jews and Agrawal community of India . ParentsVarious etiologies result in developmental delay and seizures, such as neurovascular insult , Congenital/structural brain abnormalities, metabolic and white matter diseases, genetic syndromes and other non-specific causes ,10. AbseIn conclusion, atypical cases of megalencephalic leukoencephalopathy with subcortical cysts are extremely rare and only a few have been reported in the literature. By reporting this case we are trying to increase the knowledge about the same. MLC should always be considered in patients having typical imaging pattern, even when there is no significant family history and diagnosis should be reached after all its close differentials are ruled-out. Most reported typical cases have autosomal recessive inheritance in predisposed communities, and not enough genetic research has been done in atypical cases. Future genetic studies are needed to further help clear the pattern of inheritance in atypical cases and a better understanding of disease.


A 38-year-old man presented with embolic occlusion of the brachial artery. As per his computed tomography results, a pedunculated mass in the proximal ascending aorta was detected. Since discrimination between a thrombus and a tumor was deemed difficult, the patient underwent replacement of the ascending aorta. Histopathology revealed the mass to be a thrombus. The diagnosis of antiphospholipid syndrome was then confirmed postoperatively. Six months post-surgery, a new thrombus was detected in the vascular prosthesis. The thrombus resolved after treatment with edoxaban and aspirin. To the best of our knowledge, this is the first report on graft thrombosis in antiphospholipid syndrome, highlighting the importance of seamless anticoagulation therapy. Although arterial and venous thromboses at various sites are identified as manifestations of antiphospholipid syndrome (APS), mural thrombosis of the aorta is rare. Moreover, distinguishing a mural thrombus from an aortic tumor remains to be a challenge. Herein, we report a case of recurrent mural thrombosis of the ascending aorta in a patient diagnosed with APS after the replacement of the ascending aorta.18F-fluorodeoxyglucose (FDG) in the mass. The results of laboratory screening for protein C, protein S, and antithrombin III deficiencies were deemed to be negative. Serology revealed a slightly elevated lupus anticoagulant level at 1.39 . Anticardiolipin and anti-β2 glycoprotein-I antibodies were negative.A 38-year-old man presented with numbness, cold sensation, and pain in the left arm. Contrast-enhanced computed tomography (CT) revealed occlusion of the left brachial artery as well as a pedunculated mass inside the proximal ascending aorta  was found at the location corresponding to the mass. Yokawa et al. reported that PET–CT identified the metastatic lesions of angiosarcoma of the descending aorta. However, the sensitivity and specificity of PET–CT are unknown, owing to the rarity of the disease.It remains difficult to distinguish between an aortic mural thrombus and an aortic tumor due to similar CT findings and clinical presentation. In a study by Kato et al., However, the difficulty of differentiating a thrombus from a malignant tumor preoperatively makes the procedural strategy complicated. Moreover, application of an intraoperative rapid pathological diagnosis is not straightforward because both procedures, i.e., graft replacement and simple thrombectomy, require circulatory arrest. At our institution, it takes approximately 30 min to diagnose thrombi using frozen sections stained with hematoxylin and eosin, including the time for specimen transport. It is possible to remove the mass first under short circulatory arrest and then perform graft replacement, applying second circulatory arrest in case the pathological examination turns out to be malignant.The treatment of an aortic mural thrombus is usually a straight choice between graft replacement and simple thrombectomy. incidence of thrombosis after graft replacement remains to be poorly understood. To the best of our knowledge, this is the first report of thrombosis following replacement of the aorta with a vascular prosthesis in APS. Although warfarin was administered postoperatively, it was discontinued as per the patient’s request. Even after the diagnosis of APS was confirmed, the patient refused to take warfarin and this led up to the recurrence of thrombosis in the graft. Since the patient refused taking warfarin, edoxaban was alternatively administered in conjunction with aspirin. Consequently, the thrombus resolved, and there was no relapse since the patient continued taking the drugs. However, all the major guidelines recommend vitamin K antagonists in patients with arterial thrombotic events. Although some guidelines accept the use of direct oral anticoagulants in patients with venous thrombotic events and single/double antiphospholipid antibody positivity, vitamin K antagonists remain the first line of anticoagulants in APS.Although replacement of the ascending aorta for acute aortic dissection in a patient with APS has been reported,18F-FDG in the mass was confirmed through PET–CT; (2) positive lupus anticoagulant indicated the possibility of APS; and (3) thrombosis following graft replacement in patients with APS was uncertain.In retrospect, surgical strategy using simple thrombectomy might be an optimal choice due to the following reasons: (1) no uptake of To the best of our knowledge, this is the first report on graft thrombosis in APS. Following aortic replacement, seamless and long-term anticoagulation with vitamin K antagonists is strongly recommended.


Acrometastasis is rare with a very low incidence of all bone metastasis. It can present with swelling, pain and warmth with erythema that may mimic an infection especially in the distal phalanx. Due to its rarity and subtle clinical presentation, it can be misdiagnosed as an infection causing the treatment to be delayed. We report a 42-year-old female with an acrometastasis to the distal phalanx of the left middle finger which we mistook as an infection thus delaying her treatment. It was a terminal presentation of her endocervical adenosquamous carcinoma. We would like to highlight that acrometastasis has an indistinct presentation and in cases where the lesion does not respond to treatment, acrometastasis should be included as one of the differential diagnoses. Thus, physicians need to have a high level of suspicion in patients with a primary malignant tumour. The most common sites for the primary tumours are namely – lung, colorectal, breast and genitourinary. Acrometastasis from endocervical adenosquamous carcinoma is extremely uncommon4. Though rare, they are an indicator of poor prognosis, and survival has been reported to be only up to seven months from diagnosis4. They can present as a subtle swelling, with or without pain and sometimes they present as an infection to the fingers following trivial trauma. A high index of suspicion should be present when the patient has a known history of malignancy. Despite that, acrometastasis could be a terminal presentation of an undiagnosed primary malignancy4. An accurate history, clinical examination and adequate imaging are needed to diagnose acrometastasis.Acrometastasis is defined as metastasis distal to the elbow and knee. It has a rare occurrence with only 0.1% of cases reportedWe would like to present a case of acrometastasis to the finger that has been misdiagnosed as an infection.A 42-year-old female with a known case of endocervical adenosquamous carcinoma, presented with a complaint of progressive swelling and pain over her left middle finger for two months. She had been diagnosed with endocervical adenosquamous carcinoma stage 3 six months ago and had undergone 27 cycles of radiotherapy and chemotherapy. She has no metastasis to the bone or other organs. It was treated as paronychia – an incision and drainage procedure was performed and she was discharged with antibiotics. Two weeks later she returned with the swelling increasing in size. Radiographs showed scalloping of the distal phalanx with increase in soft tissue shadow of the middle finger .Another incision and drainage was performed and she was started on six weeks antibiotics course. However, she presented again three weeks later with increased swelling of the lesion with severe pain. Amputation was suggested however she sought a second opinion at our centre. Upon presentation, it was a fungating mass that has extended proximal to the distal finger crease .She also complained of severe upper lumbar pain which was investigated concurrently. MRI showed multiple metastases to the spine as well as to the bilateral lungs.Subsequently, an MRI of the lesion was performed, and it showed a lobulated soft tissue mass extending from the distal phalanx and middle phalanx of the middle finger likely representing a locally aggressive tumour. HPE showed a metastatic lesion with primary from the endocervical adenosquamous carcinoma. She was planned for amputation of the middle finger; however, she developed superior vena cava obstruction and surgery was delayed due to her unstable conditions. In the end, she succumbed to her advanced-stage disease.2. Any history of malignancies should be highlighted, and a high suspicion index should be maintained throughout. Radiographs usually show a lytic, sclerotic or mixed lesion depending on the primary malignancy. MRI is more useful where the marrow and soft tissue extension of the tumour can be evaluated1. Our patient presented with swelling and pain in the finger where an incision and drainage was done and she was started on antibiotics, however it did not resolve. With her history of previous malignancy, this should have triggered the attending physician of a possibility of acrometastasis. Unfortunately for this patient, her acrometastasis was a terminal sign of the primary tumour whereby the correct diagnosis was delayed. Although we knew that amputation was the solution, however we were debating on performing a proximal interphalangeal joint level amputation (for an infection) versus a Ray amputation  causing another delay. Other differential diagnoses that need to be excluded are felon, gout, osteomyelitis, rheumatoid arthritis, pyogenic granuloma, tuberculosis and primary skin tumours4.Acrometastasis can present as pain and swelling of the finger. Sometimes it can mimic an infection where the finger is swollen with erythema and pain and can further worsen with ulceration4. Metastasis happens via hematogenous spread where malignant cells from lungs have easy access thru the arterial circulation of the upper limbs4. That explains why patients with primary lung malignancy or patients with lung metastasis from other malignancies have a higher incidence of acrometatasis compared to those without4. In our patient, multiple lung metastases might have been the source of the malignant cells rather than the primary lesion. The most common locations are the distal phalanx of the middle finger followed by the thumb.Acrometastasis is rare because bone metastasis happens at the area of rich red marrow in which the phalanx is void of1. Sur et al2 reported a case of acrometastasis from the uterus which, however, was a uterine leiomyosarcoma and Ornetti et al5 presented another case which was not reported formally.Acrometastasis from the endometrium is very rare. From our search, there have only been two cases reported in the English literature1. A tissue diagnosis via a biopsy is compulsory before options of treatment can be given1. Depending on the staging, options of treatments are amputation or wide local excision with reconstruction and subsequently radiotherapy and/or chemotherapy. We have planned an amputation for our patient with the aim of pain relief and preservation of hand function at the same time allows a wide margin resection1.Staging is needed when acrometastasis is suspected to determine primary lesion, extension and prognosis4. There have been cases reported of survival rate of up to two years in renal carcinoma however this is rare1. Given the poor prognosis, acrometastasis is considered a terminal presentation of the primary malignancy4.Prognosis is usually poor; the mean survival rate is less than six monthsIn conclusion, acrometastasis presentation can mimic an infection of the finger and in some circumstances, this is a terminal presentation of patients with primary malignant tumour. Therefore, a high index of suspicion must be given to patients with a history of malignancy. Accurate history and clinical examination lead to accurate diagnosis and can accelerate treatment. Despite the poor prognosis, amputation is the most common treatment to alleviate pain, return of function and improve patient's quality of life.


An 84-year-old African American man with a medical history of prostate cancer presented with subjective fevers and abdominal pain. He denied nonsteroidal anti-inflammatory drug use or tobacco use. Surgical history included prostatectomy without radiation therapy. Physical examination was unremarkable other than generalized abdominal pain. Laboratory studies were within normal limits as well, including a complete blood count and comprehensive metabolic panel. Magnetic resonance imaging of the abdomen showed a large pelvic mass with circumferential involvement of the rectum with evidence of contained perforation Figure . Subsequ1 Although gastrointestinal plasma cell neoplasms are rare, they must be considered in patients presenting with gastrointestinal symptoms. The suspicion should increase in patients with a previous diagnosis of multiple myeloma.2The patient was referred to a multidisciplinary oncology team for further evaluation and management. Extramedullary multiple myeloma involving the colon is a rare presentation with rectal involvement as an eroding mass along with fistulous tracts not reported before.Author contributions: T. Syed and T. Abdelfattah wrote the manuscript and reviewed the literature. P. Zot edited the manuscript. R. Vachhani approved the final manuscript and is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.


Acute mesenteric ischemia (AMI) is caused by an interruption of the blood supply to the small intestine. Atrial fibrillation is a common cause of thromboembolic AMI. Patients taking direct oral anticoagulants (DOACs) for anticoagulation in atrial fibrillation are prone to anticoagulation failure and can present with thromboembolism. We present an interesting case of a 69-year-old female with a past medical history of chronic atrial fibrillation treated with a DOAC (apixaban) who was diagnosed with AMI despite being compliant with her anticoagulant. Her anticoagulation was promptly reversed and she was taken for urgent surgical intervention yielding a good outcome. Later, due to the failure of anticoagulation on apixaban her anticoagulant was changed to warfarin to prevent the recurrence of thromboembolism and follow-up showed she was doing well. Acute mesenteric ischemia (AMI) is caused by an interruption of the blood supply to the small intestine which can be secondary to mesenteric arterial embolism (50%), mesenteric arterial thrombosis 15-25%), or mesenteric venous thrombosis (5-15%) [5-25%, orA 69-year-old female with a past medical history of chronic atrial fibrillation taking apixaban for anticoagulation, hypertension, and ESRD on hemodialysis was admitted for a chief complaint of sudden onset of sharp abdominal pain and non-bloody vomiting. Her symptoms started a few hours prior to presenting to the hospital. On examination, her blood pressure was 128/62 mm Hg, pulse was 79 beats per minute, respiratory rate was 18 breaths per minute, she was afebrile and her O2 saturation was 100% on room air. Her abdomen was non-tender to palpation with normal bowel sounds. Initial lab work showed a normal white cell count, normal serum lactate levels, normal platelet count, and no increase in anion gap. Her hemoglobin was 11.1 g/dL, hematocrit 35.0%, international normalized ratio (INR) 1.3, prothrombin time (PT) 17.0 seconds and partial thromboplastin time (PTT) was 38.9 seconds. Computerized tomography (CT) scan of the abdomen and pelvis with IV contrast showed air in the portal and mesenteric vasculature as well as small bowel pneumatosis concerning for bowel ischemia  is not uncommon. Kajy, et al reported treatment failure with DOACs in their study  where thPatients with AMI on chronic anticoagulation require urgent anticoagulation reversal prior to surgical or endovascular intervention. Our patient was on apixaban which can be reversed using andexanet alfa. Andexanet alfa can also be used for rivaroxaban and edoxaban reversal while idarucizumab can be used for dabigatran reversal . If the Immediate surgical or endovascular intervention is warranted if AMI is diagnosed to reduce mortality . SurgeryFor patients with anticoagulation failure on DOACs attempts should be made to identify the cause of failure. These include evaluating compliance issues, drug-drug or drug-food interactions . If no uFor patients who have a history of atrial fibrillation and present with abdominal pain, AMI should be on the list of differentials even if they are on anticoagulation. AMI should be ruled out earlier to decrease mortality. DOAC failure is not uncommon and anticoagulated patients can still develop thromboembolic phenomena. To prevent recurrence of thromboembolism in patients with DOAC failure, anticoagulation should be pursued with a different DOAC with an alternate mechanism of action or warfarin should be considered.


Schwannomas also known as neurilemomas are benign tumors. Retrorectal schwannomas are extremely rare, accounting for 1 to 5% of all schwannomas. They are mostly asymptomatic but may present with symptoms such as pelvic pain, back pain, lower extremities pain, or constipation. Physical examination is often poor. Imaging  and fine needle biopsy can often help orient the diagnosis. The treatment of choice is monoblock resection of the mass. The prognosis is good. Recurrence has been reported especially after intralesional enucleation. We report a case of a 41-year-old male patient consulting for chronic low back pain eventually diagnosed with retrorectal schwannoma. We performed a surgical resection and the histological examination was consistent with the diagnosis of benign (ancient) schwannoma. Schwannomas also known as neurilemomas are benign tumors . They deA 41-year-old man complaining of pelvic pain and bilateral sciatica radiating towards the right inguinal and lumbar area for 2 years. He reported some abdominal discomfort but no urinary or neurologic symptoms were reported. Abdominal examination was poor. Rectal examination found a 3.5 cm smooth, fixed, retrorectal mass. Computed tomography revealed a 29.2 × 26 mm solid, heterogeneous pelvic mass with well-defined limits containing small calcifications , all consistent with the diagnosis of benign (ancient) schwannoma. The patient has remained asymptomatic, with no sign of recurrence on CT scan at 36 months of follow-up.The retrorectal space is limited anteriorly by the rectum, by the sacrum posteriorly, the ureters, iliac vessels, and sacral nerve roots on each side, it extends superiorly to the peritoneal reflection superiorly and the levator musculature inferiorly , 8. A vaSymptoms can exceptionally reveal a retrorectal schwannoma. Physical examination is often poor. Imaging  and fine needle biopsy can often orient the diagnosis. Monoblock resection remains the treatment of choice. The prognosis is good. Recurrence has been reported specially after intralesional enucleation.


A 61-year-old man presented to the emergency room with lower extremity edema. Physical exam was only remarkable for a diastolic murmur in the right carotid area and left lower extremity edema. Venous Doppler revealed a deep venous thrombosis in the left lower extremity. Chest computed tomography (CT) with intravenous contrast ruled out pulmonary embolism but showed a mediastinal mass adjacent to the pericardium. Further imaging with cardiac magnetic resonance imaging (CMR) and cardiac CT angiography (CCTA) enabled localization and evaluation of the structural characteristics of the mass. The decision was made to excise the mass due to increasing size compared with its measurements on prior chest CTs and a high degree of vascularization seen on CMR and CCTA, which was concerning for an enlarging arteriovenous malformation or a hemangioma. However, histopathologic analysis of the mass revealed it to be a micronodular thymoma. Mediastinal, cardiac and pericardial masses are rare. These tumors can be primary or metastatic, and the differential diagnosis is broad. Primary cardiac tumors have a reported prevalence in autopsy series of 0.001% to 0.03%.2A 61-year-old man with hypertension presented to the emergency room with a 3-day history of left lower extremity edema. The patient denied trauma, chest pain, dyspnea, or palpitations. His vital signs on initial evaluation were heart rate 85 bpm, blood pressure 169/92 mm Hg, respiratory rate 18 bpm, temperature 97.7 °F, and oxygen saturation 97% on room air. Physical exam was remarkable for left lower extremity edema and a diastolic bruit in the right carotid area.Figure 1). On further review of prior imaging, the mediastinal mass was found on chest CTs 1 and 8 years prior to this presentation, albeit at a much smaller size. For further characterization of the mass, the patient underwent CMR, which revealed a large, well-circumscribed mass measuring 3.3 × 2.1 cm anterior to the right atrial appendage adjacent to the pericardium. Tissue characteristics showed significant first-pass perfusion with late gadolinium enhancement uptake and hyperintensity on T2 imaging relative to the myocardium. These findings are consistent with a highly vascular structure. There was no evidence of tissue invasion . Due to concerns for an arteriovenous malformation (AVM), he underwent CTA with 0.5-mm sequential cuts, which demonstrated a large 4 × 2.5 cm AVM in the anterior mediastinum that was supplied by branches off the right internal mammary artery and the left internal thoracic vein arising from the left brachiocephalic vein .Doppler ultrasound of the left lower extremity showed a deep venous thrombosis (DVT). He had a contrast chest CT that did not show pulmonary emboli but demonstrated a 3 × 2 cm anterior mediastinal mass adjacent to the pericardium  was followed by multiple immunohistochemical stains  for more accurate characterization of the tumor. Histopathologic analysis diagnosed the mass as a micronodular thymoma (MNT).After the patient was evaluated for mass resection, he underwent surgery with localization and coil embolization of the feeding artery coming off the right internal mammary artery supplying the mass. Using cone beam CT and laser guidance, the mediastinal mass was excised using a minimally invasive procedure. The mass measured 4 × 2 cm and was sent for frozen section diagnosis followed by submission for formalin-fixation and paraffin embedding. Hematoxylin and eosin staining (H&E, Fortunately, after tumor excision, our patient has continued to do well without further symptoms and has received follow-up in the clinic every 3 months.Grossly, MNT can have variable morphology ranging from solid to cystic architectural patterns. Microscopically, MNT has a characteristic histological pattern that is described as multiple small tumor islands surrounded by abundant epithelial cell-free lymphoid stroma consisting of mature B and T cells. However, multiple studies have shown that although the histological pattern remains the same, the morphology can be highly variable.4In addition to morphology, review of the literature has shown the tumor cells of MNT have variable immunophenotypic expression. For example, CD5 and CD117 staining has been shown to vary from negative to focally and diffusely positive.The World Health Organization classification is currently used to morphologically classify thymomas; however, other histological classification systems have been proposed, including the Modified Masaoka Staging system and proposed Suster and Moran classification system.Our case had microscopic capsular invasion, placing it in the stage IIA category for modified Masaoka staging but only stage I in the TNM AJCC staging system. For MNT specifically, a review of the literature by Qu et al. shows that, regardless of MNT pathology or stage, this unique thymoma subtype has a uniformly favorable prognosis. In general, surgery remains the standard of care for encapsulated thymomas and has high cure rates.There are no specific imaging guidelines for evaluating pericardial masses. The American Society of Echocardiography states that echocardiography remains the initial imaging test for evaluation of pericardial masses because of its ease of use, availability, and cost effectiveness. However, multimodality imaging plays an integral role in evaluating cardiac masses because of its superior spatial resolution and tissue characterization capabilities.8


Soft tissue tumors are part of a wide and sometimes rare differential diagnostic landscape. Case description of these rare soft tissue masses helps the future differentiation and aids in preoperative multidisciplinary approach. Interpretation and staging, with the help of imaging, is key. Desmoplastic fibroblastoma, also known as collagenous fibroma , is a raWe describe the case of a 53-year-old woman with a mass in the right upper arm. Over the course of the last year, our patient noticed a slow-growing nodule. No pain or nervous symptoms were noted. On clinical examination, the mass is hard and positioned on/in the right-sided deltoid muscle. We suspect the mass to be slightly embedded in muscular tissue. Clinical examination is painless. No restriction in motion or alterations in sensibility are withheld. Our patient presents without relevant medical history and is an active, working woman.The general practitioner ordered an ultrasound (US) of the upper arm. US showed a sharp delineated fusiform mass (CC 8.5 × LL 6.5 × AP 3 cm) with heterogeneous echogenicity, associated with the lateral humeral cortex beneath the deltoid muscle . The masSubsequent MRI showed a well-circumscribed ovoid mass beneath the deltoid muscle abutting the humeral bone without evidence of invasion of the bone or the adjacent neurovascular structures. The mass was heterogeneous isointense to muscle on T1 and heterogeneous hyper- and isointense to muscle on T2-fat-saturated images, embedded were multiple T1 and T2-fat-saturated hypointense foci, suggesting the possibility of internal calcifications or fibrous strands A and C. To exclude calcifications, a shoulder radiograph was carried out. The radiograph confirmed a soft tissue mass located around the proximal humeral bone with an estimated size of 9 × 5 cm, without radiographically visible calcifications . A normaA successive non-contrast-enhanced computed tomography (CT) of the right upper arm confirmed the radiographic findings; a well-circumscribed isodense mass beneath the deltoid muscle without embedded calcifications or ossification , the posThe excised tumor is a well-described nodular white mass of 94 grams, with measurements of 7.3 × 6.6 × 3.1 cm. The surface is white, with no tumor capsule found. Microscopic examination shows no infiltration of the muscular tissue. The tumor is hypocellular and consists of hyaline stroma and polygonal cells with small basophile core, neither clear mitosis nor obvious atypia. The architecture is vaguely nodular.The specimen was referred to the pathophysiologic department of the University Hospital of Ghent. Protocol was completed as an encapsulated relatively hypocellular spindle cellular collagenous, partly myxoid spindle cellular mesenchymal tumoral proliferation of myofibroblast origin, confirming the diagnosis of a desmoplastic fibroblastoma.Desmoid-type fibroma or sarcoma is the primary differential diagnosis to consider in these cases. Histology is subtly more vascularized and more cellular, with aggressive local infiltrative characteristics , 8. MyoeThe mass was excised under general anesthesia in outpatient clinical setting. Operative time was 40 minutes skin-to-skin. Surgical clips were left in the operative field, anticipating postoperative follow-up treatment. Hemostasis was controlled, and the wound was closed in layers over a drain. The drain was removed later that day. Our case was discussed multidisciplinary at the skin and soft-tissue malignancy team meeting. Dermatological and surgical follow-up was arranged, with a follow-up MRI 3 months postoperative.Our patient presented with a large mass when compared with other reported measurements, with average diameters of 2.0 to 5.5 cm in small case series , 13. SexJunkins-Hopkins described the histology in 1998 as a hypocellular mass with spindled and stellated fibroblastic cells indiscriminately divided by fibrous and collagenous bundles . Tumor gRadiographs can identify soft-tissue nonspecific masses. When present, calcifications, osseous erosion of invasion can be detected . CT imagMRI shows variable signaling depending on the sequence. Desmoplastic fibroblastoma shows weak to intermediate T1 signaling and a high T2 weighted signaling , 14, 15.Immunohistochemical investigation confirms the diagnosis of desmoplastic fibroblastoma. Complete therapeutic approach equalizes a total resection , 5. To tDesmoplastic firoblastoma is a rare soft benign tumor. The differential diagnosis includes other benign or low-grade fibroblastic/myofibroblastic lesions. MRI shows recognizable characteristics to help identification.


Myxomas arising in the oral and maxillofacial areas are extremely rare. This study reports a case of myxoma arising in the soft tissue beneath the buccal mucosa of an 86-year-old man. Myxomas are benign tumors that usually arise in the heart, skin, bone, or muscle. Cases of the maxillofacial region, in which the main site of occurrence is the maxilla or mandibular bone, are relatively rare . Here, wAn 86-year-old male was referred to Saitama Medical University Hospital  from a local dentist in July 2015 due to the presence of an intraoral mass. The patient had not noticed the mass until the dentist brought it to his attention. His previous history included transitional cell cancer of the bladder, but his family history was unremarkable. The round mass, measuring 12 mm in diameter, was located in the left buccal mucosa . The masMyxoma is a relatively rare benign tumor derived from soft tissue and was first described by Virchow as a tumor histologically resembling the mucinous substance of the umbilical cord. Myxoma was defined as a neoplasm without mesenchymal cells, such as chondrocytes, myoblasts, or adipocytes, and without metastatic capacity .Myxomas most frequently occur in the myocardium, followed by the subcutaneous and intramuscular regions of the lower leg or shoulder. Myxomas arising in the oral and maxillofacial areas are extremely rare. Moreover, most of these cases occur in the maxillary or mandibular bones as odontogenic myxoma derived from odontogenic cells. Thus, only a few reports on soft tissue myxomas are available in the literature .Patients usually recognize a slowly growing indolent mass for myxomas occurring in the soft tissue of the oral and maxillofacial regions. Following gradual enlargement, functional disorders such as difficulty in chewing and/or swallowing may develop, depending on the location . In our Myxoma usually appears as a mass with smooth margins, with low intensity on T1-weighted MRI and with high intensity on T2-weighted MRI. However, these are not features specific to myxomas and are relatively common in benign soft tissue tumors. The same findings were present in our patient, leading us to a clinical diagnosis of a benign tumor in the soft tissue.In this case, cytoscreening was not performed. Generally, cytology by fine needle aspiration cannot be used to diagnose myxomas since the tumor has few cellular components. Histopathological analysis revealed spindle-shaped tumor cells with pyknotic nuclei and elongated protrusions, sparsely arranged in a matrix containing mucoid substances. Immunohistochemistry showed that the myxoma cells were positive for vimentin, an intermediate filament specific to mesenchymal cells, and were negative for desmin and S-100 protein . In addiWe encountered a case of myxoma arising in the buccal mucosa. Myxomas have no metastatic capacity but may occasionally recur. Thus, careful long-term follow-up is needed.


Background: Pneumoperitoneum is defined by the presence of free air in the abdominal cavity; gastrointestinal perforation is an important cause of this pathological condition. In emergency situations, radiology is considered vital in the early detection and identification of the site and cause of the perforation, which is critical for proper surgical planning. Aim: The aim of our study was to evaluate a new diagnostic US tool, based on the US contrast-specific software generally used during contrast-enhanced US examination (CEUS), without the administration of sonographic contrast media, and to describe the specific imaging features in the detection of free intra-peritoneal air. Subjects and Methods: One hundred and fifty-seven consecutive and hemodynamically stable patients, who arrived in our E.D. with an acute abdomen between April 2018 and October 2019, underwent US and CT examination, performed by three radiologists . The US was performed first and divided into two steps, using B-mode US and both B-mode and contrast-specific software US, with no contrast media administration. All the patients underwent CT examination. Results: In 32 out of 157 patients, the surgery confirmed GI perforation. CT correctly detected 31 out of 32 patients; the contrast-specific software US identified 30 perforated patients. CT reached a sensitivity value of 97% and specificity value of 100%; contrast-specific software US demonstrated higher values than B-mode US in sensitivity  and specificity . Conclusion: the use of contrast-specific software in emergencies improves image quality, and reaches higher levels of sensitivity and specificity with no time delay compared to standard US examination, helping radiologists expedite diagnoses. Pneumoperitoneum (PNP) is a common clinical entity defined by the presence of free air or gas in the peritoneal cavity . GastroiUntil now, the abdominal upright posteroanterior X-ray is traditionally regarded as the foremost method of detection, with the relevant signs described in ,8.However, extraluminal air is not always demonstrable on plain abdominal radiography, especially if self-sealed, well contained by adjacent organs, or if the perforation is too early or small, considering that sensitivity collapses (50–70%) for GI perforation with less than 1 mL of gas . The patComputed tomography (CT) is the modality of choice in the detection of GI tract perforation, due to its high sensitivity and accuracy 82 to 90%); it can display intra- and extra-peritoneal air, localizing the perforation site . CT demo2 to 90%;Ultrasound (US) findings of PNP were first identified in 1984 . It has In free abdominal air detection with US, the use of the linear array transducers (10–12 MHz) represents the most sensitive standard of detection, thanks to its high resolution . The supThe US detects signs of free abdominal air via the scattering of US waves in correspondence with the anatomic interfaces between soft tissue and bubble gas, associated with reverberation phenomena of the waves between the transducer and air bubbles. This event produces an increased echogenicity of a peritoneal stripe accompanied by numerous reflection artefacts, typically with a ring-down or comet-tail appearance, associated with the characteristic feature of real-time modifications as the patient’s position changes ,21,22,23The diagnostic confidence in US rises when increased thickness of the bowel wall, collected fluid effusion and a reduction in peristaltic moves are also present ; on the Moreover, US is widely recognized as an indispensable tool in the bedside diagnosis of the acute abdomen, and in the trauma context (FAST), where it has been recommended as standard procedure . It may Despite this, many text books and lecturers, especially in the field of emergency and critical care, skip the topic entirely. US has not been adequately integrated into the standard diagnostic process of PNP detection. The usual explanation for this is that gas is a strong reflector, able to prevent the transmission of US waves and create reverberation artifacts, inhibiting the obtainment of some diagnostic information. In addition, the physiological gas within the bowel may make it even more difficult to obtain an accurate interpretation .The aim of this study was to evaluate the usefulness of a new diagnostic US tool in PNP detection, based on the imaging performed by the US contrast-specific software, which is the software generally used during contrast-enhanced US examination (CEUS). In our series of tests, the contrast-specific software was routinely used in the emergency setting as the first tool to assess any patient with an acute abdomen. This was performed in an innovative way, as it was not dependent on the administration of contrast agents, and was defined as contrast-specific mode (C-mode). The C-mode operates in real-time, with a low mechanical index (pulse inversion technology), and uses a digital subtraction in order to isolate the signal in double harmonic.  Thanks tOur study included 157 consecutive patients who arrived in our emergency department with acute abdomen between April 2018 and October 2019. Hemodynamic instability and renal failure were considered exclusion criteria. All the included patients underwent US examination first, divided into two steps, and then a CT examination . This woThe US examination was performed using a Resona 7 system , equipped with both curved- and linear-array probes, and with dedicated software for acquisition of contrast-specific imaging. No administration of US contrast media was used.All CT examinations were performed with a 128-slice DSCT  after iodinated contrast media administration ; images were acquired in a single portal venous phase.The US examination was performed by two different radiologists with no less than 5 years of experience in the emergency department (R1 and R2); CT evaluation was performed by a radiologist with 25 years of experience (R3).The US examination was divided into two steps, consisting, first, of an examination performed using baseline US (B-mode), and a second examination using the mentioned US technology consisting of C-mode, with no contrast media administration, to focus on the free air detection. R1 and R2 conducted the two steps of the US examination for each patient; the interobserver concordance rate was calculated to explore the diagnostic performance and reproducibility.All patients underwent CT examination after the US study was performed by R1 and R2 and the CT was examined by R3. Radiologists were blinded to the results of the other examinations. Since CT is considered as the gold standard in free air detection, the statistical analysis allowed us to estimate the sensitivity, specificity and diagnostic accuracy for CT, US B-mode and C-mode. Positive and negative predictive values of US B-mode and C-mode were also evaluated. Written informed consent was obtained from each patient.Our population of study included 157 patients with an acute abdomen . The main characteristics are described in n = 39), intestinal occlusion (n = 24), acute appendicitis (n = 18), acute pancreatitis (n = 14), acute cholecystitis (n = 12), ischemic colitis (n = 5), renal colic (n = 5), intestinal volvulus (n = 3), inflammatory bowel disease (n = 3), and ovarian torsion (n = 2).In this study, 32 out of 157 patients (20%) received surgical confirmation of GI perforation. The other causes of an acute abdomen were acute diverticulitis  in showing free air.In the analysis results of both R1 and R2, C-mode US demonstrated higher average values than B-mode US in sensitivity , specificity  and diagnostic accuracy . C-mode US identified 30 perforated patients in R1’s examinations and 29 in R2’s examinations, while B-mode reached the diagnosis in 23 and 21 cases, respectively, in R1 and R2’s examinations.B-mode US examinations performed by R1 erroneously suspected the presence of PNP in 9 cases , while R2 obtained 10 false positives (6.4%). C-mode US obtained only two false positives (1.3%) from R1 and three false positives (1.9%) from R2.In no case did any CTs performed by R3 result in a false positive.On the other hand, the false negative average value for B-mode and C-mode was, respectively, around 6% and 1.6%, while the false negative rate for CT examinations was 0.6% (1 case). Therefore, the negative predictive average value was 98% for C-mode US and 93% for B-mode US, while the positive predictive value was 94% for C-mode US and 71% for B-mode US.See k: 0.979); the same index for B-mode was 99% (Cohen’s k: 0.946). The R1 intraobserver concordance index for C-mode and B-mode detection of PNP was 77%, and the R2 intraobserver concordance index for C-mode and B-mode detection of PNP was 74%, but the Choen’s k results were unsatisfactory in both , confirming the limited validity of B-mode US as a diagnostic test for air detection.The interobserver concordance index for C-mode between R1 and R2 was 99% , and peri-duodenal space.The rationale of our study was to utilize the strengths of US in the assessment of PNP, and demonstrate its diagnostic power without the use of contrast media; to date, we have not found similar studies in the literature.In most European emergency departments, US is routinely performed by radiologists in their first assessment of any patient with an acute abdomen .Today, the majority of modern US machines are already equipped with specific software for CEUS, with a large possibility of scan acquisition and co-registration after the administration of contrast agents.The evaluation of B-mode plus C-mode examination was important to understand if any significant diagnostic information was added, as confirmed in our results.One patient, whose micro-perforated duodenal ulcer was found via surgery, could not be diagnosed by CT, probably due to the low amounts of sufficiently detectable free gas and the poor communication of indirect signs. In the same patient, C-mode and B-mode were also not able to provide the diagnosis for both US examinators.As reported in our results, 30 patients were correctly detected on C-mode by R1. In two patients, C-mode was not able to reach the diagnosis of GI perforation; surgical intervention confirmed the presence of a micro-perforated duodenal ulcer and self-sealed peri-diverticular air, respectively. The C-mode performed by R2 identified 29 perforated patients, adding one more missed diagnosis of PNP in a case of peri-duodenum perforation in post-attinic parietal change due to pancreatic carcinoma history.B-mode US was not able to correctly detect the presence of free abdominal air in 9 and 10 patients, respectively, missing the diagnosis.Two cases of C-mode false positives were obtained from R1 and R2 examinations, in the first hypothesis, due to intraluminal bowel gas artefacts.In our experience, the statistical results showed higher sensitivity and specificity in C-mode than in B-mode US ; taking CT into consideration as the gold standard, with a reported diagnostic accuracy rate of 99%, the results also confirm the high diagnostic accuracy of this innovative tool (97%) and its high negative predictive value (98%).The high value of the inter-observer concordance index (99%) reflects well upon the reliability of the C-mode method, demonstrating its reproducibility.The qualitative superiority of C-mode over B-mode is adequately demonstrated by the imaging.In our patients, larger air bubbles appeared as bright, highly echogenic lines with distal reverberation and shadowing artifacts, as ring-down or comet-tail artifacts on B-modea; free aC-mode gave a more intense appearance to the peritoneal stripe when compared to B-mode, identifying the amount of free air, similar to the strongly enhanced peritoneal lines in the pre-hepatic space , and betTherefore, in some cases of our study population, a small amount of air under the abdominal wall was not clearly visible, and was potentially lost when the examination was not performed in expert hands, where it was misunderstood as a simple anatomic interface on B-mode a,b. In tIn another case, C-mode was able to detect free abdominal air around the duodenum and the pancreatic head with certainty a, which As observed in Moreover, in one obese patient, C-mode better revealed the presence of PNP and demonstrated its efficient performance, despite the thick fat plane in the anterior abdominal wall and the interposed meteorism, when compared with B-mode.In addition, in one single case of a child with appendicitis complicated by perforation (excluded from the present study for the lack of CT examination), our diagnosis was confident, thanks to the clear integration of C-mode scans during the US examination; the diagnosis was then surgically confirmed.As mentioned in our results, air bubbles were most frequently located in the anterior abdominal wall, hepatic interspace , and peri-duodenal space. However, the presence of suvra-mesocolic free air does not exclude a sub-mesocolic site of leakage in the GI system. Moreover, one must consider the spontaneous trend of air to move upwards, according to the anti-gravity effect; CT examination results were mandatory in order to detect the leakage.Although the localization of detected free air bubbles cannot be considered a reliable criteria of C-mode, to obtain deep information about the site of perforation, the benefits of C-mode are proved when compared to B-mode US, as shown in our study. GI perforation does not display specific symptoms, and abdominal X-rays only detect free air in a limited percentage of cases, dependent on the size and progress of the perforation; nevertheless, not all the patients with acute abdomen immediately undergo CT examination. Therefore, any patient who arrives at the E.D. with acute abdomen should receive a C-mode examination, so that PNP may be detected and diagnosed as soon as possible. Consequently, the decision to quickly and decisively utilize CT examination and treatment will save time and reduce the number of people with undiagnosed PNP.The limitations of our study are as follows: (1) The small population size of our test group. It will be necessary to apply the same method to a larger population to confirm our results; (3) False negatives. The number of false negatives is small in this study, but represents a limit to exceed in order to increase the reliability of C-mode’s diagnosis of PNP.The use of C-mode US examination in the emergency department demonstrated its superior image quality, and its higher levels of sensitivity, specificity and diagnostic accuracy.This method did not change the number of necessary scans and the timing of US examination. Furthermore, it has demonstrated that it can reliably diagnose PNP without the use of iodinated radiation or the administration of contrast agents.In addition, this method’s performance has proven reliable, even when dealing with patients who would otherwise be difficult to diagnose, such as children and the obese. It may, therefore, be used instead of a CT examination, which may be held in reserve should abdominal pain remain undiagnosed after US examination.In our experience, this new method could provide better visibility of the diagnostic elements of free abdominal air detection, resulting in increased confidence in the diagnosis of PNP; the C-mode US could help young radiologists, or radiologists with poor experience, in emergency clinical situations, to not miss this important diagnosis.


DICER1 gene. Despite being rare, PPB is the most common lung tumor in children below 6 years of age. International registry of the disease has a total of 350 cases worldwide. We report the first case of PPB in the state of Qatar, which presented as a large cystic lung lesion. The patient was first thought to have benign congenital pulmonary airway malformation (CPAM) based on chest X-ray findings. The diagnosis of PPB was suspected based on chest CT scan findings and was confirmed after surgical resection of the cystic mass. The case highlights the need to consider PPB in the differential diagnosis of cystic lung lesions in children and the need for further radiological imaging , genetic testing, and/or excisional biopsy to confirm the diagnosis.Pleuropulmonary blastoma (PPB) is a rare intrathoracic malignancy, which arises from the lung parenchyma and/or pleura. PPB has strong genetic association with mutations in  Congenital cystic lung lesions are a group of lung diseases which represent variable pathology ranging from benign congenital malformation to neoplasm. These lesions can present with an overlapping clinical and radiological features. Based on the type of the lesion, treatment approach can range from observation to surgical resection. Several classifications have been proposed based on the radiological and pathological features . PleuropDICER1 gene. The identification of such mutation in patients with cystic lung lesion can help with diagnosis and guide management. We report the clinical presentation and outcome of the first case of PPB in the state of Qatar with identified DICER1 gene.PPB has strong genetic association with mutations in The patient is a 35-month-old boy, previously healthy who presented to emergency department with history of low-grade fever, rhinorrhea, and abdominal pain. There was no history of recurrent chest infections, bone pain, weight loss, or fatigue. Physical examination was significant for decreased breath sounds over posterior aspect of left lower chest zone. Chest X-ray showed large cystic lesion in left lower lobe . No prevPatient was referred to pediatric pulmonology clinic with a preliminary diagnosis of congenital pulmonary airway malformation (CPAM). Therefore, chest computed tomography (CT) was performed and showed multiseptated large cystic lesion within the left lower lobe with multiple solid nodules. Enlarged lymph nodes were also noted in the left paratracheal region; the largest lymph node measured 10 mm . The preResection of the lesion via left lower lobectomy was done through left thoracotomy. A large cyst measuring 8 × 8 × 10 cm was seen within the left lower lobe with adherence to left hemidiaphragm, but no evidence of invasion of the chest wall or the diaphragm .Histopathological examination of the mass revealed multiloculated cystic and solid components containing atypical rhabdomyoblasts with diffuse cytoplasmic expression of desmin and patchy nuclear expression of myogenin . The patPatient had uneventful postoperative course. Chemotherapy was commenced according to the recommendation of the International Pleuropulmonary Blastoma Registry (IPPBR), which consists of four agents  over a period of 36 weeks.The patient completed a year of the disease-free period as evidenced by normal chest CT, normal brain MRI, and normal ultrasound of abdomen and thyroid.DICER1 gene. On the other hand, the patient's father and 2-year-old sibling were also tested positive for the same mutation. However, both were completely asymptomatic and had no evidence of lung cysts or masses by chest X-ray screen.Genetic testing showed that the patient has heterozygous pathogenic mutation in Pleuropulmonary blastoma (PPB) is a rare intrathoracic malignancy arising from the lung parenchyma and/or pleura. It is considered the most common primary intrathoracic malignancy of childhood. PPB was first described in 1988  as a dysPPB is classified into three subtypes: type I consists only of cystic lesions; type II consists of mixed cystic and solid components, whereas type III consists of only solid tumors. These subtypes represent a progression process based on reported cases of type I progression into type II and type III , 6. The DICER1 mutation [DICER1 mutation status did not affect outcome or prognosis [DICER1 mutation predisposes to other tumors, such as Sertoli-Leydig cell tumors, ciliary body medulloepithelioma, Wilms tumor, and carcinoma of the thyroid gland [Mutation in the DICER1 gene was described in majority of PPB cases. According to the largest International Pleuropulmonary Blastoma Registry (IPPBR), which reported 350 cases, 66% of the 97 tested patients had a heterozygous germline id gland , 9.To our knowledge, only five cases of PPB were reported from the Middle East –13,, andMany prognostic factors affecting the outcome of PPB were investigated. The subtype of the PPB and the presence of metastases at diagnosis were the only statistically significant unfavorable prognostic factors , 16, 17.The mainstay of PPB management is complete surgical resection of the tumor with or without chemotherapy depending on the subtype , 18. ThePPB is a rare and potentially aggressive, intrathoracic malignancy which can be insidious. Early radiological and histological testing is imperative for early diagnosis and differentiation from benign pulmonary cystic lesions, which would highly influence outcomes and survival.


Solitary fibrous tumours (SFTs) are rare tumours of mesenchymal origin, most commonly found in adults with a median age of 45-50 years. Cases in the head and neck are uncommon, and definitive diagnosis relies on histomorphological features supported by immunohistochemical staining. Here we present a case of a 26-year-old gentleman with a one-year history of right-sided nasal obstruction and bloody discharge on a longstanding background of recreational cocaine use. A computed tomography scan of the paranasal sinuses demonstrated a mass arising from the anterior skull base extending into the right middle turbinate. Immunohistochemistry testing for tumour characterisation showed hematopoietic progenitor cell antigen (CD34) and signal transducer and activator of transcription 6 (STAT6) positivity in keeping with an SFT. The patient underwent definitive surgery via endoscopic piecemeal resection with no further reoccurrence at follow-up. Solitary fibrous tumours (SFTs) are rare tumours of mesenchymal origin, first described as primary spindle cell neoplasms of the pleura in 1931 by Klemperer and Rabin . Cases iA 26-year old gentleman presented with a one-year history of right-sided nasal obstruction and bloody discharge. There were no sinonasal or associated respiratory symptoms. Anterior rhinoscopy revealed a large fleshy mass present within the right nasal cavity. The contralateral nasal cavity was clear with no associated cervical lymphadenopathy. Flexible nasal endoscopy was not feasible past the nasal vestibule due to the obstruction present. The patient had a longstanding history of recreational cocaine use with no other past medical history. A computed tomography (CT) scan of the paranasal sinuses was undertaken and demonstrated a mass extending into the right middle turbinate from the anterior skull base. The mass displaced the ipsilateral uncinate process and nasal septum to the right and left respectively as seen in Figures There was no local bony erosion or intra-orbital involvement and intracranial appearances were normal. Differentials to consider based on the clinical presentation and radiological findings included nasopharyngeal carcinoma, haemangiopericytoma and fibrosarcoma.Diagnostic biopsies (1.0 x 1.0 x 0.3 cm) were performed under general anaesthesia that determined cellular uniform spindle cells infiltrating the nasal mucosa with focal ulceration in keeping with an SFT. Table The patient underwent definitive surgery via endoscopic piecemeal resection where the vascular tumour was found to arise near the first olfactory fibre. Intraoperative pathology samples revealed three separate tumour areas. Post-operatively, the patient was observed with no complications and subsequently discharged the same day with a course of oral steroids and nasal sinus washouts. At the 15-month follow-up, the patient had no further nasal obstruction and continued to remain symptom free with no reoccurrence.SFTs were first described by Wagner in 1879 and further characterised by Klemperer and Rabin in 1931 . To the Most SFTs occur in adults with a median age of 45-50 years and a mean age of of 50.4 years, in equal distribution between men and women . ExtrathDefinitive diagnosis relies on histomorphological features supported by immunohistochemical staining and increasingly, molecular analysis to distinguish SFTs from other tumours. Microscopically, SFTs are hypocellular collagen-rich areas mixed with a proliferation of uniform spindle cells. Almost all SFTs express CD34 positivity, which is a myeloid progenitor cell antigen also present in endothelial cells. Signal transducer and activator of transcription 6 (STAT6) has recently been identified as a consistent finding in SFTs ,10. VimeSurgical removal is curative and the definitive management option, with resectability identified as the single most important indicator of clinical outcomes . HoweverThe effects of cocaine as a vasoconstrictor and an irritant to the epithelium on the nasal mucosa are well cited in the literature with the recurrent use resulting in mucoperichondrial ischaemia, inflammation, and localised necrosis of the tissues often leading to septal perforation . In our Solitary fibrous tumour is a rare and unusual pathology particularly in the nasal and paranasal region. It should be considered as a differential diagnosis in patients presenting with nasal obstruction and bloody rhinorrhoea and the use of cocaine may be a predisposing factor. Diagnosis relies on histomorphological features supported by immunohistochemical staining. Surgical intervention is the definitive management; however, there is a high risk of intraoperative bleeding due to the vascular nature of the tumour. Residual tumours may benefit from post-operative stereotactic radiation.


Acute appendicitis is common in children and adolescents. Recently, conservative antibiotic treatment is regarded to be a safe approach to treat uncomplicated appendicitis. It is already established as initial treatment in cases of perforated appendicitis with perityphlitic abscess, commonly followed by interval appendectomy. We report on a 13-year-old boy with uncomplicated appendicitis and a 17-year-old girl with complicated, perforated appendicitis and perityphlitic abscess in whom initially successful antibiotic treatment led to a delay in detection of a carcinoid tumor  of the appendix. NET of the appendix, with an incidence of 0.03 to 0.8% in the pediatric population undergoing appendectomy for acute appendicitis, are usually incidental findings after appendectomy with no secure method for detection prior to surgery. Raising concern about this rare but severe disease, we recommend information of patients and their parents about the potential risk of belated diagnosis before opting for conservative their treatment of acute appendicitis. Furthermore, patients successfully treated conservatively require a close follow-up by ultrasound. In presence of any conspicuous finding, especially on imaging, appendectomy should be considered. Acute appendicitis is common in childrenGeneral guidelines for this treatment strategy, as well as long-term data of outcome in the pediatric population, are currently missing.In contrast to the conservative treatment of uncomplicated appendicitis, the initial non-operative therapy with interval appendectomy for complicated appendicitis with appendiceal abscesses is well established and has advantages in terms of postoperative complications, especially regarding long-term obstruction events, and should be considered the first treatment of choice for pediatric patients with complicated appendicitis.Carcinoid tumors of the appendix, which are highly differentiated NETs, are usually found incidentally in the course of an appendectomy due to acute appendicitis, with an incidence of 0.08 to 0.3% of children undergoing appendectomy.A 13-year-old boy presented with pain in the lower right abdomen, which had lasted for 2 days. He was otherwise healthy and without any comorbidity. He had no prior episodes of abdominal pain, nor a history of weight loss or intermittent fever. Symptoms of carcinoid syndrome were absent as well. On clinical examination, he showed the classical signs of an acute appendicitis. His temperature was 36.5°C (97.7°F). Initial inflammatory parameters were within normal range with leukocytes of 5.1/nL, neutrophils of 2.6/nL (51.3%), and a C-reactive protein (CRP) of <3 mg/L. On ultrasound, the appendix was displayed over a long distance with a maximum caliber of 7 mm at the apex surrounded by a slight layer of free fluid showing the ultrasonographic picture of an acute appendicitis. An appendicolith was not present. Due to the mild clinical presentation, as well as the boy's and his parents' preferences, we opted for antibiotic treatment, which soon led to complete resolution of symptoms. An ultrasound 2 days later showed a reduction of the appendix size (maximum 5 mm). The patient was released after 3 days of intravenous antibiotic treatment (ampicillin/sulbactam) and oral antibiotic application was continued for 10 days. In want of general guidelines for monitoring therapeutic success of conservative treatment of acute appendicitis, we routinely perform an ultrasound 6 weeks after patient's discharge for follow-up. In this examination, the apex of the appendix of the boy was distended to a diameter of 7 mm, showing hyperemia and missing visualization of bowel layers as well as surrounding perityphlitic edema 23, whEscherichia coliandCandida albicans, wherefore an antimycotic intravenous therapy with caspofungin was added. Due to persistent abdominal distention and paralysis but without peritonitis as well as an increase in inflammatory parameters (CRP up to 290 mg/L and leukocytosis with 39.1/nL), another MRI was performed. Two abscesses in the pouch of Douglas and dorsolateral to the cecum were detected, which were treated with two drains placed under CT guidance by an interventional radiology. The further recovery of the patient was slow but uneventful. After 2 weeks, the drains were removed. Antibiotic and antimycotic therapies were stopped 1 week later. The girl was discharged in good condition, with normal laboratory findings and full enteral feeds 4 weeks after admission. One month later, we performed an elective appendectomy in single-incision laparoscopic surgery technique. Intraoperatively, there were postinflammatory adhesions in the right lower abdomen, hyperemia, edema, and moderate fibrinous exudate of the appendix. Histology revealed a well-differentiated NET measuring 1.4 cm in largest diameter with infiltration into the mesenteriolum (infiltration depth: 0.2 cm), and no infiltration of lymphatic vessels, blood vessels, or perineural sheaths. The resection margins were free of tumor cells resulting in a grading: G1; pT3, pNX M0, L0, V0, and Pn0 (UICC stage II). The levels of chromogranin A and 5-hydroxyindoleacetic acid were within normal range. Since the tumor was smaller than 15 mm in diameter and the resection was complete, there was no indication for right hemicolectomy. The patient was included in the German Society for Paediatric Oncology and Haematology—Malignant Endocrine Tumours registry with 3-month follow-up intervals .A 17-year-old girl was transferred to us from a primary care hospital with suspected perityphlitic abscess. She was presented there 2 days prior with pain in the lower right abdomen for 5 days, diarrhea, and fever up to 39.6°C (103.3°F) as well as elevated CRP (134 mg/L). Her gynecologic history was empty. Abdominal imaging  showed a perityphlitic abscess and the patient was transferred to our tertiary center. On clinical examination, she presented with moderate pressure pain in the right lower abdomen, without rebound tenderness, percussion pain, or guarding. She had a normal heart rate, no fever, and her CRP was 200 mg/L. An intravenous hydration as well as an antibiotic therapy with imipenem was initiated. An additional MRI of the abdomen showed a multichamber abscess with the right ovary included into the inflammatory mass. The abscess was drained by ultrasound-guided transrectal puncture under general anesthesia. Microbiology displayed imipenem-sensitiveWatanabe et al were the first to report an adult, who was successfully treated conservatively for on acute appendicitis and showed the signs of acute appendicitis with a dilated lumen at the apex on a follow-up ultrasound 3 months later again.Nevertheless, for complicated appendicitis with periappendiceal abscess, initial antibiotic therapy followed by interval appendectomy has advantages in terms of a lower complication rate, including surgical wound infection, postoperative peritonitis, or formation of a reabscess as well as lower incidence of adhesive small bowel obstruction.If antibiotic treatment of acute appendicitis is primarily chosen, clinics need to be aware of the potential risk of NET of the appendix being missed, however, rare this tumor entity may be. This emphasizes out on the necessity of follow-up imaging after successful conservative treatment of acute appendicitis. The examples of patients given in this article underline that radiological signs of appendicitis may be visible on imaging, even in a patient free of symptoms. Though a NET is not likely to be detected, it may provoke anatomic a aberrations of the appendix. In our opinion, any abnormality should lead to perform appendectomy. In this course, in clinic or imaging appendectomy should be generally suggested for recurrent appendicitis following conservative treatment of acute appendicitis not to miss a hidden NET.Furthermore, in the case of a conservative treatment option, the possible risk of delayed detection of NET of the appendixAfter nonoperative, antibiotic treatment of appendicitis, follow-up ultrasound is required. An interval appendectomy should be performed in any case of conspicuities to reveal a hidden carcinoid tumor (NET), according to the medical dogma “if in doubt take it out.” Furthermore, the risk of delayed detection of a possible NET due to conservative therapy needs to be part of the initial patient's and parents' enlightenment for this option of therapy, especially in case of uncomplicated acute appendicitis.