Sclerosing stromal tumor (SST) is a rare benign neoplasm of the ovary. There are only a few cases of sclerosing stromal tumor of the ovary during pregnancy that have been reported in the literature. The presenting symptoms are nonspecific, including pelvic pain or menstrual irregularities. We describe a case of a young 22-year-old pregnant woman who presented with pelvic pain in the second trimester. On imaging she was found to have a 12 cm left adnexal mass with solid features on MRI. The patient underwent exploratory laparotomy and removal of the mass that was attached to the left ovary via a stalk with preservation of the left ovary. The frozen section diagnosis was “sex cord stromal tumor, favor benign”. The final pathology confirmed the diagnosis of the sclerosing stromal tumor of the ovary where characteristic features of SST including a heterogenous, pseudolobular growth pattern with hypercellular and hypocellular areas were identified along with prominent luteinized stromal cells attributed to pregnancy. In this case report and review of literature, we emphasize consideration of this rare ovarian tumor in the differential diagnosis for a young pregnant woman who presents with pelvic pain. Sclerosing stromal tumor (SST) of the ovary is a benign neoplasm that was first reported in 1973 by Chalvardjan and Scully , 3. It uA 22-year-old G1P0000 at 19 weeks and 5 days of gestation presented to the labor and delivery triage with severe left sided pelvic pain that started earlier that day. Pain was initially intermittent that became constant, severe, and stabbing in nature and lasted for 2 hours, thus prompting a visit to the labor and delivery floor. Patient reported nausea, vomiting, and nonbloody, loose bowel movements for 2 days prior to presentation as well. Patient reported her pain was worse with lying down and got better with leaning forward. She denied fever, sick contacts, trauma, chest pain, shortness of breath, vaginal bleeding, contractions, leakage of fluid, and decreased fetal movement. Prenatal labs were unremarkable.The past medical history was remarkable for history of attention deficit disorder. Surgical history was significant for appendectomy performed in the current pregnancy at 7 weeks of gestation. The review of her chart revealed that she had an ultrasound at the time of appendectomy that showed the left ovary measuring 4.9 × 5.2 × 4.7 cm containing hemorrhagic corpus luteum cyst with normal right ovary. At the 12 weeks' nuchal translucency scan, the left ovary was measuring 6.3 × 5.4 × 5.1 cm.Vitals in triage for this acute visit were in normal range. On physical exam, patient was in moderate discomfort with severe bilateral lower abdominal tenderness to palpation without rebound or guarding. No masses were felt due to gravid uterus. Genitourinary exam revealed closed cervix with left adnexal tenderness on pelvic examination. Fetal status was reassuring and patient had no contractions.Pelvic ultrasound showed a solid hypervascular, mostly hypoechoic, partially isoechoic/partially hypoechoic left ovarian mass measuring 12.6 × 9.8 × 9.4 cm, which had been persistently increasing in size over the course of the pregnancy . Peak arMRI pelvis without contrast revealed heterogeneous T2 hyperintense and T1 isointense-to-hypointense left ovarian mass measuring 12 × 9× 10 cm; this mass was encapsulated with minimal cystic/fluid component centrally . There wDifferentials included gynecological and nongynecological causes of acute pelvic pain during second trimester. This included, but were not limited to, ovarian torsion, placental abruption, ruptured hemorrhagic cyst, round ligament pain, degenerating fibroids, and ovarian tumors both benign and malignant including sex cord stromal, epithelial, and germ cell tumors.Patient was admitted and underwent exploratory laparotomy. There was a large amount of clear peritoneal fluid noted in the abdominal cavity. A 15 cm left adnexal mass adherent to posterior cul-de-sac was seen. The ovary was removed from the posterior cul-de-sac using blunt dissection. The mass appeared to be attached to the left ovary by a small stalk which was cauterized and cut with LigaSure device. The left ovary appeared to be normal and was left behind intact. The right ovary appeared normal on inspection.Pathologic examination revealed a 436 gram, solid, gray-tan mass with a focal infarct. Microscopic features included a pseudolobular pattern with alternating hypercellular and hypocellular areas and edema Figures . The celPost operatively, patient did well. She continued with the pregnancy with no further complication, and had a normal spontaneous vaginal delivery of a healthy baby with no postpartum issues.Sex cord stromal tumors (SST) of the ovaries are rare ovarian neoplasms accounting for approximately 5–8% of ovarian tumors. They originate from sex cords and the ovarian stroma or mesenchyme. This group of ovarian tumors includes granulosa cell tumors, fibroma, thecoma, steroid cell tumors, Sertoli–Leydig cells tumors, sclerosing stromal tumors, and other morphologically indifferent cells . SclerosSclerosing stromal tumors are rarely seen in pregnancy making this a unique case . OzdemirSclerosing stromal tumors of the ovaries are generally hormonally inactive; however, in the literature there have been some cases of tumors that are hormonally active. These active hormonal tumors may have estrogenic and rarely androgenic effect ,6. The aOn ultrasound sclerosing stromal tumor appears as a solid hypervascular mass with hypoechoic area in the center . SeveralSclerosing stromal tumors demonstrate a characteristic constellation of histologic findings including a pseudolobular growth pattern with variably cellular areas, edema, prominent vascularity that has been described as hemangiopericytoma-like in appearance, and stromal cells admixed with luteinized cells. Luteinized stromal cells are recognized by their oval and round shape and originally eosinophilic to clear, lipid containing cytoplasm. In pregnancy, Luteinized stromal cells can become quite pronounced and create diagnostic confusion, in some cases suggesting consideration of a signet ring carcinoma or Krukenberg tumor.In most instances, clinical context and recognition of characteristic histologic features of SST will avoid misdiagnosis. In difficult cases, special stains and immunohistochemistry stains can be employed to allow destruction. Mucicarmine and immunohistochemistry epithelial markers, such as Pankeratin will decorate metastatic signet ring carcinoma cells, while luteinized stromal cells will be negative.Sclerosing stromal tumors are rare, benign ovarian neoplasm occurring in young females. Clinical, radiological, and morphological findings are needed to make a diagnosis and to differentiate them from other types of sex cord stromal neoplasms . HistoloSclerosing stromal tumor (SST) is a benign neoplasm of the ovary and can present with nonspecific symptoms such as pelvic pain in pregnancy. It is importance to consider all possibilities related or unrelated to pregnancy while evaluating a patient's complaint during pregnancy. The morphologic histopathology can pose diagnostic dilemma in pregnancy if there is an abundance of luteinized cells, raising a differential diagnosis that may include malignancy. Intraoperative frozen section can be used to confirm the benign nature of the neoplasm and allow a conservative, ovary sparing surgical approach.


Hirschsprung's disease and, more rarely, intestinal duplication can both cause intestinal obstruction in neonates. The simultaneous occurrence of these two diseases is reported in only two studies, and in both cases, intestinal duplication was an incidental finding, as it had not determined clinical intestinal occlusion. This paper reports a unique case of coexistence of the two conditions, with both causing intestinal obstruction, delayed appropriate, and definitive surgical treatment. Hirschsprung's disease (HD) is defined by the absence of enteric neurons in the distal part of the bowel. Neonates with HD usually present with a distended abdomen, feeding intolerance with bilious vomiting, and delayed passage of meconium. Failure to promptly diagnose HD can result in death secondary to recurrent enterocolitis.Intestinal duplication (ID) is a rare congenital condition usually involving the small intestine, located on the mesenteric side of the bowel, with which it may share blood supply. Although it is symptomatic at birth in only 30% of cases, diagnosis is made before 2 years of life in up to 70% of patients. Symptoms vary as ID can affect any part of the gastrointestinal tract.To date, no cases of intestinal obstructions simultaneously caused by both HD and ID have been reported.A full-term male neonate born at our Institute by induced vaginal delivery presented with bilious vomiting and abdominal distension starting from day 2 of life. X-ray revealed substantial distension of the small bowel, and abdominal ultrasound showed a simple cystic mass in the right hypochondrium (38 × 27 mm). Explorative laparotomy found an occlusive duplication at the ileocecal junction . Since Postsurgical course was characterized by recurrent bilious vomiting, abdominal distension, and constipation. At 1 month of life, due to exacerbation of his symptoms, the child underwent explorative relaparotomy: anastomotic stenosis and fibrous bands were excluded as the cause of occlusion. Instead, we found massive intestinal adherences, not apparently due to the previous surgery, as they were generalized and not localized, and were not causing bowel obstruction.Despite a second surgical procedure, abdominal distension persisted, associated with the absence of spontaneous evacuation and impaired weight gain. Since postsurgical complications had already been excluded at the second laparotomy, we started suspecting HD. Another explorative laparotomy was planned a month later: ileostomy was performed along with multiple intestinal biopsies, which confirmed the diagnosis of short-segment HD .At nine months of life, the child successfully underwent transanal endorectal pull-through (De La Torre). Intestinal recanalization followed 3 months later. At 1 year follow-up, the child had normal bowel function, and no more episodes of abdominal distension have occurred.Only two cases of co-occurring HD and ID are reported in the literature in English. The first, published in 2012, is that of a 35-year-old woman with a medical history of HD treated with Soave procedure at 29 months of life presenting with an adenocarcinoma originating from a rectal duplication.The coexistence of ID and HD is extremely rare, and only two cases have been described in the English literature. As shown in our report, the presence of HD and ID together can mislead the diagnostic work-up and delay appropriate therapy.


Osteoid osteoma (OO) apparent in the intra-articular region of the elbow is very rare. Although computed tomography-guided excision and radiofrequency ablation have been recognized as useful treatment options, arthroscopic excision has recently received focus as an alternative strategy for lesions close to neurovascular structures or intra- and juxta-articular lesions. We herein report a 17-year-old female who underwent arthroscopic treatment for intra-articular OO located at the olecranon/coronoid fossa. Her symptoms included elbow pain that was exacerbated at night and contracture of elbow flexion-extension, and she was diagnosed with intra-articular OO after 12 months of symptomatic history. Arthroscopically, thorough synovectomy for both the anterior and posterior aspects of the joint enabled definition of the tumor margin with hyperemic alteration and excision of the lesion as an en bloc specimen. At the 12-month follow-up, the patient had no recurrence of elbow limitation or pain. This case report describes the advantages of arthroscopic treatment, including a low-invasive approach and easy accessibility to the whole intra-articular space, which can provide clear visualization of the tumorous lesion. Osteoid osteoma (OO) is a benign bone tumor generally apparent in the first to third decades. It has been reported that approximately 50% of OOs occur in the femur and tibia with the diaphyseal shaft or toward the metaphysis, with the elbow joint very rarely affected . AlthougIn addition to tumor excision through the open approach, computed tomography- (CT-) guided excision and radiofrequency ablation have been recognized as viable treatment options , 5. ArthA 17-year-old right-handed female presented in our outpatient clinic with a 12-month history of pain and limited motion of her left elbow. The symptoms included mild pain during the day time that became increasingly severe at night. A physical examination revealed elbow contracture with a maximal extension of -20° and flexion of 125° Figures . The patUnder a diagnosis of intra-articular OO at the elbow, the patient underwent arthroscopic treatment to excise the lesion. A routine anteromedial portal was created 1 cm anterior and 2 cm proximal to the medial epicondyle, and the scope was introduced. Severe proliferation of synovial tissues was observed throughout the joint space . A 4 mm We herein reported a case of arthroscopic excision for intra-articular OO of the elbow joint. The advantages of this technique include a low-invasive approach and easy accessibility to both the anterior and posterior aspects of the tumorous lesion. Under the classical open approach, in contrast, a relatively long incision is required, especially for determining the accurate degree of excision; consequently, this approach carries a risk of scar formation, residual pain, and contracture. Arthroscopically, thorough synovectomy enabled us to identify the tumorous lesion with hyperemic alteration. Arthroscopic maneuvers such as capsular release and debridement can be added to improve the joint motion. This patient did not undergo such release since the loss of the range of motion was considered mild. Bhatia  suggesteTo our knowledge, 5 case reports and 1 case series have described a total of 17 patients who underwent arthroscopic treatment for elbow OOs , 6–10; aThe difficulty in diagnosing OO based on imaging findings has been mentioned in cases with severe inflammatory changes, such as a prominent periosteal reaction, exaggerated synovial hypertrophy, and joint effusion with extensive bone marrow and soft tissue edema . In addiWe herein report a 17-year-old female who underwent arthroscopic treatment for intra-articular OO located at the elbow. This case report describes the advantages of arthroscopic treatment, including a low-invasive approach and easy accessibility to the whole intra-articular space, which can provide clear visualization of the tumorous lesion.


Background: Ameloblastoma is a rare head and neck tumor characterized by a high incidence of BRAF mutation providing a rationale for the use of BRAF inhibitors in patients with advanced disease.Methods: We report the case of a 26-year old female presenting with metastatic ameloblastoma. A molecular screening of the tumor revealed a BRAF V600E mutation.Results: The patient started treatment with dabrafenib and trametinib and experienced complete response which is still ongoing 30 weeks after treatment onset.Conclusions: The complete response observed here illustrate the role of molecular profiling in complicate clinical situation of rare head and neck cancer and the potential benefit of BRAF-targeted therapy in ameloblastoma carrying BRAF V600E mutation. Precision oncology aims to tailor the therapeutic strategy based on tumor's molecular alterations. Previous studies have suggested the validity of such approach in rare and ultra-rare tumor subtypes, including rare head and neck cancers; with the identification of targetable alterations in up to 93% of cases . AmeloblIn November 2018, a 26-year old female was referred for hemoptysis and cough of several weeks' duration. Her past medical history was significant for the diagnosis, at the age of 13 years, of an ameloblastoma of the right mandible (tooth 48) treated by surgery with clear margins and no evidence of locoregional relapse since then. A CT scan was performed which showed numerous bilateral nodules. The patient underwent a CT-guided percutaneous lung biopsy of one of these nodules. Histological examination was in favor of lung metastasis of ameloblastoma.BRAF gene V600E mutation [The patient was enrolled in our molecular screening program after signature of informed consent  and gave also written informed consent for the publication of this case report. Next-generation sequencing of the metastatic tumor sample was performed as previously described and revealed the presence of a The ameloblastoma is a histologically almost always benign odontogenic tumor of the jaw bones with a potential of locoregional recurrence . DistantBRAF mutation (BRAF V600E mutation.Anecdotal response has been reported with platinum salts agents but there is no standard of care in this setting . A seminmutation . In melamutation . The toxmutation . The comAll datasets generated for this study are included in the article/supplementary material.This study was approved by the institutional review board of Institut Bergonié.AI: conception and design. EK and AI: collection and assembly of data. All authors: data analysis, interpretation, manuscript writing, and final approval of manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Femoral hernia accounts for 3% of all the hernias, and in 0.5–5% of cases, the appendix can migrate through the femoral hernia and is called de Garengeot hernia. It is a very rare condition, and the incidence of appendicitis in this type of hernia is as low as 0.08–0.13%.We bring into discussion a case of a 47-year-old female who presented to the emergency department with a painful right-sided groin lump for the past 2 days. After initial resuscitation, a CT scan was requested which showed the presence of inflamed appendix inside the femoral canal. She was taken to the operative theatre, and during the laparoscopy, the appendix was identified migrating through the femoral canal and it could not be retracted into the peritoneal cavity; therefore, the mesoappendix was divided and the operation converted to the open low approach. After identifying the femoral hernia sac and opening it, the appendix was removed and herniorrhaphy was performed. Our patient had an uneventful recovery and was discharged on the following day.We report a rare case of de Garengeot hernia which was diagnosed preoperatively. Because of its non-specific presentation, patients are usually diagnosed with incarcerated femoral hernia and are taken to operative theatre and the final diagnosis is made intra-operatively. Due to its rarity, there is no standard approach for this condition, and emergency appendicectomy and concurrent herniorrhaphy is the mainstay of treatment. In this paper, we present different surgical methods for the treatment of this type of hernia. Hernias are usually named after the surgeons who first described them. The eponym Littre’s hernia refers to an inguinal hernia containing a Meckel’s diverticulum and was named after Alexis de Littre. Maydl’s hernia, which describes the presence of an incarcerated small intestinal loop in a “W” configuration inside a single hernia sac, was first described by Karel Maydl. The presence of the appendix inside the inguinal canal is called Amyand’s hernia after being first reported by Claudius Amyand .In 1731, Rene Jacques Croissant de Garengeot 1688–1759), who was a Parisian surgeon, first described a rare case of the appendix inside the femoral canal  and Hevi9, who waIn this paper, we present a middle-aged female patient who presented with an inflamed appendix inside the femoral canal who underwent surgery. We also describe different surgical techniques that may be employed in the treatment of this type of hernia.A 47-year-old female was referred to the emergency department by her general practitioner after noticing a lump in her right groin. She mentioned that 2 days prior to presentation that a lump appeared suddenly and was initially uncomfortable but then developed increasing pain and erythema. The patient denied nausea, vomiting, fever, or change in bowel habit. The patient did not have any past significant medical history apart from being a smoker and had a BMI of 25.6. On arrival to the ED, the patient was resuscitated, and on examination, a 3 × 3 cm erythematous, irreducible lump with minor local tenderness was identified in the right groin below the inguinal ligament. The patient had a leucocytosis of 12.1 with normal serum biochemistry. A CT scan demonstrated a blind-ended structure with surrounding fat stranding inside the femoral canal (Fig. The patient underwent laparoscopy where the appendix was found to have migrated through the femoral canal Fig. , and attSince the first description of the de Garengeot hernia in 1731, less than 100 cases have been reported in the literature . FemoralPre-operative diagnosis of de Garengeot hernia can be challenging due to its non-specific presentation. Patients usually present with a tender right-sided groin lump and after being diagnosed with an incarcerated femoral hernia are brought to the operating theatre and found to have an appendix in the femoral canal intra-operatively . These pRadiologic findings are non-specific. Although ultrasound is frequently used for detection of groin herniae, it is operator-dependent and only two cases have been reported that were diagnosed by ultrasound pre-operatively . MRI shoEmergency appendicectomy and femoral herniorrhaphy is the treatment of de Garengeot hernia. Due to the rarity of this condition and its typically intra-operative diagnosis, there is no standard surgical approach for this condition. Laparoscopic and open approaches have been advocated in the literature. Beysens et al. first described laparoscopic appendicectomy with totally extraperitoneal repair of the femoral hernia in 2013 , which hThe major post-operative complication of de Garengeot hernia repair is wound infection which occurs in 14 to 29% of cases . Delay iDe Garengeot hernia is a rare condition, and clinicians should have a high index of suspicion when they encounter a patient with right-sided incarcerated or strangulated femoral hernia. CT scan is the modality of choice for diagnosis but most cases are discovered intra-operatively. The treatment of this type of hernia is emergency appendicectomy and concurrent herniorrhaphy.


Massive subchorionic thrombohematoma (MST), termed Breus' mole, is a rare condition in which a large maternal blood clot separates the chorionic plate from the villous chorion. Common complications of MST include fetal growth restriction, preeclampsia, and intrauterine fetal death. Here, we present a case of a 17-year-old Japanese woman referred to our institution at 21 weeks of gestation. Ultrasound examination revealed a large placental mass with mixed high and low echogenicity measuring approximately 7.6 cm in thickness. Doppler examination showed absence of end-diastolic velocity of the umbilical artery. At 22 weeks of gestation, the patient had a stillbirth weighing 138g. The placenta weighed 502 g and was 8 cm thick, and the total blood loss was 270 g. Macroscopic examination revealed that a subchorionic blood clot measuring 12 cm × 5 cm covered a large portion of the placenta with well-defined margins on the fetal surface. Microscopic examination revealed an intervillous hematoma and fibrinous deposits directly beneath the chorionic plate with adjacent compressive effects. Based on these findings, MST was diagnosed. Because MST is rare, it must be considered in the differential diagnosis of parental conditions. Magnetic resonance imaging can be optimal for diagnosing MST when ultrasound diagnosis is difficult. Massive subchorionic thrombohematoma (MST) is a rare condition in which a large maternal blood clot separates the chorionic plate from the villous chorion. It was first described and termed Breus' mole in 1892 , and itsHere, we report a rare case of MST that presented with placentomegaly and complicated by FGR and oligohydramnios at 21 weeks of gestation.A 17-year-old Japanese woman, para 0, was referred to our institution at 21 weeks and 6 days of gestation following the observation of FGR, oligohydramnios, and placental enlargement which were observed at a private clinic. Ultrasound  revealedIn the present case, ultrasound revealed placentomegaly with mixed high and low echogenicity, FGR, and severe oligohydramnios. Doppler examination revealed AEDV of the umbilical artery. However, prenatal diagnosis of MST could not be performed because of severe oligohydramnios.Ultrasound findings of MST have revealed extensive echogenic areas near the chorionic plate, indicating hemorrhage, which differs from normal placental tissue. Fung et al.  reportedAlthough magnetic resonance imaging (MRI) findings of MST are variable, MRI is reportedly useful for differentiating MST from other placental diseases, such as placental abruption, chronic abruption oligohydramnios sequence (CAOS), and placental mesenchymal dysplasia (PMD) , 7. In aThe etiology of MST remains obscure. In MST, a large amount of blood, particularly of maternal origin, collects and separates the chorionic plate from the villous chorion. DNA analysis has revealed that 85% of the blood in the thrombus is maternal in origin . FurtherUteroplacental insufficiency is the underlying mechanism of FGR. In cases of severe FGR, at least half of placental surface might be covered with hemorrhage under the chorionic plate . In suchMST is associated with poor pregnancy outcomes. Fung et al.  reportedHere, we reported a case of MST that presented with placentomegaly complicated by FGR and oligohydramnios. Because of severe oligohydramnios, prenatal diagnosis of MST in the patient was not possible. Nevertheless, MST must be considered in the differential diagnosis of parental conditions because it is a rare condition. Furthermore, this case highlights the potential use of MRI for diagnosing MST when ultrasound diagnosis is difficult.


Herein, we report magnetic resonance imaging (MRI) findings of a mucinous borderline tumor of the ovary, which we observed as a mainly solid tumor with large solid components in the lower pelvic cavity. The appearance of ovarian epithelial tumors on imaging is often complex. Cystic to solid appearing masses may be observed, and they often resemble epithelial carcinoma. Due to mucinous or hemorrhage components of packed small or microcystic components, MRI depicts slightly high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. Mucinous borderline tumor of the ovary with a large solid component is very rare, but it is clinically important to recognize the possibility of mucinous borderline tumor to avoid unnecessary surgical intervention. Mucinous tumor, a common subtype of epithelial tumor of the ovary, is classified as adenoma, borderline malignancy, or carcinoma based on cytological and structural atypia . In geneHerein, we describe a case of ovarian mucinous borderline tumor with a large solid component with MRI findings of slightly high signal intensity on T1-weighted imaging and slightly low signal intensity on T2-weighted imaging, which reflected the tumor's histological characteristics.A 39-year-old woman with no medical history was referred to the Department of Gynecology at our facility after experiencing abdominal pain for the previous 2 weeks. She exhibited no additional symptoms and biological data were normal. Ultrasonography of the pelvis revealed a large mass extending from the right side of the uterine body to the adnexal region. The mass appeared solid and hypoechoic with sound attenuation. Serum levels of carcinoembryonic antigen, carbohydrate antigen 19-9, and carbohydrate antigen 125 were within normal ranges.The patient then underwent computed tomography (CT) and MRI. Plain CT and contrast-enhanced CT revealed a large solid mass with cystic areas Figures . T1-weigThe surgical specimen from right adnexectomy consisted of a 12 × 9 × 7 cm mass with a yellowish-white cut surface, a cystic component containing dark yellow fluid, a smooth internal surface, and an almost solid component . MicroscIn 1973, Hart and Norris  first deThe MRI features of mucinous ovarian borderline tumor include a larger size than mucinous cystadenoma and manifestation as a multilocular mass with thick septations and a solid component or components –4. The sThe diffuse proliferation of tumor cells tends to result in malignant lesions exhibiting a proportionately greater solid tissue component . Early pYon et al.  recentlyIn summary, we visualized a mucinous borderline tumor of the ovary as a large solid component with slightly high signal intensity on T1-weighted imaging, low signal intensity on T2-weighted imaging, and high signal intensity on diffusion-weighted imaging. These signal patterns reflected fluids of mucinous composition or hemorrhage, and the solid entities were packed cystic components.


MRI sequences as it is more sensitive than T2 weighted imaging. Once diagnosed, imaging of the entire brain and spine must be undertaken to assess for an underlying cause.If superficial siderosis is suspected based on clinical presentation, susceptibility weighted imaging should be undertaken in addition to standard  We present a case of a woman with sensorineural hearing loss and difficulty swallowing due to superficial siderosis secondary to a spinal myxopapillary ependymoma, and highlight the importance of an imaging strategy that enabled the identification of this uncommon but important diagnosis.2A previously healthy 46‐year‐old woman presented with difficulty swallowing. She also reported headache, vertigo, loss of balance, and hearing loss. On examination, she had left sided sensorineural hearing loss, multidirectional rotational gaze‐evoked nystagmus, and impaired tandem gait. A barium swallow study and CT head examination were both normal.An MRI head was performed given the multiple neurological deficits. The susceptibility weighted images demonstrated extensive supratentorial and infratentorial hemosiderosis Figure . The othThe patient was referred to neurology, and further investigated with an MRI of the whole spine to determine if there was an occult source of bleeding. This revealed an intradural enhancing lesion centered on the filum terminale that was deemed the likely source of the bleeding Figure . The les3With the increasing availability of more advanced blood‐sensitive sequences, the diagnosis of superficial siderosis is being made more frequently. The constellation of symptoms was described in the 1990s with sensorineural hearing loss, cerebellar ataxia, and pyramidal signs the most commonly recognized signs.Superficial siderosis is subclassified into “infratentorial” superficial siderosis given its predilection for the posterior fossa and to distinguish it from the cortical superficial siderosis associated with cerebral amyloid angiopathy or previous isolated subarachnoid hemorrhage. The posterior fossa predominance is thought to be due to the presence of large numbers of Bergmann glia (with high levels of ferritin synthesis) in the cerebellum as well as the flow of CSF over this area. The vestibulocochlear nerve is also often affected due to its long glial segment and abundant microglia compared to other cranial nerves, hence the prevalence of sensorineural hearing loss (as seen in our case).The classical imaging features of superficial siderosis are T2 hypointensity associated with blooming artifact on T2* weighted imaging along the cerebellar, cerebral, and spinal surfaces as well as the intrathecal spinal nerve roots and cisternal portions of the cranial nerves.A recent review of 65 cases of infratentorial superficial siderosis reported that there were no cases in which blooming artifact on gradient echo/SWI sequences was not associated with concurrent T2 hypointensity.Susceptibility weighted imaging is a relatively new MRI technique, which incorporates both magnitude and, crucially, phase information. Phase information is important because it is more sensitive to local changes in magnetic fields, due to substances with a different susceptibility  such as blood or iron.Once the diagnosis of superficial siderosis has been established, an underlying cause must be sought. In a group of 48 infratentorial superficial siderosis patients with a classical triad of symptoms and a chronic and progressive history, 27% had a cause demonstrated on brain MRI, 52% on spinal MRI, and 10% on CT myelography . None had additional potentially causative findings demonstrated on angiography. Dural abnormalities were the most common cause, for example, due to previous traumatic or iatrogenic injuries. Only one had a spinal tumor as seen in our case. Other causes included pineal tumors, a thrombosed giant aneurysm, and a thalamostriate tumor.This highlights the importance of initial complete brain and spine MR imaging in the investigation of these cases; this was particularly true in our case, as the myxopapillary ependymoma seen was clinically silent. Despite the small number of spinal tumors seen in the largest case series, there have been a number of case reports of myxopapillary ependymomas causing superficial siderosis.4Superficial siderosis is an important diagnosis and may be missed without appropriate imaging—we believe SWI is the most sensitive imaging sequence for its detection. As this case demonstrates, the cause of the superficial siderosis may be remote and clinically silent and as such imaging of the entire brain and spine is required.The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation  and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from the patient discussed in this report.None declared.TC: performed literature search and manuscript preparation. FA: performed manuscript editing and figure preparation. AA: performed case identification, manuscript editing; as principle investigator, takes overall responsibility for the integrity of the content of the manuscript.


Acute chest pain remains one of the most challenging complaints of patients presenting to emergency departments (EDs). The diverse etiologies of chest pain frequently lead to diagnostic and therapeutic challenges. Esophageal perforation is a rare but potentially life-threatening disease. It results in delayed diagnosis and an estimated mortality risk of 20% to 40%. Prompt diagnosis and immediate therapeutic interventions are key factors for a good prognosis.Case 1 involved a 66-year-old man who presented to the ED with acute chest pain radiating to the back and hematemesis. Emergent contrast thoracic computerized tomography (CT) indicated the presence of a massive pneumothorax with pleural effusion. The continuous drainage of a dark-red bloody fluid following emergent thoracic intubation led to the discovery that the patient had experienced severe vomiting after whiskey consumption before admission to the hospital. Re-evaluation of the CT indicated spontaneous pneumomediastinum, whereas barium esophagography confirmed the presence of an esophageal perforation. Case 2 involved an 18-year-old Vietnamese man admitted to our ED with acute chest pain and swelling of the neck after vomiting due to beer consumption. A chest x-ray indicated diffuse subcutaneous emphysema of the neck and upper thorax. Contrast CT indicated pneumomediastinum with extensive emphysema and air in the paraspinal region and spinal canal.Both of the 2 cases were diagnosed as spontaneous perforation of the esophagus (Boerhaave syndrome [BS]).Case 1 received surgical interventions, whereas case 2 decided not to avail our medical services.Case 1 was discharged after a good recovery. Case 2 lost to follow-up.We recommend all physicians in the ED to raise their index of suspicion for BS when dealing with patients having acute chest pain, dyspnea, confirmed pneumothorax, or newly-developed pleural effusion. Full-thickness rupture of the esophagus results in the extravasation of gastric juice and oral secretions, which causes peri-esophageal space contamination, pleural space inflammation, and systemic sepsis. Esophageal perforation has an estimated mortality risk of 20% to 40%.–8 Therefore, prompt diagnosis and appropriate immediate therapeutic interventions are key for a good prognosis.Acute chest pain remains one of the most common and challenging complaints of patients presenting to emergency departments (EDs). In the United States, the number of ED visits for chest pain is approximately 8 million, which accounts for 5% of all ED visits per year.1.1A 66-year-old man presented to our ED complaining of acute chest pain radiating to the back accompanied with hematemesis. He had a past medical history of left-side breast cancer and had undergone total mastectomy with a sentinel lymph node biopsy 2 years ago. The patient was currently under oral Tamoxifen therapy.Upon arrival at the ED, the patient appeared restless and acutely ill. The vital signs were measured and appeared to be normal. Physical examination revealed a coarse and diminished breathing sound in the chest on the left side. No other remarkable findings were observed. Initial electrocardiogram examination indicated a normal sinus rhythm. Laboratory tests indicated only a marginal elevation in the white blood cell counts. Based on the suspicion of a ruptured aortic dissection, emergent contrast thoracic computerized tomography (CT) was performed. A massive pneumothorax with mild pleural effusion was observed on the left side Fig. . Thus, a1.2An 18-year-old Vietnamese man presented to our ED complaining of acute chest pain and swelling in the neck after several episodes of vomiting following beer consumption. The initial vital signs were normal except for a pulse rate of 125 beats/min. Physical examination revealed bilateral neck crepitus with tenderness. A chest x-ray indicated diffuse subcutaneous emphysema in the soft-tissue layers of the neck and upper thorax Fig. . The pat2,9 BS (spontaneous barogenic perforation of the esophagus), was first reported by Dr. Herman Boerhaave in 1724. Differing from the pathologic rupture caused by malignant or inflammatory esophageal diseases, BS indicates the perforation of a previously healthy esophagus which is most frequently affected by forceful vomiting or retching after the consumption of large amounts of alcohol or food.,11 The typical symptoms of BS include chest pain followed by vomiting or retching, and subcutaneous emphysema (Mackler triad); however, these symptoms generally occur in only 14% of all patients with BS.–13 Therefore, the non-specific symptoms presented could easily confuse the emergency physician and lead to a missed or delayed diagnosis, which can result in a disastrous outcome. The mortality rate of BS has been reported to be 25% when appropriate intervention is activated within the first 24 hours of admission. The mortality rate sharply increases to almost 100% when precise diagnosis and interventions are delayed over a period of 48 hours.,14 Surgery with primary esophageal repair and debridement remains the most effective method for treating BS. Other treatment options include endoscopic stenting/clipping, adequate pleural drainage, broad-spectrum antibiotics as well as sufficient nutrition support.–12 Prompt diagnosis is considered a major determinant of good prognosis.Esophageal perforation is a rare condition; however, it has been recognized as the most sinister trauma of the gastrointestinal tract. The degree of severity ranges from a small leakage of air into the mediastinum to a more wide-spreading destruction with massive air and fluid breaching and draining to the pleural cavity, which leads to an overwhelming sepsis, shock, and death.,16 However, we disregarded the potentially life-threatening cause for the disease at the time until a continuous drainage of dark-red bloody material was observed and additional information regarding a history of vomiting after alcohol consumption was obtained from the family. These factors raised our suspicions about a possible diagnosis of BS. Fortunately, the patient received timely thoracotomy with repairment of the esophageal rupture and debridement within the first 12 hours. A longitudinal laceration was documented over the left posterior lateral part in the lower third of the esophagus, which was in agreement with the most frequent site of perforation reported. The patient recovered well and was successfully discharged without complication. We recommend that emergency physicians should remember that BS could mimic spontaneous or even tension pneumohydrothorax. Inquiries about any precipitating factors, careful evaluations for signs of subcutaneous emphysema or sepsis, and arrangement of appropriate diagnostic tools are warranted for maximizing the chances of survival of patients with BS.,11,17,18In the first case presented in this report, spontaneous hemopneumothorax was first diagnosed immediately after a quick CT scan reading and emergent thoracostomy tube drainage was promptly performed. The development of this condition can result from thoracic malignancies, idiopathic pneumothorax with torn vascular adhesion band, and a variety of infectious events. Unfortunately, the patient refused any further treatment and was lost to follow up.Based on the experience from case 1, we could diagnose the highly suspicious case of BS in the second patient who presented with the typical Mackler triad and other promoting factors, including severe vomiting after beer consumption. As expected, the chest radiograph and focused CT scan displayed diffuse subcutaneous emphysema, pneumomediastinum, and notably, pneumorrhachis, which refers to the existence of air in the spinal canal or intervertebral foramens.3We recommend that all physicians at the ED should consider BS in the differential diagnosis when dealing with patients with acute chest pain, dyspnea, confirmed pneumothorax, or newly-developed pleural effusion. A high index of suspicion, thorough collection of the medical history, focused physical examination, suitable diagnostic tools, and the implementation of individualized treatment strategies are key factors for achieving a satisfactory outcome.Conceptualization: Huei-Chun Lu, Hsin-Hung Chen, Feng You Lee.Supervision: Wei-Kung Chen, Kuan-I Lee.Writing – original draft: Ching-Hsuane Tzeng.Writing – review & editing: Yung-Shun Wu, Feng You Lee.Feng You Lee orcid: 0000-0002-5824-1574.


Pleomorphic adenomas occurring in the adult nasopharynx are rare, with our literature search identifying only 11 previous English-language reports. We document the unusual case of a large nasopharyngeal pleomorphic adenoma that was resected using radiofrequency coblation via an endoscopic transnasal approach.  A 39-year-old male presented with worsening nasal congestion, intermittent otalgia, and a progressive change in voice. Flexible nasendoscopy showed a large homogeneous mass occupying the postnasal space, and computed tomography confirmed a 28 × 31 × 22 mm nasopharyngeal tumour. The biopsy-proven benign tumour was locally dissected using a coblator-assisted transnasal approach.  Histology confirmed complete excision of a myoepithelial-rich pleomorphic adenoma. The patient was symptom-free postoperatively, and no signs of recurrence were seen at one-year follow-up.  This is a useful addition to the existing literature on surgical procedures used to treat benign pathology in the nasopharynx. The minimally invasive technique was well tolerated and had favourable patient outcomes. Pleomorphic adenomas are benign neoplasms, with diverse morphologies, comprised of variable proportions of epithelial and myoepithelial elements embedded within a mucopolysaccharide stroma . They arAlthough benign, pleomorphic adenoma can be locally invasive and untreated tumours may grow to exaggerated proportions. Pleomorphic adenoma can also undergo malignant change to become the malignancy, carcinoma ex pleomorphic adenoma . For theWe document the endoscopic, radiographic, and histopathological features of a large nasopharyngeal pleomorphic adenoma resected using a coblator-assisted transnasal approach. We discuss our case within the context of the other cases reported in the literature; however, to the best of our knowledge, this is the first published description of this pathology to be treated with this surgical technique.A 39-year-old male, with no significant medical history, presented to our Otolaryngology Department. He reported several months of worsening nasal congestion, intermittent otalgia, and a progressive change in voice.Clinical examination confirmed bilateral obstruction of the nasal airway and showed the patient was a habitual mouth breather. Diagnostic flexible nasendoscopy demonstrated significant hypertrophy of the turbinates and the presence of a large homogeneous non-indurated soft tissue mass occupying the nasopharynx.Computed tomography (CT) showed a well-defined 28 × 31 × 22 mm tumour in the nasopharynx obstructing both Eustachian tube orifices, but with no signs of local or regional lymphadenopathy. Contrast magnetic resonance (MR) imaging  demonstrFollowing an incisional biopsy that showed histological features of pleomorphic adenoma, the multidisciplinary team consensus was to offer surgery to resect the entire tumour for definitive histology. The patient was consented and operated using an endoscopic transnasal approach under general anaesthesia. Standard functional endoscopic surgery instrumentation was used, in a procedure assisted by a radiofrequency coblator device . The tumour's pedicle was identified endoscopically as originating from the left lateral nasopharynx and, using coblation, was carefully dissected en bloc from its mucosal attachment  leaving Definitive histology confirmed the complete excision of a myoepithelial-rich pleomorphic adenoma with negative resection margins. Microscopic sections  showed aThe patient was symptom-free postoperatively, and follow-up flexible nasendoscopy at one year demonstrated no signs of local recurrence.Pleomorphic adenomas occurring in the adult nasopharynx are rare. Our literature review identified only 11 previously published case reports; the mean age of patients affected was 56.8 years (range 29–80 years) with a male : female distribution of 3 : 8 . The preWe evaluated our patient's tumour with diagnostic endoscopy, cross-sectional imaging, and tumour biopsy. Imaging findings were documented in nine previous cases , 5–12. TThe large size and postnasal location of our patient's pleomorphic adenoma made the choice of surgical access an important consideration. Open approaches to the nasopharynx, extensively summarised by de Almeida et al. , can offWe chose to use a radiofrequency coblator for tumour resection. Coblation is widely used in adenoidectomy, tonsillectomy, and inferior turbinoplasty; however, applications have also been demonstrated in the resection of other benign pathologies, including juvenile angiofibroma and nasopharyngeal cysts , 17. TheFrom a patient perspective, this minimally invasive procedure was associated with favourable outcomes. The direct transnasal access produced no visible scars and facilitated local dissection that avoided overtreatment, with no unnecessary resection of the normal tissue. The hospital stay required was minimal, and the patient could promptly return to his normal daily activities.No tumour recurrences were reported amongst the previously published cases, after a mean follow-up interval of 24.7 months (range 6–52 months) –11. We dWe have documented the coblator-assisted resection of a large nasopharyngeal pleomorphic adenoma. The endoscopic transnasal technique used was straightforward to perform, and we found that use of a coblator offered the surgeon clear visualisation of the operative field during dissection whilst facilitating excellent haemostasis. The procedure was well tolerated and had favourable patient outcomes. This is a useful addition to the existing literature on the surgical procedures used to treat benign pathology in the postnasal space. Although further studies will be necessary to establish technique reproducibility and limitations, with careful case selection, we suggest that a coblator-assisted resection could be considered when approaching similar lesions in future.


Abdominal pain after colonoscopy is a relatively common symptom and usually benign. Colonoscopy-induced pancreatitis is an extremely rare phenomenon that can sometimes be missed leading to delayed diagnosis and treatment.A 53 year old woman presented to the Emergency Department with abdominal pain, a significantly raised lipase and a CT scan revealing pancreatitis. She had no previous history of pancreatitis or any aetiological risk factors. Her pain started 2 h after having a routine outpatient colonoscopy for polyp surveillance. The endoscopist had no difficulty during the procedure and the findings were unremarkable. She developed a Systemic Inflammatory Response Syndrome (SIRS) and an ileus requiring a prolonged hospital admission. However with conservative management she improved and was discharged on day 11 post-admission in stable condition.The mechanism of colonoscopy-induced pancreatitis is not well understood. Hypotheses include mechanical trauma to the pancreas caused by the endoscope particularly at the splenic flexure, over-insufflation of the colon, external abdominal pressure, and transmural colonic burns via electrocautery causing irritation to the pancreas.Pancreatitis should be considered in the differential diagnosis of abdominal pain post-colonoscopy after the more common explanations are excluded. Well recognised complications include perforation, bleeding, post-polypectomy syndrome and side effects related to sedation and analgesia. However there are also a number of rare complications reported in the literature including splenic trauma, infection, diverticulitis and appendicitis. Pancreatitis is a well-documented complication of endoscopic retrograde cholangiopancreatography , but gen2A 53-year-old otherwise fit Caucasian woman underwent a routine colonoscopy for polyp surveillance. Her past medical history revealed gastro-oesophageal reflux, dyslipidaemia, hip bursitis, and laparoscopic cholecystectomy two years ago for cholelithiasis. She was a non-smoker, rarely consumed alcohol, and had no drug allergies. Her regular medications were esomeprazole and atorvastatin which she had commenced 3 years ago. The procedure itself was not technically difficult and deep abdominal palpation was not performed during the colonoscopy. A scar was seen at the site of a previous polypectomy in the transverse colon with no residual polyp. A 2 mm ascending colon polyp was removed with a cold snare and no electrocautery was used throughout the procedure. She was premedicated with midazolam, propofol and alfentanil.9/L , C reactive protein of 67 mg/L , and a lipase of 809 U/L . Haemoglobin, liver function tests, calcium and lipid profile were all normal. Computed tomography scan of the abdomen showed inflammation in the body of the pancreas, with peripancreatic stranding, and a small amount of surrounding fluid consistent with acute pancreatitis  and had not consumed any alcohol for at least 6 months before her colonoscopy. She was tested for autoimmune pancreatitis, lipids and a metabolic/electrolyte workup, all of which were negative. Her bowel preparation was tolerated well with no symptoms to suggest dehydration contributed to her developing pancreatitis. Her imaging showed no anatomical anomalies of the pancreas, and she denied any abdominal trauma prior to her procedure.It is highly unlikely that the atorvastatin was the cause of her pancreatitis, as the patient had been on treatment for more than two years. As rare as statin-induced pancreatitis is, most published case studies report that the onset of symptoms usually occur within months after commencement of therapy . Further4Abdominal pain after colonoscopy is a relatively common symptom and usually benign. Pancreatitis should be considered in the differential diagnosis after the more common explanations are excluded. Awareness of this complication can help initiate early diagnosis and treatment.Authors have no conflict of interest to disclose.None.Ethical approval is not applicable.Written 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.Dr Masood Sidiqi contributed in medical record review, literature search, and writing of the draft. Dr Bill Gong contributed towards review of the paper.None.Both authors have read and approved the manuscript and accept full responsibility for the work.Not commissioned externally peer reviewed.


Echinococcus granulosus usually involves lung and liver but can appear in other organs. We report a 29-yr-old woman presented to Fatemi Hospital, Ardabil, Iran in 2017 with progressive painful swelling of the left gluteus which in imaging showed hydatid cyst. The cyst was successfully en blocked and the patient was discharged on albendazole treatment with no recurrence in the symptoms during the first week, first and second months after surgery follow-up and in the final visit at third months. In the endemic regions, the possibility of hydatid cysts should be considered in differential diagnosis of any cystic mass.Hydatid cyst caused by  Its primary hosts are dogs, sheep and cattle with humans as coincidental intermediate host  of abdomen and chest x-ray were also normal. The US of the left gluteal showed 97*90*48 mm cystic lesion in the upper lateral quadrant with 220 cc volume with multiple septations indicative of daughter cysts. Computed tomography of pelvic showed similar findings with size of 108*76*48 mm . MagnetiDue to the intense and persistent gluteal pain, the patients were subjected to surgical cystectomy. Albendazole 400 mg twice daily were administered a week prior to surgery. Under general anesthesia, en block surgical excision of the mass was performed with care without perforating the cyst wall . Post-opWritten informed consent for patient information and images to be published was provided by the patient.Hydatid cyst can appear in different organs, mostly lung and liver, but it is also reported in other areas, even in rare cases such as uterus  and glutHydatid cyst is usually diagnosed by history, physical examination, imaging findings and serological tests ,4,5. In Total surgical excision without opening the cyst is the best option for treatment of symptomatic and painful hydatid cysts, especially if the size is more than 5 cm ,9. MedicThe hydatid cyst in muscles is rare with incidence of 0.5% to 5.4% in the literature . HoweverAlthough lung and liver are the common regions for hydatid cyst, it should be considered in any patient with growing mass in any organ especially in endemic areas.


Scapulothoracic articulation has several bursae which allow a sliding movement of the scapulothoracic joint. The two major anatomical bursae are the supraserratus bursa and infraserratus bursa.It was a case of a 59 year-old female patient with a professional load and a clinical finding of bilateral subscapular resistances of the thorax. The finding of bilateral collections in the intermuscular spaces between external intercostal muscles and heads of serratus anterior muscle was verified by magnetic resonance.Due to progressively increasing bilateral findings an open surgical resection was implemented, with good result. In consequence of mechanical stress, sport or trauma, a bursa inflammation arises: bursitis . The scaThis case report has been reported in line with the SCARE criteria.2A 59 year-old female patient, who has been employed as rehabilitation worker, has observed gradually enlarging formations under both her right and left scapula for approximately eight months. In anteflexion, elevation of the upper extremities and when stretching the arms forward, swellings reaching up to the rear axillary lines appear bilaterally subscapularly. They were of soft consistency at palpation. The patient also described pain in the upper extremities, and in the region of arms. She had no recollection of any accident or fall. However, she had undergone neurosurgical operating procedures of disc extrusion in the cervical and thoracic spine, and the findings of bilateral resistances were present already pre-operatively. In the another surgical workplace repeated punctures and partial resection of the swelling on the right side were implemented 5 months ago, and it came to its subsequent recurrence.The magnetic resonance (Owing to progressing swelling and increasing difficulties a surgical resection was indicated in the female patient. She was operated on under general anaesthesia, and a resection of the encapsulated collections of fluid was implemented bilaterally (3Scapulothoracic articulation has several bursae which enable a sliding movement of scapulothoracic joint. The two major anatomic bursae are the supraserratus bursa and infraserratus bursa. The supraserratus bursa lies between the musculus serratus anterior and musculus subscapularis, the second bursa is between the musculus serratus anterior and thoracic wall . There aA clinical examination of patients with bursitis should begin with a physical examination accompanied by taking a history. Scapulothoracic bursitis in patients manifests itself by pain, swelling, without reddening. The pain is usually escalated at increasing activity. By inspection a cystic resistance between musculus serratus anterior and thoracic wall, well defined and worse movable will be discovered. In some patients a crepitus at scapula movement can be audible and tangible .In differential diagnostics of the thoracic wall focus in the scapulothoracic region it can be a case of abscess, haematoma, elastofibroma, sarcoma, malignant fibrous histiocytoma or liposarcoma. In differentiation between the scapulothoracic bursitis and tumours of soft tissues of the thoracic wall imaging examinations like computer tomography and magnetic resonance are useful . The MagThe therapy of bursitis can be nonoperative or operative. Conservative treatment includes exercises of the arms, anti-inflammatory drugs, intracystic injections of long-term-acting corticoids or ethanol . Also loThe surgical therapy of bursitis is indicated, if a conservative treatment was shown as unsuccessful ,2. AboveThe surgical treatment of scapulothoracic bursitis has good results, and the patients are able to return into employment, alternatively to sport activities .4This case report describes rare bilateral cystic lesions of thoracic wall, which were a manifestation of scapulothoracic bursitis. Radical surgical therapy represented an effective treatment strategy with good postoperative results.No potential conflict of interest was reported by authors.This case report had no involvement sponsors.This case report is exempt from ethical approval by our institution.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 requestDzian - study concept, data collection, surgical therapy for this patientSkaličanová - study design, writing the paperFučela - surgical therapy for this patientMalík - data collectionMičák - analysis and interpretation of histological preparationNone.Anton Dzian, M.D.Not commissioned externally peer reviewed.


Fasciola hepatica infestation. To our knowledge, this is a unique case report of a patient with a known malignant neoplasm. We also present an overview of the literature about human fascioliasis in Turkey.A patient who underwent mastectomy of the left breast owing to breast cancer was referred to our department for abdominal ultrasonography during her routine check-up. Radiological examinations demonstrated multiple masses that tended to form clusters in the liver parenchyma, and the lesions were initially thought to represent metastases from the breast cancer. Multisite biopsies and serological tests confirmed the diagnosis of  Its human infestation can be seen in Anatolia (the western peninsula of Asia that forms the mainland of Turkey). As its radiological findings may mimic metastases, it is important to consider F. hepatica in the differential diagnosis while evaluating imaging findings of patients with previously known malignancy. We herein present the case of a 38-year-old female patient with a history of breast cancer who had presented with multiple liver lesions that were finally proven to be consistent with fascioliasis.Owing to their long historical background, environmental and climatic features, biodiversity and proximity of the people to animals some zoonotic diseases are seen more frequently in the countries of the Mediterranean and the Middle East.A 38-year-old female who had undergone right mastectomy for breast carcinoma was referred to our department for evaluation of the multiple liver masses detected on routine follow-up examinations.Sonographic examination of the patient revealed hepatosplenomegaly and multiple heterogeneous hypoechoic masses of varying sizes that were located centrally in the right lobe of the liver and tended to form clusters. Some of the larger lesions had central necrosis and cavitation areas . We obseContrast-enhanced CT obtained in the portal venous phase revealed multiple, clustered, hypodense nodular liver masses with irregular margins . In addiF. hepatica infestation. The patient was discharged after a course of triclabendazole treatment. A follow-up CT scan, obtained 2 years after her first admission, showed slight regression in the size of all the liver lesions -borne trematodiases and is caused by two species of parasitic flatworms: F. hepatica has been reported in humans with increasing frequency. Despite the belief that it has a European origin, F.hepatica has shown a great capacity to spread and can be seen in all the continents except Antarctica. According to the recent estimates, several million people are infected in more than 70 countries worldwide, with millions of others being at risk. The parasite can easily adapt and colonize in rural areas and wetlands, where there are plenty of freshwater Lymnaea snails (the intermediate hosts) and herbivorous mammals (the definitive hosts). However, human fascioliasis (HF) has a patchy geographical distribution and there are some endemic regions such as the Caribbean, northern Africa, western Europe and the Caspia. Certainly, the lifestyle and dietary habits of the people, social and economic factors, hygiene and sanitation conditions, and travel or immigration, all add to the frequency of the disease. If it is detected in some livestock animals, human cases may also exist.6Although the natural final hosts of this parasite are sheep, goats, cattles and other herbivores, Lymnaea snails as their first host; once they metamorphose into motile, tailed cercaria forms, they leave the snails. Cercariae use the aquatic plants  as another group of intermediate hosts; the cercarial larvae encyst and develop into the metacercarial stage. The main transmission of F. hepatica occurs by ingesting water or raw plants contaminated by the metacercaria forms of the parasite. The metacercariae change form during duodenal interference; they penetrate the intestinal wall and migrate through the peritoneal cavity to reach the Glisson’s capsule. After piercing the capsule of the liver, the parasites migrate through the liver parenchyma and reach the biliary system, where they grow into adults and release new eggs. The eggs reach the intestines via bile and are evacuated in the faeces, thus completing the transmission cycle of the parasites. The average size of a mature fluke is 20–40 mm in length and 8–13 mm in width.8The eggs of the parasite are excreted with the final host's faeces. These eggs are immersed in freshwater, and the swimming, ciliated miracidia forms are released. Miracidiae use hepatic  phase and a chronic biliary  phase.7Human infestation by this trematode has two characteristic phases: an acute 7The first phase is the hepatic phase. In this phase, the parasites pierce the Glisson’s capsule and migrate through the liver parenchyma towards the bile ducts in a random manner. This stage lasts for 1–3 months after metacercariae infection. The clinical features of this stage include anorexia, fatigue, nausea, vomiting, right upper quadrant pain, pruritus, fever, weight loss, respiratory symptoms, hepatomegaly, jaundice and urticaria. Laboratory findings such as elevated liver enzymes, increased erythrocyte sedimentation rate, hypergammaglobulinaemia and marked eosinophilia can be encountered in this stage as well. Mild hepatitis, severe hepatic subcapsular haemorrhage or liver necrosis may also be seen rarely in this hepatic phase.9 Adult flukes can live for years and the chronic phase may persist in untreated patients.10F. hepatica can rarely settle in unusual organs and lead to ectopic disease.13The second stage may be asymptomatic for a long time or may be characterized by intermittent right upper quadrant pain. As a result of chronic inflammation of the bile ducts, ductal wall thickening, common bile duct obstruction, bile duct stones or gallstones, cholestasis, cholangitis, cholecystitis or pancreatitis may occur.14Suggested diagnostic criteria for fascioliasis in endemic regions, reported by the WHO in 2009, are:history of eating raw aquatic plantsclinical symptoms such as abdominal pain in the epigastric or right-upper quadrant region, lasting at least a weekeosinophiliapositive ultrasound or CT scan findingsF. hepatica eggs (detected by Kato–Katz thick smear or sedimentation technique)positive for the presence of positive serologic tests .−1 of body weight) is given in a single administration. If necessary, a double dose (20 mg kg−1 of body weight) can be administered for the management of individual cases.14For the treatment of the cases diagnosed with the above-mentioned criteria, the recommended drug triclabendazole  can be seen. Also, serpentine, clustered, small necrotic cavities can be detected. These two findings, which were also observed in our case, are defined as the “tunnels and caves sign” in the literature10 Adult forms of parasites attach to the inner wall of the bile duct through their ventral suckers.10  When we retrospectively re-examined our patient, we detected a thin, linear echogenicity 1.5 cm long, one end of which was fixed to the posterior wall of the common bile duct  in the diagnosis and treatment of the chronic phase of the disease. In cases of cholestasis, adult parasites can be seen in the biliary tract and ERCP enables the removal of the parasites.17 In ERCP or MR cholangiography, the flukes are seen as filling defects in the bile ducts.18With the use of ultrasound imaging, adult worms can be visualized in the gallbladder and/or in the extrahepatic bile ducts. Ultrasound examination may demonstrate single or multiple, elongated filamentous structures or moving echogenic flukes.ile duct . Althoug15Periportal lymphadenopathies may be accompanied by other radiological findings, as in our case.27 However, only one case of hepatic fascioliasis has been reported in a patient with breast carcinoma by Koc et al28 in 2009. The patient was asymptomatic and only choledochal dilatation was found incidentally during abdominal ultrasound examination; without any other suspicious imaging findings of metastasis. To our knowledge, except for our report, there is no other report of HF mimicking liver metastases in a patient being followed up for breast carcinoma.Other cases of hepatobiliary fascioliasis mimicking cholangiocellular or hepatocelluler carcinoma or Oddi sphincter malignancy have been reported. Extrahepatic fascioliasis mimicking colon, ovarian, peritoneal carcinoma, or liver metastases of unknown origin have also been reported in the literature.29  in endemic regions who present with right upper quadrant pain, eosinophilia and multiple hepatic lesions.Hepatobiliary fascioliasis can mimic primary or secondary hepatic malignancies.“Tunnels and caves sign” is a finding of HF in radiological examinations.Written informed consent was obtained from the patient for publication of this case report, including accompanying images.


A rare case of a jejunal mesenteric pseudocyst treated by robotic resection is reported. A 25-year-old woman was admitted to our hospital with intermittent abdominal discomfort which was exacerbated by strenuous physical activities. Physical examination revealed a fluctuant mass without tenderness. Contrast-enhanced computed tomography revealed a 4 cm-sized non-enhancing heterogeneous mass on a proximal small bowel loop mesentery. Based on the findings, a differential diagnosis of a gastrointestinal stromal tumor, hematoma, desmoid tumor, and mesenteric cyst was made. Robotic diagnostic laparoscopy was performed to obtain an accurate diagnosis and treatment. Exploration of the cavity revealed a 4 cm fairly mobile mass originating from the mesentery of the jejunum. Segmental resection of the jejunum and its mesentery, including the mass and extracorporeal anastomosis, was performed without any complications. Macroscopically, the mass was cystic and the lumen had grumous material. The final pathological diagnosis was a mesenteric pseudocyst. The patient had an uneventful postoperative course. Mesenteric cysts are very rare abdominal growths. They may be localized anywhere in the mesentery, from the duodenum to the rectum, but they never have been reported to originate from or be attached to any abdominal organs. In clinical presentations, these cysts are most commonly located in the small bowel mesentery 50% - 80%). The second most common location is in the large bowel mesentery 15% - 30%), and very rarely, they can present in the retroperitoneal space 7% - 20%) [5% - 30%,0% 5% - . Clinici0% - 80%.A 25-year-old young woman was admitted to our hospital with intermittent periumbilical abdominal discomfort and pain. She had a history of depression and was otherwise a healthy individual. She complained that the discomfort was ongoing for six to eight months, and she usually rated it three to four out of 10 on the pain scale. There was no association with her menstrual cycle or food nor was there any associated nausea, vomiting, constipation, or diarrhea. There were no alleviating factors but she reported exacerbated discomfort with a strenuous workout at her school. The pain and discomfort were infrequent and usually occurred five to six times per month with a duration of one to two hours of constant brief episodes. It usually resolved spontaneously, and for this reason, she did not pay it much concern. There was no increase in frequency or intensity of the discomfort. She never noticed a fever nor any distention, bloating, or dyspepsia. There was no history of known abdominal trauma. She had no family record of any similar symptoms or history. Vital signs, including blood pressure, heart rate, respiratory rate, and body temperature, were all in normal ranges. However, while the physical examination was negative for tenderness, it revealed a non-specific mass of 5 cm x 3 cm that was palpable in the left upper quadrant. The mass seemed to arise from a deep origin below the abdominal wall; it had a smooth surface without any tenderness. It was freely mobile below the abdominal wall and appeared fluctuant. Blood test results found that the hemoglobin level was 11.6 g/dL , the white blood cell was 10.5 K/µL , the platelet count was 149 K/µL , the erythrocyte sedimentation rate was 5 mm/h , and the C-reactive protein level was 2 mg/L . Liver function tests, basic metabolic panel, amylase and lipase levels, and urinalysis were all within normal limits.Contrast-enhanced computed tomography (CT) revealed a non-enhancing intra-abdominal mass 4.2 x 4.3 cm) with a heterogeneous pattern located on a proximal small bowel loop at the mesenteric border Figures -2. CT fi x 4.3 cmExploration of the abdominal cavity identified a 4 cm mass Figure , which oMesenteric cysts are rare intra-abdominal lesions arising with an incidence of one in 100,000 admissions of adults and one of 20,000 admissions of children . MesenteVery few cases have been reported in the past regarding mesentery pseudocysts . Most ofRobotically-assisted surgeries have become more commonly used in a variety of surgical procedures. Improved precision and dexterity with “wristed instrumentation” allows for freedom to maneuver all laparoscopic incision sites comfortably. Additionally, a three-dimensional image allows for an improved ability to visualize the precise anatomical location of interest with reduced fatigue, further minimizing fatigue-related complications such as tremor. The availability of the robot and the robotic stapler allowed us to provide the benefit of minimally invasive surgery. In addition, robotic procedures can reduce surgical time, thus lowering the rate of postoperative complications, minimizing exposure of anesthetic agents, and reducing the recovery time postoperatively . In our Although mesenteric pseudocysts are rare and preoperative diagnosis is difficult due to non-specific signs and symptoms, the disease must be considered in the differential diagnosis of intra-abdominal masses. They can be successfully managed by complete resection; laparoscopic and robotic excision of these cysts have become an increasingly popular option. We believe that robotic resection might serve as an alternative treatment for mesenteric cysts when the cysts are of small to moderate size and, more specifically, when the patient has a shortened mesentery. Surgical alternatives to the midline or paramedian incision, such as laparoscopic and further advanced robotic mesenteric cyst excision, warrant further data to determine if morbidity is significantly reduced. In this presentation, we have shown that robotic mesenteric cyst excision and bowel anastomosis is a safe alternative to open surgical enucleation.


Spigelian hernia is uncommon and frequently presents with features of intestinal obstruction. Clinical diagnosis is difficult in patients without obvious abdominal mass and a computed tomography scan is very helpful in making diagnosis. We report a patient who presented with a strangulated sliding left sided spigelian hernia who was pre-operatively diagnosed and successfully managed surgically.A 56-year-old woman was to referred to the surgical emergency unit of our institution with abdominal swelling and pain of three days. There was no abdominal distension or fever and had no history of recurrent abdominal pains, abdominal swelling or surgery. Examination revealed a middle aged woman with a tender mass measuring about 10 cm by 8 cm in the left iliac fossa region of the abdomen. Bowel sounds were hyperactive and digital rectal examination revealed an empty rectum consistent with the diagnosis of acute intestinal obstructions. Investigations done by the patient at the referring hospital included a computed tomography (CT) scan which was suggestive of an obstructed Spigelian hernia with the sac containing a small bowel loop and mesentery.She had emergency herniorrhaphy and findings were herniation through a facial defect of about 5 cm by 4 cm along the lateral border of the rectus sheath with the hernia sac containing sero-sanguineous peritoneal fluid, gangrenous ileal segment and part of herniated urinary bladder forming the lower wall of the sac. Resection of gangrenous bowel with an end to end anastomosis was carried out, viable contents of the sac were reduced and defect repaired with interrupted non absorbable sutures to approximate the internal oblique and transversus abdominis to rectus sheath. In addition, nylon darning from inguinal ligament to the rectus sheath was also done. Her post-operative recovery was satisfactory and she remained well six months after surgery.Pre-operative diagnosis of strangulated Spigelian hernia is difficult but can be aided by a CT. The use of nylon darning to re-inforce the repair can be rewarding where mesh cannot be used or unavailable. They arSpigelian hernias are thought to result from fascial weakness related to perforating vessels. Some authorities suggested that up to 50% of these hernias result from previous abdominal operations that weaken the semilunar line prompting herniation . FactorsA high index of suspicion is required to make diagnosis of this rare entity. Abdominal ultrasonography is useful while Computerized Tomography (CT) scan of the abdomen with contrast has become the best imaging method in confirming the diagnosis especially when in doubt .Spigelian hernia requires surgical repair to prevent strangulation while those presenting with complications need immediate surgery. We report the first case of strangulated sliding spigelian hernia in a middle-aged woman seen in our institution. This work has been reported in line with the SCARE criteria .2A 56-year-old woman was referred to the surgical emergency of our institution with abdominal swelling and pain of three days duration. She vomited recently ingested food twice prior to presentation. There was no abdominal distension or fever. She had no history of recurrent abdominal pains, abdominal swelling or surgery.Examination revealed a middle aged woman in no painful or respiratory distress. She was afebrile, anicteric and not pale or dehydrated. Her pulse rate was 80 beats per minute regular and of good volume. Blood pressure was normal while temperature was 37 °Celsius. A tender mass measuring about 10 cm by 8 cm was present in the left iliac fossa region of the abdomen . Bowel sShe had emergency herniorrhaphy within two hours of admission after satisfactory resuscitation. Under general anaesthesia, a transverse left lower abdominal incision was made and findings were herniation through a facial defect of about 5 cm by 4 cm along the lateral border of the rectus sheath . Hernia 3Spigelian hernia is a rare type of ventral abdominal wall hernia which occur secondary to a defect in the transversus abdominis muscle and rectus sheath aponeurosis allowing abdominal contents to herniate through the linea semilunaris. It often starts as a protrusion of pre-peritoneal fat through the hernia ring, a well-defined defect in the Spigelian aponeurosis at the “Spigelian hernia” belt. This is the widest part of the aponeurosis where 85–90% of the hernias occur and lies between 0 and 6 cm cephalad to the inter-spinous plane .Herniation is very rare above the umbilicus because the semilunar line is supported by the aponeurosis of the external oblique on the anterior aspect and posteriorly in the cranial two thirds by the transversus abdominis muscle which is muscular almost to the midline in the upper abdomen. Hernia sac is found in most cases and contents are commonly greater omentum, small intestine as in present case or part of the colon. Rare contents of the sac include acutely inflamed appendix, Crohn’s appendicitis and an incarcerated Meckel’s Diverticulum. Bilateral Spigelian hernias and Richter type of Spigelian hernia have also been reported ,5. Such Peak incidence of spigelian hernia is between the 4th and 7th decade of life and occurs mostly on the right side. The presenting symptoms are commonly abdominal pain, an intermittent swelling in the anterior abdominal wall or signs of intestinal obstruction . It is rPlain abdominal X-rays are not specific and can only show features of bowel obstruction in those presenting with intestinal obstruction. Ultrasound scanning is recommended as first line imaging investigation in suspected cases. It is rapid, fairly accurate, non-invasive and relatively easy to perform. It has a sensitivity and positive predictive value (PPV) of 90% and 100% respectively. However, drawbacks include being operator dependence and reduced diagnostic accuracy in obese patients. It is advocated that scanning of the semilunar line should be done in all patients with obscure abdominal pain and swelling of the abdominal wall in both supine and erect positions and while patient performs a Valsalva maneuver to increase accuracy ,10,11. PPrompt surgical repair is recommended for spigelian hernia to prevent subsequent strangulation while those presenting with bowel obstruction will require emergency surgery. Open or laparoscopic approach could be employed depending on experience and availability of laparoscopy facilities. Techniques of open repair followed the trend in repair of hernias generally with simple closure of the defect in the form of hernioraphy in earlier reports . HerniopLaparoscopic approach has been widely utilised in both elective and emergency repair of the hernia using intra-peritoneal onlay mesh (IPOM), trans-abdominal pre-peritoneal (TAPP) and total extra-peritoneal (TEP) techniques . It offe4Sliding Spigelian hernias are not common and clinical diagnosis requires a high index of suspicion. Strangulation is common and occurs in about a quarter. Imaging studies, especially CT may aid pre-operative diagnosis. Surgery is the modality of treatment and open approach is often used where facilities and expertise for laparoscopy are not available. Tension free repair with mesh is recommended. However, in cases with strangulation where use of mesh may not be advisable or where mesh is not readily available, nylon darning may be an acceptable alternative.No Conflict of interest.No Source of Funding.Exemption of Ethical approval was given because no identifiable patient’s parts were seen.Written and signed consent to publish as case report was obtained from patient.PO Igwe; Case Design and write up.NA Ibrahim; Surprvised, proof read and approve with corrections.Case report.PO Igwe.Not commissioned, externally peer reviewed.


We present cases with full clinical and imaging workup in both the acute and chronic setting and scenarios that require exclusion of primary and secondary bone malignancies.Brown tumours do not represent neoplastic process, but they are focal bony lesions due to bone remodelling from either primary or secondary hyperparathyroidism. Their incidence is also low. The current literature on brown tumour is mainly in the form of case reports that focus on single affected sites. This pictorial review describes the full imaging workup and pathway of suspected brown tumour in the setting of both primary and secondary hyperparathyroidism. It aims to illustrate the management strategy to aid both clinicians and radiologists in suspected cases of brown tumour. We highlight the complementary roles that different imaging modalities can play in different settings including the importance of parathyroid ultrasound,  Primary hyperparathyroidism from parathyroid adenoma is the most common cause of brown tumours.99mTC-sestamibi scintigraphy or SPECT/CT.Imaging workup for suspected cases should include ultrasound, 4D-CT can also aid the localisation of parathyroid adenoma.Sclerotic bone lesions are most common but lytic lesion is also possible.It is important to consider differential diagnosis including primary and secondary bone tumours.The name brown tumour originated from their gross histological appearance being a brownish mass consisted of a combination of recurrent micro-fractures at various stages of remodelling with blood, haemosiderin, fibrous and connective tissue . Unlike The condition is more frequently seen in women than in men, and present in the fifth to sixth decade of life. The most common cause of primary hyperparathyroidism is parathyroid adenoma causing the hypersecretion of parathyroid hormone (PTH) . SecondaDisease presentation with brown tumour is rare. The reported incidence of brown tumour has been 3% and 1.5% in primary and secondary hyperparathyroidism, respectively , 12. Its99mTc-sestamibi scintigraphy are the most commonly used imaging modalities. Four-dimensional computed tomography (4D-CT) is an alternative imaging modality used in the evaluation of hyperparathyroidism.For parathyroid imaging in patients with suspected hyperparathyroidism, ultrasound and Ultrasound is commonly used for patients with suspected parathyroid adenoma and used to assess the feasibility of minimally invasive surgery. The adenoma is frequently identified as a homogeneously hypoechoic lesion overlying the thyroid gland Fig. . The low99mTc-sestamibi scintigraphy can help confirm the presence and location of a parathyroid adenoma. Both the thyroid and parathyroid glands will demonstrate tracer uptake on the initial images. However, on the delayed images usually taken at 2 h post-administration of the radioactive tracer, a parathyroid adenoma shows persistent avid uptake due to its delayed washout of the tracer compared to the thyroid gland  fused with the corresponding computed tomography (CT) is the preferred three-dimensional functional imaging for the localisation of parathyroid tumour . The add4D-CT increasingly been used for pre-operative localisation of parathyroid adenoma . The mulClinically, brown tumours present as a slow growing palpable bony swelling and may cause bone pain or pathological fractures. It is also possible to present with symptoms of weakness, weight loss, polyuria and recurrent stone formation associated with the hyperparathyroidism . The bon99mTc-sestamibi SPECT/CT were performed. On ultrasound, there was a 9-mm hypoechoic nodule posterior to the inferior left lobe of the thyroid  showed poor dentition with several absent premolar and molar teeth. Most importantly, there was a single well-defined, corticated, lucent lesion in the body of the left mandible between the premolar and only remaining molar tooth  showed a 2.5-cm left inferior parathyroid adenoma (Fig. Apart from chronic pain and/or hard swelling, patient with brown tumour could also present with acute pathological fractures. A 57-year-old male patient presented with sudden onset of left upper leg pain without history of trauma. The patient’s pelvic radiograph showed a displaced fracture of the left femoral shaft with associated lytic lesions at the fracture site Fig. . In addioma Fig. .Fig. 9PaIn the above case, the multiple brown tumours were mixed lytic/sclerotic, and some of lesions showed sclerotic rim. It is important to highlight that the lesions can also be lytic or a mixture of both. The following 69-year-old male patient with known primary hyperparathyroidism and awaiting parathyroidectomy presented after a fall. The pelvic radiograph showed a left subcapital neck of femur fracture with a lytic area in the inferior aspect of the femoral head Fig. . Close iThe next case highlights the importance of not to make immediate assumptions that bone lesions in patients with hyperparathyroidism are always brown tumours. This 54-year-old male patient, who was a keen runner, presented with chronic left knee pain. The plain film of his left knee showed a multiloculated lytic lesion in the proximal tibial metaphysis close to the cortical surface. There was no associated cortical breach or periosteal reaction Fig. . His bloThe final two cases were patients with chronic renal failure and receiving long-term haemodialysis. Patients in this category have secondary hyperparathyroidism as a result of their chronic renal disease. CT imaging of these patients demonstrated asymptomatic bilateral mixed lytic/sclerotic expansile rib lesions and lytic lesion in the left humeral head Fig. . These lBrown tumour is a rare bony disorder as a consequence of hyperparathyroidism. Apart from biochemical investigations for hyperparathyroidism, both US and sestamibi scintigraphy should be used to confirm the location of the active parathyroid gland. Patients can present with systemic symptoms of hyperparathyroidism or insidious pain, bony swelling and pathologic fracture from the brown tumour. The radiologic features of brown tumour can be variable, which can be single or multiple lesions, lytic or a mix of both. In addition to the plain film, CT and/or MRI should be performed to help differentiate from other bone tumours, which should be considered even in the context of hyperparathyroidism. If there is any doubt in the diagnosis, biopsy of the bone tumour is recommended for definitive diagnosis.


A brown tumour is benign bony lesion caused by localized, rapid osteoclastic turnover, resulting from hyperparathyroidism. In this report, we present a case of 25-year-old woman with multiple swelling and bone pain. Plain radiographs of the affected bones revealed multiple erosive bone tumours, which were diagnosed as brown tumours associated with primary hyperparathyroidism.A 25 year old female presented with swelling in left elbow since 1 month along with multiple swelling in body. Patient had pain in left elbow after trivial fall. X-ray showed lytic lesion of left elbow with pathological fracture. Biopsy was suggestive of brown tumour of distal humerus.We managed this case with reconstruction of defect with fibula grafting and plating.Pathological fracture in young adult should always be properly investigated. A high index of suspicion is necessary to diagnose unusual presentation of Primary Hyperparathyroidism. Brown tumours are one of the most pathognomonic signs of primary hyperparathyroidism; however, they are rarely seen in clinical practice. Brown tumors have been reported in 1.5%–4.5% of patients with primary or secondary hyperparathyroidism [In Primary hyperparathyroidism excess parathyroid hormone is secreted from parathyroid glands. The increased secretion of parathyroid hormone usually affects calcium and phosphate levels, resulting in hypercalcemia and hypophosphatemia. Approximately 80% of patients with primary hyperparathyroidism are asymptomatic, these patients are often identified following screening of calcium levels during other investigations . The remHere, we report a case of extensive brown tumors and pathological fractures caused by a parathyroid adenoma in a 25-year-old woman. This work has been reported in line with the SCARE 2018 criteria .2A 25 Year old woman had a trivial trauma 1 month back presented with pain and restriction of range of motion of left elbow. Patient also had swelling in left clavicle and left proximal tibia since 6 month. On clinical examination of elbow range of motion was restricted. The swelling was 5” × 5” in size, situated anteromedially just above the elbow joint. It was well-defined and bony hard in consistency. There were no signs of any neurovascular involvement. Regional lymph nodes were not palpable. She did not complain of any neuropsychiatric or gastrointestinal symptoms. She also did not have another past medical history including urinary stones.Plain digital radiographs of the affected bones  revealed multiple bony osteolytic expansile lesions with cortical thinning, diffuse osteoporosis, and sub periosteal bone resorption compatible with brown tumours .Fig. 1 revealed an approximately 2 cm mass in the inferior aspect of the left thyroid gland, suggestive of a solitary parathyroid adenoma. Diffuse uptake noted in region of medial end of left clavicle was suggestive of brown tumour. MRI of left elbow showed osteolytic lesion in distal humerus which was hyperintense on all the sequences. It was a well-defined lesion, and was extending into the soft tissue through a break in the medial cortex. Additional evaluation for hyperparathyroidism associated conditions was also performed.Plain digital radiograph of the affected left distal humerus and left proximal tibia revealed bony osteolytic expansile lesions with cortical thinning, diffuse osteoporosis and sub periosteal bone resorption with definite evidence of pathological fractures in distal humerus. These findings were thought to be compatible with brown tumors of hyperparathyroidism.Pathological fracture was approached posteriorly with triceps elevating approach. The tumour was brown in appearance and was soft in consistency. Ulnar nerve was isolated and protected. Reconstruction of medial and lateral epicondyle done with fibula grafting and bicolumnar plating . AnterioPostoperatively, the patient was immobilized for 4 weeks and calcium carbonate supplementation was given.3Primary hyperparathyroidism is a disorder in which excess Parathyroid hormone is secreted from one of the parathyroid gland. Primary hyperparathyroidism is more common in woman than man, and peak incidence occurs in 6th to 7th decade of life .Brown tumour is a benign lesion that results from bony resorption due to excessive osteoclastic activity. Brown tumour is an uncommon pathognomic sign of hyperparathyroidism. Most of the reports presented a solitary lesion, generally localized to the facial bones ,7 and moIn our case the patient presented with brown tumours involving multiple bones and pathological fracture of distal humerus. Brown tumours associated with primary hyperparathyroidism usually affect the maxilla, pelvis and ribs other than long bones ,11. In o4Pathological fracture in young adult should always be investigated. A high index of suspicion is necessary to diagnose unusual presentation of primary hyperparathyroidism. Giant cell tumour should always be considered as differential diagnosis in young women.None.This is case report study, no ethical approval were needed. In the other hand, all patient had been informed and gave their consent regarding this publication.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.Dr Eknath Pawar — contributed in performing the surgical procedure.Dr Amit kumar yadav — Evaluation and post-operative management of the case along with surgical assistance, writing the paper.Dr Abhishek harsoor — contributed in surgical assistance.Dr Prasanna kumar G S — contributed in writing the paper.Dr Hitesh rohra — contributed in data collection.This is a case report. Hence, it is not registered in the clinical trial registry.Dr Amit kumar Yadav.Not commissioned externally peer reviewed.None.