Symptomatic Meckel's diverticulum is rare in adults. The most frequent complications are intestinal obstruction and diverticulitis. Diagnosis of Meckel's diverticulitis can be challenging due to nonspecific clinical manifestation of pain in the right lower abdominal quadrant, mimicking acute appendicitis. If associated with congenital malformation, such as intestinal malrotation, the anomalous anatomy makes the diagnosis even more challenging. In such cases, radiological imaging is essential to guide further management. We present a case of Meckel's diverticulitis in which physicians were initially misguided because of the atypical clinical presentation. Yet, anamnestic details directed to a potential underlying malformation, leading to supplementary radiological examination and the final diagnosis. Meckel's diverticulum (MD) mostly remains asymptomatic with a lifetime onset of complications of 4% but decreasing with age . TherefoAcute diverticulitis of such a diverticulum may lead to perforation, and treatment is emergency surgery. Emergency physicians should be aware of this pathology and keep it in mind as a differential diagnosis of acute abdominal pain. Our case illustrates Meckel's diverticulitis in a patient presenting with left abdominal pain due to an undiagnosed intestinal malrotation.A 65-year-old male patient with a medical history of sigmoid diverticulosis presented to his general practitioner with mild acute abdominal pain localized in the left lower quadrant. The clinical examination showed no abdominal tenderness, and the patient had normal blood values. The patient was discharged with a diagnosis of mild sigmoid diverticulitis and treated with oral antibiotics. Twenty-four hours later, he presented to our emergency department with increasing abdominal pain, fever of 38.1°C, and nausea. A detailed history revealed possible malrotation of the intestine. Clinical examination revealed localized periumbilical and left lower quadrant abdominal tenderness. Laboratory tests demonstrated a normal white blood cell count but increased C-reactive protein (52 mg/l).Based on the clinical examination, the main diagnostic hypothesis was sigmoid diverticulitis. Nevertheless, the possibility of a malrotated intestine led to the differential diagnosis of acute appendicitis. Abdominal CT revealed a complete intestinal malrotation and inflamed diverticulum containing a calculus in the left upper quadrant without radiological signs of acute appendicitis . The appThe patient underwent exploratory laparoscopy, showing a perforated diverticulum at the antimesenteric border of the ileum 50 cm from the ileocecal valve with local peritonitis . A segmeMD is the most common malformation of the gastrointestinal tract and is found in 0.14-0.4% of autopsies . It is aMost MD cases stay asymptomatic with a lifetime complication rate of only 4% . These cAs the diverticulitis can lead to perforation, the treatment should be surgical. However, preoperative diagnosis can be difficult and is only achieved in 5-15% of cases, and inflamed MD is often misdiagnosed as acute appendicitis . AbdominIntestinal malrotation is a congenital malformation due to the incomplete rotation of the fetal intestine around the superior mesenteric vessels. With an incidence of 0.2%, it is diagnosed during the first year of life in 90% of cases . IncidenBecause of the possible diagnostic and therapeutic delay in patients with intestinal malrotation, occasional resection of noninflamed MD and the appendix should be considered when performing laparoscopy for other reasons.


Paget’s disease is an intraepithelial invasion by a malignant tumour and is characterised by erythema and inflammation. It can manifest as mammary or extramammary Paget’s disease (EMPD), with the latter often developing in the perianal area. Anorectal cancer can cause transepithelial invasion into the epidermis, resulting in an appearance similar to that of EMPD. This is called pagetoid spread (PS), which is completely different from EMPD. These two conditions are difficult to differentiate because of the nature of intricacy and requirements of histopathology.We present a case in which differential diagnosis between these two conditions was not possible during the preoperative examination, resulting in difficulties in treatment. The patient was a 70-year-old woman who experienced pain in the anus since the previous month and presented with red, flat and elevated lesions.Treatment for dermatitis was ineffective, and endoscopic examination did not indicate rectal or anal cancer. However, immunohistochemical examination of the biopsy specimen suggested PS. Thus, two-stage operation was planned. Transanal surgery was performed to confirm the diagnosis of PS and intersphincteric resection was allowed as a radical surgery.Thus, when differentiation between EMPD and PS is intricacy, two-stage operation is useful in selecting an appropriate radical surgery method, leading to preservation of anal function. Although these two diseases are clinically similar, the treatment method and prognoses are notably different . To diff2The patient was a 70-year-old woman who had developed red and flat elevated lesions, with surrounding inflammation on the left side of the anus that persisted for one year before treatment a. She be18F-FDG PET/CT scans  and cytokeratin-20 (CK20), but not for gross cystic disease fluid protein-15 GCDFP15; . These rOur strategy was to precede transanal local resection with local excision of the skin and full-thickness skin grafting for diagnostic purpose and to determine the need for radical surgery with a pathological diagnosis.During surgery, concordant with the endoscopy result, we observed that the mucosal lesion continued for approximately 3 cm in the 3 o’ clock direction from the skin lesion up the anal canal but did not reach the pectinate line. Therefore, we made en-bloc resection of perianal lesion of the cutaneous disease to secure a margin of approximately 1 cm from the mucosal lesion. Thus, the external anal sphincter was preserved . PatholoThe patient is currently undergoing a postoperative adjuvant chemotherapy regimen (FOLFOX), with no recurrence for 17 months.3For perianal inflammation and erythema that do not respond to typical dermatitis treatment, EMPD and PS should be considered strong candidates for the differential diagnosis, for which diagnostic imaging and immunohistochemical examinations should be used . SpecifiIt has been reported that approximately 20% of perianal skin lesions are malignant . Both prIn a few cases out of the 10 that we summarised, when differentiating between EMPD and PS, either endoscopic examination or diagnostic imaging revealed the possibility of anal/rectal cancer, which in turn led to preoperative pathological diagnosis. Eight out of 10 cases had preoperative malignant findings . There wThere are several reports on the usefulness of immunohistochemical staining for differentiation. GCDFP-15, which is expressed in apocrine and eccrine sweat glands, and CK7 and CK20, which are highly expressed in the gastrointestinal mucosal epithelium of rectal cancer, are widely used as markers for differentiation. Generally, GCDFP-15 staining should be positive and CK20 staining should be negative for Paget’s disease, whereas the inverse is true for PS . Among tIn cases that are difficult to diagnose, a two-stage operation, a local excision followed by pathological diagnosis and an additional excision, is considered feasible and useful. In the present case, diagnostic imaging did not suggest PS, whereas immunohistochemistry did, making the differential diagnosis difficult. Thus, we performed enbloc resection of the skin and mucosal lesion to make a definitive diagnosis based on the biopsy specimen. Definitive diagnosis based on analysis of the resected specimen can sometimes lead to a requirement for a more invasive surgery; two additional surgeries were indicated in this case. We opted to perform an ISR and were able to administer radical treatment. In the future, we need to examine whether the present treatment strategy is effective for cases in which differentiation between EMPD and PS is difficult.4The treatment methods and prognoses for Paget’s disease and PS are notably different, making it extremely important to clearly differentiate between the two conditions. We reported a two-stage operation case in which a transanal resection was performed for diagnosis followed by a radical ISR in a case which was difficult to diagnose EMPD or PS.The authors declare that there are no sources.IRB number: 15144-6 Osaka university.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.S.F. and N.M. conceptualized the project, designed and performed the experiments, interpreted the results, and co-wrote the manuscript. N.M. supervised the experimental design and interpreted the results. N.M., M.O., and M.Y. performed the surgeries and prepared the culture samples. N.M., T.M., Y.D., and M.M. analysed data or participated in discussions of the results.1.Name of the registry: Research registry.2.Unique identifying number or registration ID: Researchregistry5806.3.https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5f0e8b4f136e4900154e8811/.Hyperlink to your specific registration (must be publicly accessible and will be checked): Shiki Fujino is guarantors for this article.Shiki Fujino: sfujino@gesurg.med.osaka-u.ac.jp.Not commissioned, externally peer-reviewed.The authors report no declarations of interest.


Mediastinal non-seminomatous germ cell tumors (NSGCTs) are very rare, with an approximate annual incidence of 500 in the United States. Here, we present a case of a 22-year-old male presenting with hemoptysis who was found to have primary mediastinal NSGCT, endodermal sinus tumor type (or yolk sac type). We review the imaging findings, pathology, and treatment of primary mediastinal endodermal sinus tumors. Extragonadal germ cell tumors (EGCTs) are uncommon pathologies, usually occurring in early childhood or early adulthood, with a male sex predilection . They arA 22-year-old incarcerated male with no known past medical history presented with a two-month history of hemoptysis, subjective fevers, pleuritic chest pain, and unintentional weight loss of approximately 30 pounds. He had recently emigrated from El Salvador and was incarcerated for approximately seven months prior to symptom onset.CT-angiography of the chest in the ED revealed a 12 cm mass in the anterior mediastinum, with mass effect on the superior vena cava (SVC), leftward displacement of the mediastinum and heart, and a right pleural effusion Figure .The patient was treated with one cycle of bleomycin, ifosfamide, cisplatin (BIP) and filgrastim chemotherapy before discharge. No additional outpatient information was available for internal assessment of the patient’s status.Our patient was found to have a yolk sac tumor in the mediastinum. Mediastinal non-seminomatous germ cell tumors (NSGCTs) have an estimated annual incidence of approximately 500 in the United States. Mediastinal NSGCT commonly presents with nonspecific systemic signs, such as fever, weight loss, chest pain, cough, and hemoptysis . FurtherEGCTs are rare and represent approximately 1-5% of all germ cell tumors . MalignaThe treatment of extragonadal yolk sac tumours follows that of primary gonadal foci due to histologic similarities. Chemotherapeutic regimens usually include cisplatin, etoposide, and bleomycin. While surgical excision was previously not considered due to the assumption of metastasis, however, most recent studies suggest excisional surgery following successful treatment response to cisplatin-based chemotherapy ,6. PrognThis case outlined the presentation of an unfortunate 22-year-old male who presented with hemoptysis and was found to have a large anterior mediastinal mass. Although imaging provided detailed information about the characteristics of the mass, the differential remained broad. Eventually, the mass was biopsy-proven non-seminomatous germ cell tumor, yolk sac type. Due to the absence of any additional focus of tumor and a negative testicular ultrasound, his diagnosis was deemed to be a primary mediastinal yolk sac tumor . The patient was treated with a cisplatin-based chemotherapeutic regimen.Upon examining the literature, we have found that patients usually present with nonspecific systemic signs of malignancy, chest pain, cough, and hemoptysis. Treatment usually consists of a cistplatin-based chemotherapeutic regimen followed by surgical intervention. Unfortunately, yolk sac tumors have the worst prognosis of all extra-gonadal germ cell tumors with a prognosis of less than 50% at five years.


A 49-year-old woman presented with a left back mass in the subscapular region that began to cause pain with shoulder movement. Ultrasound scan was obtained to evaluate the lesion and showed a 6.9 × 6.3-cm mass between the left scapula and the posterior chest wall. It was 1-cm thick, discoid, well-circumscribed, and heterogeneous in nature and diagnosed by the radiologist as most likely elastofibroma dorsi based on the location. The patient was taken to the operating room and a fatty soft-tissue mass was removed from beneath the serratus anterior muscle. The final pathology report revealed the mass to be a lipoma.What is elastofibroma dorsi?How is elastofibroma dorsi diagnosed and what is the differential diagnosis?What are the surgical indications for subscapular masses and the potential complications?What is the surgical approach to subscapular masses?Elastofibroma dorsi is a rare, benign, soft-tissue tumor that usually develops between the tip of the scapula and the posterior chest wall. Traditionally, elastofibroma dorsi is located at the inferior border of the scapula between the serratus anterior and the chest wall anteriorly and the latissimus dorsi muscle posteriorly. However, there are a few case reports in the literature of elastofibromas occurring in other regions of the body, including the greater trochanter, ischial tuberosity, olecranon, axilla, elbow, hand, foot, tricuspid valve, stomach, rectum, eye, and inguinal region.3-2,Many patients will present with a noticeable mass in their subscapular region.4-5,4,5,Because these types of subscapular masses are relativity rare, management is based on a limited number of small case series. There are no clearly defined treatment guidelines. The predominant symptoms that prompt patients to seek medical attention are pain, snapping of the scapula, and swelling.4It is helpful to obtain imaging for subscapular masses to aid in diagnosis and for surgical planning. Ultrasound scan showed the position of the mass in this case to overly the posterior chest wall caudal to the inferior pole of the scapula and underneath the serratus anterior muscle, as is the typical location for an elastofibroma dorsi. During surgery, the patient is placed in prone position on the operating room table for ease of access. For patients who cannot tolerate being prone for anesthesia reasons, excision can also be done in the lateral position. It is helpful to mark the inferior border of the scapula as well as the latissimus dorsi muscle preoperatively. The skin incision is designed to be about 10 cm oriented obliquely in line with fibers of the latissimus dorsi muscle, approximately 2 cm beneath the angle of the scapula . DissectAlthough painful subscapular masses between the posterior chest wall and tip of the scapula can be pathognomonic of elastofibroma dorsi, more common soft-tissue masses such as lipoma can also present in this anatomic area. No matter the final tissue diagnosis, surgical resection is indicated to relieve patient symptoms.


Primary pleural synovial sarcoma (PPSS) is an extremely rare malignancy without a known cause. The diagnosis is made after excluding metastasis from an extra‐thoracic sarcoma. We report a case of a 67‐year‐old gentleman who presented with an incidental finding of a left lung mass on a routine chest X‐ray. A computed tomography (CT) of the thorax and whole‐body positron emission tomography (PET)‐CT was done confirming a left lung mass with no other extra‐thoracic involvement. A lobectomy was performed with a diagnostic and therapeutic intent. The histopathological examination and immunohistochemistry study revealed a pleural‐based tumour with features suggestive of synovial sarcoma. Subsequently, he underwent post‐operative radiotherapy. However, three months later, he developed an endobronchial recurrence, complicated by post‐obstructive pneumonia resulting in his demise. This case highlights a rare form of malignancy with a rare site of recurrence. Primary pleural synovial sarcoma (PPSS) is an extremely rare malignancy without a known cause. We report a case of a PPSS that was operated and recurred as an endobronchial metastasis. In general, synovial sarcoma, a malignant soft tissue tumour, comprises up to 10% of soft tissue sarcomas. It is a mesenchymal spindle cell tumour with variable epithelial differentiation. The lung is the usual metastasis site for soft tissue synovial sarcoma. However, this tumour can arise as a primary lesion in other parts of the body such as the lung, pleura, and chest wall. Primary synovial sarcomas of the pleura are extremely rare. Most patients present between the age of 15 and 35 years, and 90% of cases are reported before 50 years of age A 67‐year‐old Chinese man with underlying comorbidity of diabetes mellitus was referred to the pulmonology clinic after a chest X‐ray (CXR) done in January 2019 (workup prior to elective hernioplasty) showed an incidental finding of a left pulmonary mass. This gentleman had no respiratory or constitutional symptoms. Physical examination was unremarkable and his tumour markers were all within normal limits.A contrast computed tomography (CT) of the thorax showed a lobulated mass of 3.4 × 2.7 × 2.6 cm in the posterior segment of the left upper lobe. Positron emission tomography (PET)‐CT showed a lobulated FDG‐avid mass in the left upper lobe with metabolic size of 3.7 × 3.0 × 3.8 cm without any evidence of distant lesions Fig. . A CT‐guHe underwent left upper lobectomy that suggested a poorly differentiated PPSS on histological and immunohistochemistry (IHC) studies Fig. .Post‐operatively, a repeat PET‐CT in March 2019 revealed only fluorodeoxyglucose (FDG) avidity at the right hilar region [standardized uptake values (SUVmax): 3.4], but no obvious nodule was seen on low‐dose non‐contrast CT. He was then treated with radiotherapy to the previous operative site after an oncology consult. No subsequent surveillance imaging was performed.9, Hb 11.4 g/dL, an elevated C‐reactive protein 318 g/dL, and erythrocyte sedimentation rate (ESR) of 73. The CXR on admission showed a left mid‐zone opacity with air bronchogram. Physical examination only revealed coarse crepitations over the left lower zones.In September 2019, he presented with an acute history of fever, cough, and tachypnoea for three days. His blood investigations showed a raised white blood cell (WBC) count of 30.7 × 10He required endotracheal intubation and mechanical ventilation and was treated as pneumonia with intravenous antibiotics. A bronchoscopy found a fleshy growth at the main carina, obstructing both the right and left main bronchi Fig. . MultiplSynovial sarcoma, a rare mesenchymal tumour, accounts for 10% of all soft tissue sarcomas. Among pulmonary malignancies, PPSS constitutes 0.1–0.5%.The clinical symptoms of PPSS vary widely, mainly based on the histology and region of the tumour occurrence, as well as size and degree of tumour differentiation Four histological subtypes have been described: biphasic, monophasic (spindle), monophasic epithelial, and poorly differentiated. The two most common are the monophasic (spindle) and biphasic subtypes There is currently no standardized therapy for patients with primary pulmonary synovial sarcoma, and complete surgical resection remains the main strategy in these patients For our patient, we initially planned for tumour debulking and stenting of the airway as a management of the post‐obstructive pneumonia. Should he have recovered from his pneumonia, our further management would be proceeding with doxorubicin‐ and ifosfamide‐based chemotherapy depending on his clinical performance status. However, the patient's family members opted for conservative management and the patient subsequently succumbed to disease progression.Appropriate written informed consent was obtained for publication of this case report and accompanying images.


Groin hernias are extremely common surgical pathologies and usually contain intra-abdominal viscera surrounded by peritoneum. Femoral hernias are the least common types of hernia and are predominately found in females. In rare cases, an extraperitoneal organ may be pulled into the hernia sac to become part of the content. Urinary bladder diverticulum should be considered as a possible femoral hernia content in elderly patients presenting with recurrent symptoms of lower urinary tract infections and hematuria. A high index of suspicion followed by appropriate imaging assists in making a correct preoperative diagnosis and improves postoperative outcomes. We present an uncommon case of herniation of a urinary bladder diverticulum into a femoral hernia presenting with recurrent hematuria in an elderly female. Groin hernia is a common surgical pathology usually containing intra-abdominal viscera surrounded by the peritoneum. An extraperitoneal organ is not typically found within the hernia sac. However, in certain rare cases, like our case of a bladder diverticulum, extraperitoneal organs can be pulled by the sac itself and become a component of the hernia .Femoral hernias, although more predominant in females, are less common than inguinal hernias and are usually complicated with incarceration or strangulation of the organ that they contain ,3. BladdWe present an uncommon case of a urinary bladder diverticulum that herniated into the right femoral canal which presented with recurrent bouts of hematuria.A 65-year-old female patient presented to the emergency department (ED) complaining of pelvic pressure and hematuria. Although the history was somewhat limited due to dementia, the patient did report discomfort in the suprapubic area. She denied vomiting, chest pain, shortness of breath, fevers, or chills. Past medical history comprised atrial fibrillation, hypertension, and stroke. Past surgical history included left cataract extraction and closed reduction of right humerus fracture. She was anticoagulated with apixaban. The patient was oriented in time, place, and person and appeared in no marked distress. The heart was in regular rate and rhythm. The lungs were clear with equal breath sounds bilaterally. The abdomen was soft, and there was some slight suprapubic tenderness but no masses, rebound, or guarding. Extremities were atraumatic. A 12-systems review was essentially negative except for genitourinary which was positive for hematuria. The urine specimen was cloudy in appearance with marked leukocyte esterase, 3+ protein, 2+ blood, 3+ red blood cells (RBCs), white blood cells (WBCs), too numerous to count bacteria, many squamous epithelial/low-power field (LPF), and moderate transitional epithelial cells. A CT scan of the chest, abdomen, and pelvis was completed Figure .The kidneys were normal in size, configuration, and location. There was a right “urinary bladder ear” likely relating to a femoral or less likely inguinal herniation. The involved segment exhibited gross irregular mural thickening with adjacent infiltration Figure .The entrapped and adjacent mural segment was significantly thickened with adjacent infiltration with a high suspicion for strangulation/infarction. The remainder of the urinary bladder exhibited a lesser degree of mural thickening. Bilateral non-obstructing renal calculi with mild bilateral pelvocaliectasis and a Bosniak type 2 right renal cyst were also noted. The gallbladder, biliary tree, liver, spleen, pancreas, and adrenal glands were free of abnormalities as were the gut, mesenteric, nodal, and bony structures. No intraperitoneal mass or fluid or other pelvic bony or soft tissue abnormalities were noted. There was normal heart size with mitral annulus calcification. Osteopenia and thoracolumbar spondylosis were particularly advanced at L2-3 and L5-S1.Prior to transport to the operating room (OR), the patient had received IV rocephin in the ED. In the OR, she was induced with general anesthesia. The skin and deeper tissue halfway between the anterior superior iliac spine and pubic tubercle were infiltrated with local anesthetic. A 5-cm oblique incision was performed parallel to the inguinal ligament and extended down through subcutaneous tissue with cautery to the level of the hernia sac which was dissected circumferentially and freed. It led to the femoral hernia defect medial to the femoral vessels Figure .It measured 1.2 cm in diameter. The herniated tissue consisted of a diverticulum of the bladder with surrounding fatty tissue. It was soft and viable and was gradually pushed back into the pelvis. The preperitoneal space was circumferentially cleared with a sponge. The repair was done by introducing a large mesh plug through the defect into the preperitoneal space. It was attached to the inguinal ligament superiorly and to the medial tissue with a couple of interrupted 2-0 Polysorb sutures. Scarpa's fascia was closed with several interrupted 3-0 Polysorb sutures. The incision was closed with a continuous subcuticular 4-0 Polysorb suture. The area was circumferentially infiltrated with 10 cc of 0.5% plain Marcaine. A sterile dressing was taped in place. The patient tolerated the procedure well. The patient did well postoperatively, tolerating a regular diet, and her pain was adequately controlled with an oral regimen. She was discharged home on postoperative day 1. The patient was seen one week postop in the outpatient setting where she was doing well. She returned for a one-month postop appointment where she continued to be without complaints, and she has since been lost to follow-up. Bladder diverticula are relatively rare and are usually caused by weakening of muscular fibers of the bladder and increased intravesicular pressure leading to herniation of the bladder mucosa through the bladder wall . It is tBladder diverticulum can be congenital, acquired, or iatrogenic. Congenital cases are almost exclusively in boys, usually singular and large, and sometimes associated with congenital neurodegenerative disorders, such as Ehlers-Danlos syndrome and Menkes’ syndrome . AcquireGroin hernias are usually diagnosed clinically. However, it is imperative to know the true location, its relationships, and content characteristics prior to surgical intervention . AlthougEither an extraperitoneal or an intraperitoneal approach may be employed for the surgical management of a bladder diverticulum herniated through the femoral or inguinal canals . We opteAlthough rare in females, urinary bladder diverticulum should be considered as a possible femoral hernia content in elderly patients presenting with recurrent symptoms of lower urinary tract infections and hematuria. A high index of suspicion along with appropriate imaging assists in making the correct preoperative diagnosis and improves postoperative outcomes. Intraoperatively, the bladder should be checked for iatrogenic injuries and repaired. Inguinal bladder hernia is sometimes associated with urological malignancies which, if suspected, warrant appropriate follow-up.


Small bowel prolapse through uterine perforation is a rare but severe complication of unsafe abortion. Early recognition of the bowel prolapse, aggressive resuscitation and prompt surgical intervention can reduce the morbidity and mortality related to these kinds of injuries. We present here a case of small intestine prolapse through uterine perforation following dilatation and curettage requiring intestinal resection. Efforts have to be made to reduce the number of unsafe abortions. A procedure for termination of an unintended pregnancy carried out by either person lacking the necessary skills or in an environment which does not conform to minimal medical standards or both is defined as unsafe abortion . AbortioA 23-year-old woman, presented to our hospital with complaints of severe abdominal pain and something coming out through the vagina. On history taking, it was revealed that she had three months of pregnancy and had gone to a local non-medical practitioner for termination of pregnancy. She had one previous normal delivery one year back. She underwent termination of pregnancy in her village. During the procedure, the non-medical practitioner observed something coming out through her vagina and referred the patient to our hospital on the same day.On examination, her vitals were impaired. Blood pressure was 90/70 mm of Hg, and pulse was 106/ min. The temperature was normal, 98.4ᴼF. On general examination, pallor was present. Her abdominal examination was difficult to appreciate due to the presence of tenderness, muscle guarding and rigidity. Bowel sounds were sluggish. Inspection of vulva revealed prolapsed bowel loops. The length of the visible prolapsed bowel segment was about 40 cm. On per speculum examination, we could see the loop of intestine coming out through the cervix. It was bluish coloured, and some of its portions appeared gangrenous (figure The patient was resuscitated. After doing proper workup and routine investigations, an exploratory laparotomy was planned. Per operative, findings revealed a rent of about 3×3 cm in the left anterolateral wall in the body of the uterus, through which the ileum was seen entering into the cavity figure . The ute Termination of pregnancy by medical methods carried out in places outside health facilities, without a prescription accounts for about 70% of all abortions in India, amongst which 5% underwent highly unsafe methods with a high risk of complications . In deveThe risk factors associated with increased chances of uterine perforation are previous D&C, prior caesarean section, advanced maternal age, greater parity, and lack proper training of the persons carrying out the procedure . GloballThe patients with uterine perforation following surgical abortion may present with vaginal discharge, pain, abdominal cramps or fever. Bowel injury secondary to uterine perforation can lead to adhesions, partial or complete obstruction leading to abdominal pain with/without distension, vomiting, diarrhoea or absence of flatus or stool . If leftUterine perforation following surgical termination can have life-threatening complications . HoweverThe most critical factor in the prevention of this condition is the identification of patients who are at high risk of perforation. D&C should always be done under ultrasonographic guidance whenever available ,12. EarlComplications like intestinal injury due to unsafe abortion are rare but dreaded. Early recognition of the injury, aggressive resuscitation and prompt surgical intervention can reduce the morbidity and mortality related to these kinds of injuries. Efforts have to be made to reduce the number of unsafe abortions. Women should be counselled for contraception, family planning, and they should be made aware of the various contraceptive choices. There should be decentralisation of the health care facilities, so that rural population do not opt for illegal methods of termination of pregnancy. The local health providers should be given basic training so that they can diagnose and refer the patient to a tertiary care centre if any untoward hitches occur during the procedure.


Hepatocellular adenoma (HCA) is a benign neoplasm of the hepatic parenchyma. The use of oral contraceptives (OCP) in women is the most well-established risk for the development of HCA. HCA commonly presents as an intracapsular mass of the liver but there are very few cases of extracapsular HCA. This is a case of a middle-aged female who presented to the emergency department with left shoulder pain and epigastric tenderness on physical exam. Subsequent imaging of the abdomen revealed a mass arising from the anterior wall of the stomach, with evidence of surrounding hemorrhage. The patient underwent exploratory laparotomy that revealed free blood in the peritoneum and a hemorrhagic mass arising from the stomach wall. The mass was successfully removed with no postoperative complications. Histopathological examination of the mass was consistent with an infarcted inflammatory HCA. This case illustrates this unusual presentation of a rare diagnosis.  A hepatocellular adenoma (HCA) is a benign proliferation of mature hepatocytes and consists 2% of all liver neoplasms ,2. Its eA 43-year-old woman presented to the emergency department with a two-day history of left shoulder pain. The patient described the shoulder pain as sharp, constant, and non-radiating. She did not have any known past medical or surgical histories, and her only medication was OCP pills. On review of systems, she reported epigastric discomfort without nausea, vomiting, lack of appetite or recent weight changes. On physical exam, the patient was tachycardic with otherwise stable vital signs. Abdominal exam revealed epigastric tenderness with no guarding or rebound. Initial laboratory work is depicted in Table Initial computed tomography (CT) scan of the abdomen revealed a large heterogeneously enhancing mass arising from the anterior wall of the stomach with a small amount of free fluid surrounding the liver and a moderate amount of fluid in the pelvis Figure .Contrast-enhanced magnetic resonance imaging (MRI) of the abdomen demonstrated an hypoenhancing exophytic mass from the anterior wall of the stomach with evidence of small volume internal and adjacent hemorrhage. The mass measured 4 x 7.2 x 8 cm in maximum anteroposterior, transverse, and craniocaudal dimensions . In this report, we aimed to enhance clinicians’ understanding of uncommon presentations of HCA. With recent increase in the prevalence of this condition, especially among patients on OCPs, timely diagnosis and prompt intervention are likely to reduce life-threatening complications.


Inflammatory orbital lesions include a broad list of diagnoses, many of them with overlapping clinical and radiographic features. They often present a diagnostic conundrum, even to the most experienced orbital specialist, thus placing considerable weight on surgical biopsy and histopathological analysis. However, histopathological diagnosis is also inherently challenging due to the rarity of these lesions and the overlaps in histologic appearance among distinct disease entities. We herein present the case of an adolescent male with a subacutely progressive orbital mass that generated a significant diagnostic dilemma. Early orbital biopsy was consistent with a benign fibro-inflammatory lesion, but corticosteroid therapy was ineffective in halting disease progression. After an initial substantial surgical debulking, histopathological analysis revealed several key features consistent with IgG4-related disease (IgG4-RD), a systemic fibro-inflammatory process typically accompanied by multifocal tumor-like lesions. Surprisingly, within months, there was clear evidence of clinical and radiographic disease progression despite second-line rituximab treatment, prompting a second surgical debulking. This final specimen displayed distinctive features of Rosai-Dorfman disease (RDD), a systemic inflammatory disease characterized by uncontrolled histiocytic proliferation. Interestingly, certain features of this re-excision specimen were still reminiscent of IgG4-RD, which not only reflects the difficulty in differentiating RDD from IgG4-RD in select cases, but also illustrates that these diagnoses may exist along a spectrum that likely reflects a common underlying pathogenetic mechanism. This case emphasizes the importance of surgical biopsy or resection and histopathological analysis in diagnosing—and, ultimately, treating—rare, systemic inflammatory diseases involving the orbit, and, furthermore, highlights the shared histopathological features between RDD and IgG4-RD. Orbital lesions can be grouped under six general categories: inflammatory, infectious, vascular, neoplastic, metastatic (or secondarily invading), and developmental . WhereasWe present the case of an adolescent male with an inflammatory orbital mass that was especially challenging to diagnose. He presented with a subacute, progressive, inflammatory left orbital mass that was given a histopathological diagnosis of IgG4-related disease (IgG4-RD) following initial surgical debulking. However, the lesion failed to respond to both first- and second-line treatment for IgG4-RD and required further debulking due to disease progression. Biopsy specimens obtained following a second surgical debulking revealed histology that ultimately prompted a final diagnosis of Rosai-Dorfman disease (RDD).The patient was an otherwise healthy 17-year-old male who presented with left eyelid swelling, retrobulbar pressure sensation, and occasional diplopia worsening over the preceding few weeks. MRI revealed an infiltrative, enhancing, multi-compartmental lesion in the left inferolateral extraconal orbit associated with left-sided proptosis, optic nerve displacement, suspected osseous erosion of the orbital floor, and nodular lesions along the left frontal scalp and buccal region. Initial transconjunctival orbital biopsy was suggestive of a non-specific, benign, fibro-inflammatory lesion, but oral prednisone therapy resulted only in minimal symptom improvement without significant radiographic changes. An additional minimally invasive periorbital biopsy was more consistent with an atypical lymphoid infiltrate with prominent B cell and polytypic plasma cell populations—considered potentially concerning for marginal zone lymphoma. Of note, PET-CT imaging was negative for evidence of lymphoma elsewhere. During the next several months, the patient’s ophthalmic symptoms progressed, and he developed new neurological symptoms . Interval enlargement of the orbital lesion was noted on repeat MRI  was still present Fig. g-i, l anFollowing extracranial debulking, there was persistent multi-directional diplopia; however, MRIs obtained at approximately 1 month Fig. c and 4 mThis case of orbital, extranodal RDD with features reminiscent of IgG4-RD presented a diagnostic dilemma that highlights the subtleties in diagnosing either disease in an atypical location and supports the potential existence of an overlap syndrome.The differential diagnosis before surgical debulking was broad. One possibility was inflammatory myofibroblastic tumor (IMT), which tends to occur in children and can present as a well-defined soft tissue mass  , 6. AlthHistopathological analysis following the initial surgical debulking of the lesion’s orbital portion revealed several key features, described above and shown in Fig. Histopathological analysis following the second debulking surgery shifted our diagnosis towards RDD. RDD is an inflammatory syndrome characterized by uncontrolled histiocytic proliferation . It is rThe biopsy specimens obtained from the second surgical debulking were most notable for having numerous “RDD cells”: large, S-100-positive histiocytes with “watery-clear” or “foamy” cytoplasm and a hypochromatic nucleus with a conspicuous nucleolus Fig. k 25]. E. E25]. EInterestingly, a report published by Bertero et al. described a similar case of an orbito-temporal mass ultimately diagnosed as “Rosai-Dorfman meningeal disease with IgG4-related disease histological features”; just as in our case, initial histopathological analysis of was suggestive of IgG4-RD, while further samples exhibited features pathognomonic for RDD . The hisAnother key observation from Zhang et al. was that adult RDD cases harbored more sclerosis than pediatric cases . Two addThe diagnostic dilemma highlighted by this case is critically hypothesis-generating with respect to the nature of adult extranodal RDD and its potential relationship with IgG4-RD. Informative histopathological evidence was not obtainable without substantial surgical tissue sampling. Furthermore, the patient’s lesion appeared to display not only regional differences in plasma cell and histiocyte expression, but also a clinical response to treatment not clearly consistent with any previously reported RDD-related or IgG4-RD–related entity. Previous series have identified examples of RDD with features of IgG4-RD, especially in young adults with progressive, refractory disease. Further investigation into whether RDD and IgG4-RD may exist across a shared pathological spectrum due to similar molecular pathogenesis, likely dependent on T-regs, is necessary to improve our understanding and optimize our management of these rare and challenging systemic diseases.


Dermatofibrosarcoma Protuberans (DFSP) is a rare type of malignant tumor of the cutaneous soft tissue that typically involves the dermis and surrounding structures. The typical clinical presentation involves an asymptomatic, slowly enlarging, indurated plaque, usually found on the trunk.Here we present an atypical presentation of DFSP in a patient with a recurrent mass that was initially diagnosed as a lipoma, with supporting literature and clinical considerations for post-surgical managementIn its earlier stages, DFSP can mimic other benign or malignant dermatological pathologies, which can complicate diagnosis purely via history and physical exam. Atypical features such as prior surgical management, morphology, and location can complicate the clinical diagnosis of DFSP. Immunohistochemistry is often required for definitive diagnosis as DFSP is CD34+ and is histologically described as spindle-cells in whorled or storiform pattern, with uniform, small elongated cells.DFSP is a rare tumor of the skin and subcutaneous tissue. Though it commonly presents with induration, skin discoloration, and telangiectasias, it is important to keep DFSP as a differential in new masses found on previous surgical sites, especially if the previous mass had a possibility of recurrence. As the Here we present an atypical case of DFSP in a patient with a recurrent mass that was initially diagnosed as a lipoma, with supporting literature and clinical considerations for post-surgical management. This case was conducted at St. Clare’s Denville Hospital, a New Jersey Health System community hospital in the department of surgery and work has been reported in line with the SCARE criteria .2A 68-year-old Caucasian male presented for surgical evaluation with a right mid-infraclavicular chest mass from referral of his primary care physician . Three yOn physical exam, a mass was palpated at the midclavicular line of the right upper chest, within the right first intercostal space. The mass was directly under the scar from previous excision, with no skin discoloration, telangiectasia, or visible raised nodules. The patient denied any pain, tenderness, or discharge associated with the new mass. Radiological testing was performed to determine the exact location and depth of invasion. CT chest with and without contrast revealed an ill-defined, cutaneous mass, while MRI chest was nondiagnostic.Surgical excision was performed under local anesthesia, with a wide, elliptical incision to the level of the underlying bony structures to ensure clean margins. Excised specimen measured 5.5 cm × 3.5 cm × 2 cm with surrounding 4 cm × 1.6 cm × 0.4 cm of skin attached. The resulting wound was closed using interrupted 4–0 plain gut sutures for the full thickness, with 3–0 Vicryl subdermal and 4–0 Monocryl subcuticular reinforcing sutures.The specimen was sent to pathology for cryosectioning; however, due to increase in cellularity at the posterior margin, permanent fixation was performed. Within the submitted specimen, a subcutaneous firm nodule measuring 1.6 cm × 1 cm × 0.7 cm was located in the superior aspect with a 0.1 cm surrounding margin. Microscopic examination with hemolysin and eosin staining showed whorled myoid with spindled nuclei in storiform array throughout the dermis and extending into the subcutaneous fat with widening fibrous septa , Fig. 3.As a result of the close margin excision, the patient was referred for radiation therapy with imatinib for recurrence prevention. Upon the last two follow-ups status post imatinib treatment, there have been no signs of recurrence.3DFSP is invasive to surrounding tissues; the irregular, tentacle-like projections with septations and similarity to normal fibrous tracts of the tumor lends to difficulty in determining its borders, and consequently, its surgical margins for excision ,6,10. VaThis case presents a number of aspects that defy common characteristics of DFSP, which highlights the difficulty in clinical diagnosis. DFSP is commonly discovered deep to the dermis, with associated telangiectasia and skin discoloration . The casThe differential diagnosis for DFSP can be varied due to its non-specific physical manifestation. Surgical pathology considerations can include dermal and deep fibrous histiocytoma, myxoid nerve sheath tumor, myxoid liposarcoma, plexiform fibrohistiocytic tumor, desmoplastic tumor, and adult fibrosarcoma among others . Immunoh4DFSP is a rare tumor of the skin and subcutaneous tissue. Though it commonly presents with induration, skin discoloration, and telangiectasias, it is important to keep DFSP as a differential in new masses found on previous surgical sites, especially if the previous mass had a possibility of recurrence.None.None.As a case report, this article does not meet DHHS definition of research and thus does not require review by Touro College of Osteopathic Medicine’s IRB and is exempt from this process. Efforts were made by all authors to ensure compliance with HIPAA requirementsWritten 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.Name of the registry: N/A.Unique identifying number or registration ID: N/A.Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A.Justin Chin.Not commissioned, externally peer-reviewed.YaQun Zhou (Arlene): Conceptualization, Investigation, Writing - original draft, Writing - review & editing. Justin Chin: Conceptualization, Methodology, Writing - original draft, Writing - review & editing. Millard D. Strutin: Investigation, Resources, Writing - original draft, Writing - review & editing, Supervision. Christine M. Lomiguen: Conceptualization, Writing - original draft, Writing - review & editing, Project administration.


Schistosomiasis is a trematode infection rarely diagnosed in the United States. Intestinal involvement is common with chronic infection and causes abdominal pain, changes in bowel habits, hematochezia, and polyp formation. Chronic, disseminated infection can affect the intestines causing the aforementioned symptoms, but reports of intestinal polyps are rare. Most cases are inflammatory fibrous polyps in the colon. There are very few cases reported in the literature of hamartomatous polyps arising in the small intestine. We present the rare case of a U.S.-born, 35-year-old woman diagnosed with a large duodenal hamartomatous polyp in the setting of intestinal schistosomiasis. We present a unique case of a 35-year-old woman and raised in the United States who developed a hamartomatous duodenal polyp that may have been secondary to intestinal schistosomiasis.Schistosomiasis affects more than 200 million people worldwide but is rarely diagnosed in the United States.A 35-year-old woman presented to the gastroenterology clinic for evaluation of dull abdominal pain. The abdominal pain started insidiously 2 years previous, was intermittent in nature, and located in the epigastric and left lower quadrant. The patient also complained of concomitant diarrhea, flatulence, and bloating. She denied melena, hematochezia, nausea, vomiting, fevers, chills, or weight loss. She had an upper endoscopy and colonoscopy 2 years earlier with no significant findings. She had a medical history notable for type 1 diabetes mellitus and a previous benign bladder tumor with unknown pathology that was surgically resected. She was born and raised in the United States and had lived in multiple cities within the United States. Her only travel outside of the United States had been during her childhood on vacation to the Bahamas, the Cayman Islands, and Mexico. She denied any wading or swimming in any freshwater source outside of the United States. She denied any cigarette smoking, alcohol use, or illicit drug use.Her abdominal examination revealed no distention, no scars, normal bowel sounds, no tenderness, no organomegaly, and normal tympani. The rest of her physical examination was unremarkable. Her laboratory testing was within normal limits. Abdominal ultrasound was performed at a later time due to abdominal pain showed a 9-mm indeterminate hepatic lesion. Abdominal magnetic resonance with and without contrast showed multiple hyperenhancing liver lesions. The hepatic lesions were biopsied. It revealed non-necrotizing granulomas composed of multinucleated giant cells and cuffs of lymphocytes; moderate hepatic steatosis was present.Schistosoma mansoni. The patient was referred to infectious disease. She was prescribed praziquantel 20 mg/kg/dose 3 times per day for 1 day. The patient followed up with gastroenterology after treatment with praziquantel. Her diarrhea had resolved, but she continued to have intermittent left lower quadrant abdominal pain, attributed to irritable bowel syndrome. Repeat endoscopy showed no evidence of duodenal hamartomatous polyp.Upper endoscopy was performed to reveal a 40-mm pedunculated polyp with no bleeding in the second part of the duodenum; this was resected Figure . The eso13 Risk factors include exposure to contaminated freshwater in endemic areas. The patient in our case had a very remote travel history as an adolescent and did not have any exposure to any freshwater sources. The most important species infecting humans are Schistosoma mansoni, S. japonicum, S. mekongi, S. haematobium, and S. intercalatum.1 The S. mansoni life cycle involves an intermediate host (freshwater snail) and definitive host (human).12 They enter humans through the epidermis, and they travel using the lymphatic and circulatory system. Mature schistosomes are found mostly in the small inferior mesenteric blood vessels. They sexually reproduce, deposit the eggs to the gut and urinary bladder, and the eggs are excreted.Although rare in the United States, schistosomiasis is one of the most widespread parasitic infections.4 The underlying mechanism starts with egg deposition in the loose superficial layers of submucosa and subsequently progresses into cell-mediated inflammatory response with granuloma formation to form polyps.19 Most polyps are inflammatory/fibrous, but hamartomatous, hyperplastic, and adenomatous polyps have been reported; they range in size from 2 to 20 mm and sessile, pedunculated, or cauliflower.19 The tumorigenic potential of polyps caused by intestinal schistosomiasis has been long been debated, but there may be a small risk of colorectal cancer,17 especially with S. japonicum.18 There are few cases of colorectal cancer that have been attributed to S. japonicum. Consequently, schistosomal infections have been linked to other cancers, such as the link between S. haematobium and bladder cancer.18 We did not find any link between intestinal schistosomiasis and bladder tumors in the literature search. Also, schistosoma-lodged eggs lead to granulomatous inflammation in the liver and healed by periportal fibrosis. Pathology shows granulomatous changes in the portal triad and may be consisted of lymphocytes, multinucleated giant cells, and eosinophils.20 We believe that explains the pathology of the liver lesions in our patient's case.Intestinal schistosomiasis can also occur in the small or large intestine and may present with polyps, acute colitis, or cancer, depending on acuity of infection and species.7 However, intestinal involvement in schistosomiasis is usually confined to the ileum, colon,16 and rectum,8 but duodenal involvement can occasionally be present.16 Intestinal schistosomiasis of any kind in the United States is rare.10 We are aware of only 1 previous case of a duodenal polyp caused by intestinal schistosomiasis.11 The diagnosis of intestinal schistosomiasis requires egg identification from stool samples or endoscopy biopsy. Serology to detect antischistosomal antibodies in serum or urine can be helpful to rule out infection in the epidemic area, but its sensitivity and specificity can sometimes be challenging in the nonepidemic area.7 Treatment for schistosomiasis is relatively safe and effective, especially in the developed countries where the resistance to praziquantel has not been reported yet.7There have been a few reported cases of colon polyps in the absence of inflammation in endemic areas.Author contributions: A. Gonzalez, K. Gupta, and V. Wadhwa wrote the manuscript. S. Rodriguez and R. Charles edited the manuscript. P. Bejarano was the pathologist. K. Gupta is the article guarantor.Financial disclosure: none to report.Informed consent was obtained for this case report.


Cholecystocolic fistulas are uncommon, with rare cases of colonic obstruction described in the literature and even rarer cases of intestinal perforation due to gallstones.We describe a case of a 73-year-old man who presented to our ED with complaints of diffuse abdominal pain, vomiting, constipation, and fever for the past week. Abdomen CT showed signs of acute perforated appendicitis. An exploratory laparotomy was proposed which revealed cecal perforation caused by a 3 cm gallstone. A right colectomy was performed with primary anastomosis, without cholecystectomy or fistula repair. The postoperative period was complicated due to an anastomotic dehiscence on day 12 with the need for a re-laparotomy with an ileotransverse colostomy confection. The patient was in the ICU care for five days and was discharged on the 13th day after the second intervention. The clinical presentation of gallstone ileus is nonspecific and vague often leading to a delay in the diagnosis and treatment. CT scan has the best specificity and sensibility for the diagnosis but abdominal X-ray may show the pathognomonic Rigler´s triad. The surgical treatment consists of removing the gallstone with or without simultaneous cholecystectomy and fistula repair.Reports of colonic perforation due to gallstones are very scarce, which makes this a very low suspicion diagnosis. The ideal surgical approach is not established. The morbidity of these cases can reach 50%. Gallstone disease is a common condition known to predominantly affect female patients . It can Signs and symptoms of gallstone ileus are nonspecific, with reports of nausea, vomiting and abdominal pain, often leading to a delay in the diagnosis and prompt treatment. More than 50% of cases are discovered only during laparotomy . The lacA 73-year-old male with a personal history of ischemic heart disease, chronic pulmonary obstructive disease, hypertension and a previous partial gastrectomy with a Billroth II reconstruction due to a peptic ulcer, presented to our ED with a one-week history of diffuse abdominal pain, vomiting, constipation, and fever. Physical examination revealed a distended, tender abdomen, with pain upon palpation of the right lower quadrant, showing clinical signs of peritonitis. Laboratory data showed a slightly elevated white blood cell count of 11.9 x 103/μL, hemoglobin of 13.1g/dL, platelet count of 269 x 103/μL, normal renal function with urea 48 mg/dL, creatinine 1.3 mg/dL, and a C-reactive protein of 28.60 mg/dL  without electrolyte or liver enzymes alterations. The patient performed a CT scan . The patient has not had more complaints since the discharge and is being followed at our outpatient clinic for programming re-establishment of intestinal continuity.The presentation of gallstone ileus may be preceded by a history of biliary symptoms, which can be absent in up to one third of the cases, with intestinal obstruction with vomiting and abdominal pain being the most common clinical presentation.Laboratory tests may reveal slight leukocytosis, electrolyte imbalance, signs of dehydration and abnormalities in liver function in up to 41% of patients, which are of little diagnostic value [In 1941 Rigler described a triad composed by three pathognomonic radiological signs: 1) aerobilia, 2) bowel obstruction, and 3) presence of an ectopic gallstone. However, these features are only present in one third of patients . ContrasCholecystoenteric fistulas are a rare entity, with an incidence of 0.4%-1.9% . FistulaGallstones larger than 2 cm  may impaGallstone ileus causing obstruction of the colon is a rare condition with cases of colonic perforation due to gallstones being even rarer. A literature research showed only six reported cases of colonic obstruction and perforation attributable to gallstones, all involving the sigmoid colon -12. HencGallstone ileus is a condition most commonly seen in the population over 65 years , usuallyLess invasive techniques such as use of laxatives, colonoscopy retrieval of the impacted stone and gallstone fragmentation using lithotripsy have been successfully employed in some selected cases, depending on the gallstone’s sizes and composition .Surgery remains the mainstay of treatment although, due to the lack of case reports and case studies, no formal recommendations exist on optimal management in an acute setting. The current surgical options are: 1) enterolithotomy, 2) enterolithotomy, cholecystectomy, and fistula repair (one-stage procedure) and 3) enterolithotomy with a deferred cholecystectomy and fistula repair after four to six weeks (second-stage procedure) . Bowel rA retrospective study conducted by Tan et al. studied 19 consecutive patients treated in an emergency setting for gallstone ileus, comparing enterolithotomy alone and enterolithotomy combined with definitive biliary tract surgery and fistula closure. They concluded that the one-stage procedure, despite associated with prolonged operating time, should be offered to patients with lesser comorbidities and a better ASA score, thus excluding the risks related to the persistence of a bilioenteric fistula such as recurrent gallstone ileus, cholecystitis, and recurrent cholangitis .In contrast, on the largest review of published reports on gallstone ileus, Reisner and Cohen reported a lower morbidity after enterolithotomy alone, with a <5% risk of gallstone ileus recurrence and only 10% of patients requiring surgical re-intervention for persistent symptoms. They also reported a lower mortality rate associated with the enterolithotomy group (11.7%), compared to 16.7% of those who underwent the one-stage procedure , relief Halabi et al. also determined that when bowel resection was needed, it was associated with higher mortality rates than enterolithotomy alone .The morbidity described in these patients can reach 50%, with wound infection being reported as the most common postoperative complication , despiteAll of the previous reported cases found in the literature involving sigmoid perforation by gallstones -12 referIn this case, we chose to only address the cecal perforation with a right colectomy considering our patient´s age and previous co-morbidities and the fact that given the multiple adhesions found on the supramesocolic compartment, trying to correct the cholecystocolic fistula could add significant morbidity to the procedure. In light of the current evidences, relief of the intestinal obstruction remains the goal of the treatment as, in the long term, most of the remnant fistulas appear to close spontaneously, particularly when the cystic duct is patent and there are no residual gallstones , 14, notGallstone ileus is a rare clinical manifestation that must be taken into consideration when approaching elderly patients with symptoms consistent with bowel obstruction and recurrent cholecystitis. Contrast enhanced CT scan is the best diagnostic test to be used. Treatment plan must be tailored to each patient according to age and comorbidities, with the management of bowel obstruction remaining the cornerstone of treatment. In cases where bowel resection is indicated, there is a higher morbidity and mortality involved.


PIK3CA mutation excessively activates mammalian target of rapamycin (mTOR) pathway, which promotes angiogenesis and lymphangiogenesis. Histologically, FAVA is composed of intramuscular fibrous and adipose tissues with venous malformation (VM). Although sirolimus known as a mTOR inhibitor has good response to FAVA, expression pattern of the mTOR pathway was still unclear. Herein, we immunohistochemically investigated three novel FAVA patients with an emphasis on the mTOR pathway .Fibro-adipose vascular anomaly (FAVA) is a new entity of vascular anomalies with somatic and mosaic gain-of-function mutations of the Case 1: A 10-year-old female had complained of pain in the left thigh since she was 6-year-old. Under the clinical diagnosis of VM, she underwent surgical resection for the lesion. Case 2: A 29-year-old female patient had complained of discomfort and mild pain in the left shoulder since she was 18-year-old. After childbirth, she had severe ongoing pain and contracture of the shoulder. Under clinical diagnosis of VM, surgical resection was performed. Case 3: A 53-year-old female had complained of pain and knee restriction after surgical treatment of a knee tumor at the age of 31. Under the clinical diagnosis of atypical lipomatous tumor or high grade liposarcoma, surgical resection was performed. Histologically, all three patients presented with characteristic features of fibrous and adipose tissues with abnormal vessels within the skeletal muscle, leading to diagnosis of FAVA. Although VM has been reported as an important finding in FAVA, immunohistological findings demonstrated that abnormal vessels comprised complex of VM and lymphatic malformation (LM) in all cases. Furthermore, besides vascular malformation, abnormal fibrous and adipose tissues of FAVA expressed mTOR pathway components.We presented three new cases of FAVA. Histological and immunohistochemical analyses revealed that VM and LM complex was an important finding in FAVA, and that the mTOR pathway components were expressed in abnormal fibrous tissue, adipose tissue and vascular malformation. These findings suggested that FAVA might be a mesenchymal malformation caused by PI3K/AKT/mTOR pathway. Fibro-adipose vascular anomaly (FAVA) is a new entity of vascular anomalies, and has not been included in the International Society for the Study of Vascular Anomalies (ISSVA) classification . FAVA isphosphatidylinositol-4,5-bisphosphate 3-kinase Catalytic Subunit Alpha (PIK3CA) gene were found in FAVA, and FAVA belongs to the spectrum of PIK3CA-related overgrowth syndromes (PROS) [PIK3CA mutation excessively promoted activation of mTOR pathway [Recent study identified that somatic and mosaic gain-of-function mutations of the s (PROS) . PIK3CA s (PROS) . Activats (PROS) , 9–12. I pathway , 13. Mor pathway , 15. ConA 10-year-old female had complained of pain in the left thigh since she was 6-year-old. She had no significant prior medical or surgical history. Both axial T2-weighted Magnetic resonance imaging (MRI) and coronal fat-saturated enhanced T1-weighted MRI revealed heterogenous hyperintense within the skeletal muscle . In contrast to abnormal veins’ staining, abnormal lymphatic vessels were positive for CD31, D2–40 and PROX1, and negative for CD34 .First, we performed CD31 , CD34 , D2–40  and PROX1  immunostaining to provide additional evidence of VM and LM in FAVA. In abnormal veins, CD31 and CD34 were positive and D2–40 and PROX1 were negative in all three cases , p-4EBP1  and p-AKT . Normal connective tissues surrounding FAVA lesions served as a control. Control normal tissues were mainly composed of skeletal muscle and normal vessels, because FAVA arises within skeletal muscle Fig. a, b and In this study, we described three cases of previously unreported immunohistochemical characteristics of FAVA. Histological and immunohistochemical analyses revealed that lymphatic-venous malformation (LVM) was an important finding in FAVA, and the mTOR signaling pathway was expressed in various FAVA components.Identification of vascular type was conducted using CD34 as markers for blood vessels, as well as D2–40 and PROX1 for lymphatic vessels. Histological and immunohistological findings demonstrated presence of complex of abnormal veins and lymphatic vessels in all three cases  presented two cases of FAVA with mTOR inhibitor sirolimus treatment . Before 017 presePIK3CA mutation. We presented three new cases of FAVA. Histological and immunohistochemical analyses revealed that LVM was an important finding in FAVA, and that the mTOR pathway components were expressed in abnormal fibrous tissue, adipose tissue and vascular malformation.FAVA is a rare vascular malformation with


Retropharyngeal abscess (RPA) in adults is a potentially life-threatening condition that relates in most of the cases with local trauma. Non-traumatic RPA complicated by spinal osteomyelitis and epidural abscess is a rare entity in immunocompetent adults and represents an emergency medical condition when the patient develops neurologic symptoms. This article presents a case of non-traumatic RPA complicated by spinal osteomyelitis and epidural abscess in a 77-year-old male with the free past medical history. We highlight the importance of early and meticulous daily drainage as well as sequential MRI scanning for early diagnosis, treatment and follow-up for signs of vertebral involvement. The patient had a full recovery and was subsequently discharged with per os four-month antibiotic treatment. The definitive mechanism is unclear for non-traumatic cases with “hematogenous path” being the closest description. Spontaneous RPA can develop from bacteria infection spread of adjacent structures, local inflammatory process and microthrombosis formation can impair the blood supply of vertebral and intervertebral disks. Retropharyngeal abscess (RPA) is usually observed in children younger than five-year-old . RPA in Α 77-year-old male presented at the emergency department of a provincial hospital complaining of dysphagia, hoarseness, neck and lumbar pain. He had chills and fever up to 39°C. His laboratory tests revealed white blood cell count: 12.360 Κ/μL and C-reactive protein: 80.8 mg/L. His past medical history was free. He denied any trauma or foreign body ingestion. Clinical examination was unremarkable and chest X-ray had no findings. There was no breathing impairment or palpable neck masses. He was admitted and treated under broad-spectrum antibiotics.A CT scan was performed that revealed an RPA that was drained intraorally under local anaesthesia.The following days his symptoms had partially improved but neck and lumbar pain persisted. The patient was still febrile and it was decided to transport him to our department after 10 days of hospitalisation. Clinical examination revealed pyorrhoea from the posterior pharyngeal wall. Daily drainage was performed with no improvement and it was decided to resume imaging tests.CT scan revealed RPA with an epidural abscess in the cervical segment of the spine, distorted cervical vertebral anatomy and thrombosis of the left jugular vein Figure .MRI scan revealed cervical osteomyelitis involving the second and third vertebral bodies, prevertebral and epidural abscess with spinal cord compression. Spinal stenosis in C5/6 segment was also observed Figure .The possibility of injury from foreign body and tuberculosis was excluded by clinical examination, imaging and lab tests.Neurosurgical and orthopaedic assessment recommended conservative treatment as far as there was no neurological involvement.The patient continued his treatment with antibiotics, low molecular-weight heparin (LMWH), analgesia and hydration. Instructions for using soft cervical collar and bed rest were given. Drainage of the RPA was performed daily under local anaesthesia. Pus was sent for cultures that were positive for Staphylococcus aureus. Follow-up imaging with MRI and laboratory tests showed improvement Figure .He was discharged on day-42, after six weeks of hospitalisation and combination of IV and oral antibiotics for four months.RPA occurs most frequently in children younger than six years old, due to retropharyngeal space lymph node degeneration after adolescence. In adults, cases have been reported in patients with immunodeficiency such as diabetes mellitus, HIV infection, patients undergoing hemodialysis or related to trauma and foreign bodies ,5. Our pEarly diagnosis of RPA is crucial as it can affect neighbouring structures and can lead to airway obstruction, sepsis, suppurative mediastinitis, aspiration pneumonia, empyema or carotid artery erosion . ThromboThe incidence of RPA associated with epidural space abscess is very rare .A pathophysiological mechanism for trauma-related cases has been proposed .In non-traumatic cases, the definitive mechanism is unclear. Spontaneous RPA can develop from bacteria infection spread of adjacent structures of upper aerodigestive track like tonsils, nasopharynx and sinuses. Local inflammatory process and microthrombosis formation can impair the blood supply of vertebral and intervertebral disks. Bone and disk ischemic necrosis and the direct action of bacteria proteolytic enzymes can lead to destruction, deformity and epidural abscess formation. Many authors have reported such cases as a result of bacteria “seeding” in the course of systemic infections originating from genitourinary tract, skin, soft tissues, respiratory tract, gastrointestinal tract, oral cavity and endocarditis . StaphylDiagnostic tests to evaluate vertebral osteomyelitis include CT, contrast MRI and CT-guided biopsy from the vertebral lesion for cultures. Although CT scan is useful describing bone lesions and early destruction of the discs, MRI is the method of choice for diagnosis and follow-up with 96% sensitivity and 92% specificity. Furthermore, it is more accurate in the differential diagnosis of infectious lesions caused by neoplastic and degenerative lesions of the spine, identifying tissue inflammation and spinal cord compression [Epidural abscesses in cervical spondylodiscitis can cause severe and rapidly worsening neurological symptoms . SeveralRPA complicated by cervical spondylodiscitis and an epidural abscess is a rare entity. RPA can involve the cervical spine and disk segments in the development of the disease therefore, one should keep a high suspicious index. “Hematogenous path” is the closest description and a proposal pathophysiological mechanism for intraspinal involvement in non-traumatic RPA cases. Treatment requires daily drainage and IV antibiotics for several months. MRI scanning is recommended for early diagnosis and follow up. Bacterial cultures should define the choice of antibiotic treatment. Orthopaedic or neurosurgical intervention is needed when symptoms from cervical spine develop.


Giant cell tumor of bone (GCTB) is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic tumor. In this article, we present a case of a 26-year-old woman who presented with swelling at the left lower ribs during pregnancy. Surgical excision was done, and histopathology showed tumor with features consistent with GCTB. MRI preformed after delivery revealed recurrence of the mass with extensive growth reaching 17 cm with two subcutaneous satellite nodules in the adjacent abdominal wall. positron emission tomography-computed tomography (PET-CT) scan revealed bilateral fluorodeoxyglucose (FDG)-avid lung nodules. Surgical resection was done, and histopathology showed no evidence of malignant transformation. Few months later, the tumor recurred again, with peritoneal deposits. The patient underwent wide massive resection of the recurrent mass and then started on denosumab therapy. Molecular analysis of the tumor detected H3F3A G34W mutation with no copy number alterations. We are presenting this case of GCTB with pulmonary distant metastasis and extrapulmonary seeding to upsurge awareness among clinicians about the possible extreme aggressive biological behavior of GCTB that can mimic the presentation of malignant bone tumor and also to discuss the possible predictive factors of such aggressive behavior. The tumor arises most commonly from the epiphysis of long bones. It has wide biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic bone tumor.2 Metastasis occurs in approximately 2% to 5% of cases, most commonly to the lungs.3 In this article, we present an unusual case of conventional GCTB with an aggressive clinical course mimicking the behavior of malignant bone tumor. The tumor underwent rapid progression and growth during pregnancy, exhibited aggressive behavior in the form of multiple recurrences with cutaneous and peritoneal seeding along with distant metastasis to the lungs.Giant cell tumor of bone (GCTB) is a benign locally aggressive bone tumor that has a capacity to metastasize. It accounts for approximately 5% of all primary bone tumors.A 26-year-old Sudanese woman presented to a private hospital with painless swelling at the left lower ribs for 6 months' duration that showed rapid increase in size over the last 3 weeks before her presentation. She was 16 weeks pregnant at that time. Ultrasonography showed a well-defined complex mass at the left anterolateral costal margin measuring 2 × 1 × 1.4 cm. Fine needle aspiration done at the private institute showed atypical cells, followed by an unplanned excision done under local anesthesia 1 month later.Review of the paraffin blocks and hematoxylin and eosin–stained slides at the pathology department of our facility revealed multiple fragments of tumor composed of mononuclear stromal cells with abundant large osteoclast-type multinucleated giant cells. The tumor was extending to the adjacent soft tissue and skeletal muscle. There was no evidence of marked atypia, necrosis, or atypical mitotic figures. The morphological and radiological features were consistent with GCTB. The patient was then referred to our facility for more advanced care.Two months after the initial procedure, clinical follow-up revealed reappearance of soft-tissue mass at the site of surgery. Ultrasonographic examination confirmed the presence of a heterogeneous lesion measuring 7.4 × 4.2 cm at the site of surgery involving the left 11th rib with increased vascularity on Doppler examination. The decision by the bone tumor multidisciplinary team was to closely follow the patient up clinically, with imaging studies to be postponed after delivery of the baby. After the birth of her child, CT and MRI of the thorax were done and showed a large heterogeneous soft-tissue mass measuring 17 × 12 × 8 cm in the left side of the chest arising from and destructing the 11th rib with intra-abdominal extension to the left side of the peritoneum, compressing the lower half of left kidney and displacing the bowel loop medially. Two small nodules were seen in the adjacent abdominal wall measuring 8 mm and 12 mm. The overall picture was suggestive of a local recurrence of the tumor which was confirmed by histopathologic examination of the ultrasound-guided biopsy taken from the lesion.PET-CT scan examination confirmed the presence of hypermetabolic large mass centered on the left lower chest wall along with peritoneal involvement and bilateral FDG-avid lung nodules consistent with lung involvement Figure . CompletFour months after this procedure, another recurrence of the tumor occurred. The patient started to feel pain at the surgical site radiating to the lower abdomen. Examination revealed palpable mobile hard mass at the surgical bed. MRI confirmed the presence of multiple variable sized large intra-abdominal and retroperitoneal soft-tissue lesions, denoting recurrence of the tumor.PET-CT scan confirmed the presence of multiple peritoneal and abdominal wall lesions on the left with perihepatic peritoneal lesion on the right as well. The previously seen lung involvements showed increasing size and uptake. Ultrasound-guided biopsy from the recurrent lesion was done to rule any malignant transformation. However, no features of malignancy were noted.Considering the atypical and very aggressive clinical behavior of the tumor, it was sent for DNA methylation study. Molecular testing was done on genomic DNA extracted from the tumor in formalin-fixed paraffin embedded tissue to detect hotspot mutations in the H3.1 gene (Hist1H3A and Hist1H3B). H3F3A G34W mutation was detected, but no copy number alterations were found.The patient had another pregnancy, and rapid progression of the tumor was noticed. She travelled to another medical facility where she had termination of her pregnancy followed by wide massive resection of the left retroperitoneal local recurrence together with partial resection of left diaphragmatic copula, left-sided hemicolectomy with end-to-end transversosegmoidostomy, and extensive resection of the abdominal wall with mesh reconstruction.Clinical and radiological follow-up of the patient (6 months after the latest procedure) showed no evidence of local recurrence and a stable course of the lung nodules. The patient was on denosumab for 3 months after the last surgery, and the latest PET-CT scan did not reveal any recurrence or change in the size of lung nodules. She is now on regular follow-up.1 It is slightly more common in females and occurs most commonly in ages between 20 and 40 years. It has a major preference for the epiphysis of the long bones . The tumor is locally aggressive with high rate of local recurrence. Distant metastasis can occur in up to 5% of cases, most commonly to the lungs.3 There are isolated case reports of metastasis to other sites such as lymph nodes, bone, skin, and breast.45678GCTB is a locally aggressive primary bone neoplasm that accounts for about 5% of all primary bone tumors.The tumor is characterized morphologically by proliferation of mononuclear stromal cells which comprise the neoplastic component of the tumor admixed with numerous osteoclast-like multinucleated giant cells. The multinucleated giant cells can be very large with up to 100 nuclei and have even distribution. A variable number of mitotic figures can be seen; however, the presence of atypical forms suggests malignancy.10 Kim et al10 reported a rare case of GCTB involving the metacarpal bone with rapid growth during pregnancy. We have done immunohistochemical stains for hormonal receptors including estrogen receptor and progesterone receptor, which may explain the rapid growth of these tumors in pregnancy if they are overexpressed. Estrogen receptor was negative, but progesterone receptor showed focal weak nuclear staining in our case.Our case is unusual in many aspects. First, the patient was diagnosed with GCTB for the first time during pregnancy, when she presented with a mass arising from the left 11th rib. The tumor was initially small measuring 2 cm in maximum dimension. Unplanned excision under local anesthesia was done. Two months later, clinical examination revealed reappearance of soft-tissue mass at the site of surgery, and ultrasonographic examination confirmed the presence of a mass measuring 7.4 × 4.2 cm. This is mostly a progressively growing residual tumor that was not completely excised at the initial procedure especially that the procedure was done under local anesthesia. MRI done after delivery revealed a huge mass measuring 17 cm in maximum dimension at the same location. The rapid progression of GCTB in pregnancy is well established in the literature.8 The tumor in our case was arising from the left 11th rib. Pulmonary metastasis was detected for the first time by PET-CT scan done after delivery after the first recurrence of the tumor.Second, the patient also developed bilateral multiple lung nodules demonstrated by PET-CT scan that was done after delivery. The nodules have radiological features consistent with metastatic GCTB. Metastasis occurs rarely in GCTB, and it most commonly develops in the lungs. The factors that contribute to increase risk of metastasis in GCTB may include the primary site of the tumor, history of multiple local recurrences, and modality of treatment of the primary tumor.11 In our case, no atypical mitotic figures, marked nuclear atypia, or any features of malignant transformation were noted in all recurrences.In our experience, there are no morphological features that can predict the clinical behavior of GCTB. We did extensive sampling to rule out the possibility of malignant transformation, which can occur rarely in GCTB, and may explain the aggressive clinical course in our case. Primary malignancy in GCTB is seen at initial diagnosis as an area of high-grade sarcoma within an otherwise conventional GCTB. In secondary malignant GCTB, a high-grade sarcoma arises subsequent to previous radiation or surgical treatment, and the pre-existing GCTB is not always evident anymore.Moreover, our patient developed two subcutaneous skin nodules over the abdomen after the first recurrence. Histopathologic examination revealed that those nodules have the same morphological appearance of the main tumor; therefore, they are regarded as local cutaneous tumor seeding after the initial surgery. No features of malignant transformation were identified in the skin deposits as well.13 H3F3A mutational testing may be a useful adjunct to differentiate GCTB from giant cell-rich sarcomas. Although the presence of H3F3A mutations does not exclude with certainty a diagnosis of sarcoma, the possibility of a malignant evolution of GCTB should also be considered.11 No copy number alterations were detected in our case.The aggressive clinical behavior of the tumor in the terms of multiple local recurrences along with regional seeding and distant metastasis as well as the rapid progression encouraged us to send it for molecular analysis. H3F3A G34W mutation, which is a characteristic feature of conventional benign GCTB, was detected. This mutation can be found in more than 90% of cases of conventional GCTB.14The treatment choices of GCTB are essentially curettage with adjuvants is reasonable depending on the extent of the soft-tissue component. If initially inoperable, neoadjuvant systemic targeted therapy may facilitate intralesional surgery at a later stage. Recently, denosumab has become a new treatment option for locally advanced GCTB. Denosumab is an inhibitor for receptor activator of nuclear factor kappa-Β ligand that blocks osteoclast maturation. It remains unknown whether local recurrence rate will be affected by denosumab treatment.In summary, we are reporting an unusual case of conventional GCTB that underwent rapid progression and growth during pregnancy, exhibited aggressive behavior in the form of multiple recurrences with regional cutaneous and peritoneal seeding and distant metastasis to lungs, mimicking the behavior of malignant bone tumor. The patient life quality was affected by the consequences of this aggressive tumor as she had to terminate her second pregnancy. There were no histological features of malignant transformation. In our experience, the histomorphological and radiological features alone cannot predict the clinical behavior of these tumors. It is not clear whether the genotype and molecular alterations of this tumor can predict the biological behavior, and further study and research should be pursued.


Primary malignant pericardial mesothelioma is a rare tumor that is very difficult to diagnose. Furthermore, it is a lethal disease, because patients usually have progressed at the time of referral.We report a 44-year-old man with primary malignant pericardial mesothelioma. He was referred to our hospital for the diagnosis and treatment of a massive pericardial effusion and huge tumor. Pericardiocentesis was performed, but we could not obtain definitive diagnosis, and the cardiac tamponade continued along with the signs/symptoms. He required surgical intervention for the diagnosis and treatment. After surgery, his signs/symptoms improved. He received adjuvant therapy, although he died 7 months after surgery.Primary malignant pericardial mesothelioma is a rare tumor. The most common signs and symptoms are related to constriction of the heart by the tumor and/or effusion. Even if the pericardial fluid specimen obtained by pericardiocentesis is negative for malignant cells, primary malignant pericardial mesothelioma should be included in the differential diagnosis. Because the malignancy is usually advanced at the time of diagnosis, it has been difficult to cure. Radiation and chemotherapy have been used in addition to surgery, but have been minimally effective.The outcome of our patient with pericardial malignant mesothelioma was dismal. The indications for surgical intervention should be carefully considered except for critical cases requiring alleviation of immediate life-threating conditions. The treatment options are limited because of its rapid growth. Surgical treatment can be curative if the tumor is completely resected ,2. Howev2The patient was a 44-year-old man who had gone to a regional hospital with worsening dyspnea on exertion and lower extremity edema approximately 2 months prior to admission. He was referred to our hospital for diagnosis and treatment. The patient did not have an obvious history of occupational or incidental exposure to asbestos. The physical examination at admission revealed jugular distension and lower extremity edema. His blood pressure was 120/58 mm Hg and heart rate was 120 beats/min. Transthoracic echocardiography and computed tomography showed massive pericardial effusion, with a maximum diameter of 53 mm at the apex of the pericardial sac and a large tumor (95 × 99 mm in diameter) occupying the lateral to posterior pericardial space A, B. The3PMPM is rare. Its prevalence in a large autopsy study was less than 0.0022% , althougThe relationship between PMPM and asbestos exposure is unclear ,7. PMPM According to the World Health Organization classification, there are 3 histological types of malignant mesothelioma, as follows: epithelioid, sarcomatoid, and biphasic . EpithelComplete resection of the tumor is the only curative treatment ,2. BecauThe survival of patients with PMPM has been very poor. The mean or median survival time from the first disease manifestations has been reported to range from 3.5 to 9 months ,6,7. OurIn summary, because the prognosis of PMPM is very poor, the indications for surgical treatment should be carefully considered, except for critical cases presenting with pericardial constriction or suppression of cardiac function by the tumor.No authors have any conflict of interest.No funding was receivedEthical approval was not required for this case report in our institution.The patient provided written, informed consent to the publication of this case report.Dr. Shigefumi Matsuyama ― corresponding author; reviewing patient notes, writing articles, analysing images, approving final submission.Dr. Masateru Uchiyama ― revising article and collecting the data and images.Dr. Hiroo Ota ― carrying out the research and collecting the data and images.Dr. Mitsuru Iida ― revising article and collecting the data and images.Dr. Tomohiro Imazuru ― revising article and collecting the data and images.Dr. Tomoki Shimokawa ― major contributing in writing the article and approving final submission.Not applicable .Dr. Shigefumi Matsuyama.Not commissioned, externally peer-reviewed.


Spontaneous splenic rupture is a rare but potentially life-threatening condition. More common infectious causes include infectious mononucleosis, cytomegalovirus (CMV), human immunodeficiency virus (HIV), and malaria. We present a case of a 42-year-old male who was admitted with persistent fevers, myalgia, and a recent ulcerative lesion on the base of his left thumb after a cat bite. He developed abdominal and back pains, left axillary lymphadenopathy, and near syncope. Abdominal computed tomography (CT) scan showed splenomegaly with subcapsular splenic rupture and large hematoma requiring emergent splenic embolization. Infectious work-up revealed tularemia as a cause which was successfully treated with oral doxycycline. Though not a common cat zoonoses, tularemia should be considered in a patient with splenomegaly or spontaneous splenic rupture in the setting of cat bite. Splenic rupture is an uncommon occurrence in the absence of trauma. It is potentially life-threatening and often challenged by a delay in diagnosis . Common oF and generalized body aches. He was treated with a course of amoxicillin/clavulanic acid, but within one week he returned to the clinic for soreness in his left arm, axillary lymphadenopathy, and a small ulcer at the base of his left thumb. Surface swabs of the ulcer were sent for culture but ultimately finalized with no growth. The patient was then treated with a course of trimethoprim/sulfamethoxazole, but symptoms progressed to include recurrent fevers, myalgia, mild abdominal pain, and constipation. His regimen was transitioned to doxycycline but was hospitalized after having a near syncopal event.A 42-year-old male with a past medical history of type II diabetes was admitted with left shoulder pain, abdominal and back pain, and a near syncopal event. Approximately one month prior to hospitalization, the patient was in his typical state of health when he sustained a cat bite at the base of his left thumb. He later developed a fever of 102.7oF, heart rate 97 bpm, blood pressure 156/94 mmHg, respiratory rate of 21 breaths/minute on room air. Initial laboratory findings are summarized below , and HIV were negative. Serology for endemic fungal infections including In this paper, we present a case of a 42-year-old male with atraumatic spontaneous splenic rupture as a complication of tularemia. This case adds another infectious agent that can be associated with spontaneous splenic rupture.  Bartonella henselae is well documented in the literature to present with splenic involvement as a complication [The etiology of spontaneous splenic rupture can be categorized into six main categories including neoplastic, infectious, inflammatory, drug-induced, mechanical, and idiopathic. Various infectious agents have been associated with spontaneous splenic rupture including EBV, HIV, Plasmodium species, Salmonella, and much more . Among tlication . Howeverlication . Our revFrancisella tularensis. It is an uncommon human pathogen most often associated with contact from either contaminated animal products or an insect or animal bite [In the United States, there are around 57 million domestic cats living in one-third of all households . Tularemmal bite . Clinicamal bite . The diamal bite .Francisella tularensis is not a common cat zoonoses. This case highlights the need for clinicians to broaden the differential diagnosis and include tularemia when evaluating patients with regional lymphadenopathy and splenic involvement following a cat bite.Spontaneous splenic rupture is a rare complication of tularemia. Additionally,


An accessory spleen (AS), a common condition, is usually located in the hilar region of the spleen. ASs are not often large; however, after splenectomy, the initially inactive AS may become reactive and hypertrophic. Therefore, an AS can be misdiagnosed as a neoplastic tumor and removed unnecessarily. An undiagnosed abdominal mass located in the spleen site in a patient who has had a splenectomy must be managed carefully. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) may provide useful information for the diagnosis, preventing unnecessary surgery.Herein, we report the case of a 38-year-old female with an enlargement of AS after splenectomy that was misdiagnosed as a primary tumor of the pancreas and managed by a nonessential surgery.An AS should be added to the differential diagnosis of a pancreatic tail tumor for patients with prior splenectomy in order to avoid nonessential surgery to ensure the patient’s safety. ASs are2A 38-year-old female underwent a medical check-up at our institution. The patient’s medical profile had no history of weight loss, anorexia, or weakness. She had had a splenectomy 20 years prior for traumatic splenic rupture. Laboratory tests, including complete blood count, liver function test, and alpha-fetoprotein levels, were within the normal range. An abdominal CT scan without contrast enhancement revealed the absence of a normal spleen, with a homogeneous mass situated at the site A and B. 3An AS is defined as ectopic splenic tissue that develops during embryonic growth . ASs areIn this case report, the patient had had a splenectomy many years prior. As the lesion was related to the tail of the pancreas, and due to lack of experience, the patient received an unnecessary surgery. The mistake was thought to be an exclusion of an AS in the preliminary diagnosis for a patient with prior splenectomy.4AS is a common congenital condition typically without severe symptoms. CT and MRI features of an AS are the same as those of the normal spleen. In patients who have had a splenectomy, ASs may be enlarged and can mimic a tumor. Clinician should take into consideration that for patients who have had a splenectomy, an AS must be included in the differential diagnosis of a pancreatic tail tumor in order to avoid nonessential surgery like that described in the present report.The authors report no declarations of interestThis research did not receive any specific grant from funding agencies in order to execute this case report.The study is exempt from ethical approval.Informed consent of patient was obtained.LTL and NMD contributed equally to this article as co-first authors. Conceptualization: LTL and NMD; data curation: Thieu-Thi TM and NMD; formal analysis: LTL and NMD; writing—original draft: Thieu-Thi TM and NMD; writing—review and editing: LTL, Thieu-Thi TM, and NMD; All authors have read and agreed to the published version of the manuscript.Not applicable.The Guarantor’s of this article was Nguyen Minh Duc.Not commissioned, externally peer-reviewed.Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.