Encephaloceles are the type of dysraphism in which a skull defect allows for herniation of meninges, with or without the inclusion of neural tissue, and are commonly associated with agenesis of the corpus callosum. Encephaloceles are classified as frontal, occipital, or parietal, with parietal cephaloceles, or vertex cephaloceles (VC), being the least common. Despite this, VCs present as the most common cause of a midline scalp mass, displaying complex venous and neural malformations commonly referred to as the “tip of the iceberg.” Atretic parietal encephaloceles (APC), a type of VC, are benign lesions arising from meningeal and vestigial tissue which have undergone fibrotic degeneration. As a result, prognosis will generally be better than other encephaloceles due to vestigial tissue involvement. Here, we report a neonate presenting with APC, corpus callosum agenesis, and a cingulate gyrus lesion, along with a sinus pericranii companion case for comparison. Birth defects affect nearly 3% of all neonates . While tEncephaloceles have been described as a form of dysraphism in which a skull defect allows for herniation of meninges, with or without the inclusion of neural tissue, and are commonly associated with agenesis of the corpus callosum . AlthougEncephaloceles are classified as frontal, occipital, or parietal, with each having further sub-distinction. Parietal cephaloceles, or vertex cephaloceles (VCs), account for 15-38% of all cephaloceles, making them the least common of all cephaloceles . DespiteAtretic parietal encephaloceles (APCs), found in 31% of all parietal encephaloceles, are benign lesions arising from meningeal and vestigial tissues which have undergone fibrotic degeneration . As a reA 22-hour-old female infant presented with a suspected encephalocele to the neonatal intensive care unit. The patient’s mother was a 39-year-old female with a past medical history significant for melanoma, status post excision with positive margins, and sentinel lymph node biopsy during the pregnancy. The mother was negative for typical congenital infections apart from unknown status of rubella and varicella. Five months prior to birth, a 7 mm posterior occipital encephalocele, along with a previously described Chiari malformation in the posterior fossa was noted on ultrasound. A subsequent fetal MRI was performed - a 3 mm T2-hyperintense lesion along the parietal scalp with no intracranial extension was noted and the Chiari malformation was not noted.The mother presented to labor and delivery for a scheduled cesarean section. Artificial rupture of membranes one minute prior to delivery with clear fluid was noted. The delivery course proceeded without complications. The neonate posted appearance, pulse, grimace, activity, and respiration (APGAR) scores of 9/9, at one minute and five minutes. The newborn’s head was wrapped in plastic wrap at site of protrusion on posterior scalp to keep the area moist. The patient was put on 10% dextrose IV, and oral sucrose. The patient’s total fluid intake was 58.8 mL and output was 45 mL.The patients’ vitals were stable, and physical examination showed the infant was awake in the incubator in no acute distress. A 1 cm protrusion was noted on the posterior aspect of the crown of the head with no breaks in the skin. A small indentation in the skull could be palpated immediately anterior to the protrusion, which was soft but full to palpation with no erythema. The remainder of the physical examination was normal.9/L, and platelets were greater than 164 x 109/L. On non-contrast CT and MRI, an atretic parietal cephalocele, as well as dysplasia involving the corpus callosum and both cingulate gyri, was seen. Magnetic resonance angiography was within normal limits. Magnetic resonance venography showed findings consistent with atretic parietal cephalocele, with no thrombosis. No surgery was planned. The patient was to be discharged when tolerating full feeds with a stable temperature in an open crib. Follow-up with neurosurgery to monitor the encephalocele and ventricular size were recommended. The parents were advised to avoid trauma to the scalp and to protect the region.Lab results were normal with exceptions of hemoglobin, elevated at 20.5 g/dL, white blood cell count at 18.33 x 10An MRI performed in the hospital with and without IV gadolinium contrast revealed a small cystic-appearing structure within the parietal scalp just at the midline, adjacent to the posterior fontanelle. The cyst measured approximately 0.7 x 0.4 x 1.0 cm in size. A cerebrospinal fluid (CSF) tract connecting this cystic structure with the intracranial CSF space, along with a primitive falcine vein and superior beaking of the posterior tentorium was seen  often associated with APC . SP is aThough diagnostic imaging can help differentiate the two, interestingly, SP and APC can occur together and are believed to be associated . As aforA common diagnostic sign of APCs is fenestration of the sagittal sinus underneath the scalp lesion. This fenestration correlates with the CSF tract seen leading to the cephalocele and its fibrous stalk . OftentiDuring the 11th and 12th weeks of fetal development, the straight sinus can be observed in its vertical orientation. From here, the transverse sinus continues to enlarge. By the 19th week, the mass effect of the telencephalon combined with transverse sinus enlargement displaces the meningeal layers further into the developing hindbrain, causing gradual descent of the straight sinus into its adult horizontal orientation Figure  14]. In. In14]. This theory establishes that the fibrous stalk must have formed before the 19th week of fetal development, possibly the 11th or 12th week, when the straight sinus is first observed in its vertical orientation . AdditioOf note, in our patient, an occipital encephalocele and a previously described Chiari malformation were both seen during a 20-week prenatal ultrasound evaluation, both of which regressed upon follow-up. This course of apparent malformation and regression may be explained by the orientation of the straight sinus and the hypoechoic space created by its venous content. This may represent an additional consideration when assessing fetal growth via ultrasound.In our patient, we see a cystic structure in the midline parietal region of the scalp with a connecting CSF tract. The cystic structure was identified as an APC due to its midline parietal location and the characteristic venous findings of vertically oriented straight sinus, vertically oriented primitive falcine vein, and superior beaking of the posterior tentorium . Each ofEncephaloceles arise from a defect in the skull that allows for meningeal herniation that may or may not contain neural tissue. The etiology is not well understood, though it is regarded as a post-neurulation defect. Encephaloceles can be classified by location , with the least common presentation being parietal. APCs are benign lesions that arise in the parietal midline. They occur due to partial neural tube closure failure, and they arise from meningeal and vestigial tissue following fibrotic degradation. In our case, we have a patient who presented with a midline parietal scalp lesion, vertically oriented straight sinus, and primitive falcine vein along with superior beaking of the tentorium, all characteristic signs of APCs. Our patient also presented with occipital encephalocele and Chiari malformation, which were both seen at a 20-week prenatal ultrasound, though this ultimately regressed. Although further investigation is required, the findings of this case may shed light on the development of APCs and relationships between origin of the defects and characteristic venous findings commonly seen in APCs. The information gathered may aid in early clinical diagnosis that can give clinicians the ability to make decisions regarding treatment of these defects early on in prenatal care. In cases such as these, further imaging studies may also allow for the prompt delivery of advanced medical management from neurosurgery teams and other specialists that may improve morbidity and mortality among these types of defects.


Ovarian dysgerminoma, a subtype of malignant germ cell tumor (GCT), is a rare ovarian neoplasm that is infrequently found in the gravid patient. When dysgerminomas do occur in pregnancy, the rapidly growing tumors can have a heterogeneous presentation and lead to peripartum complications and morbidity. Due to the rarity of this condition, diagnostic and therapeutic strategies are not well described in the literature.A healthy multigravida with an uncomplicated antenatal history presented for elective induction of labor. She had a protracted labor course, persistently abnormal cervical examinations, and eventually developed a worsening Category II tracing that prompted cesarean birth. Intraoperatively, a 26 cm pelvic mass later identified as a Stage IA dysgerminoma was discovered along with a massive hemoperitoneum. The mass was successfully resected, and the patient remains without recurrence 6 months postoperatively.Although rare and generally indolent, dysgerminomas can grow rapidly and cause mechanical obstruction of labor and other complications in pregnancy. Pelvic masses, including malignant neoplasms, should be included in as part of a broad differential diagnosis when evaluating even routine intrapartum complications such as abnormal labor progression. Additionally, we demonstrate that adnexal masses can be a source of life-threatening intraabdominal hemorrhage. Malignant ovarian neoplasms rarely occur during pregnancy, with an estimated incidence of 2.8–11 per 100,000 pregnancies . DysgermA previously healthy Caucasian 32-year-old gravida two, para one was admitted to our obstetrics service at 40 weeks gestational age (GA) for elective induction of labor. Her pregnancy was complicated by mild anemia diagnosed in the second trimester, chronic constipation that worsened around 36 weeks GA, and excessive weight gain of 17.3 kg . Her medical, obstetrical, gynecological and surgical history were non-contributory.She underwent a transabdominal ultrasound (TAUS) at 9w1d GA that showed fetal growth consistent with GA. Both ovaries were visualized and determined to be normal appearing with a post-ovulatory-appearing right ovary Fig. . Her pal9 /L. Cervical exam was extremely difficult initially, with the cervix located anterior and shifted toward the patient’s left. Fetal station was −2. Her induction began with vaginal misoprostol followed by mechanical dilation with a Foley balloon. After Foley expulsion, the fetal station persisted at −2 despite a uterine contraction frequency of 1–3 min. An epidural catheter was placed for neuraxial anesthesia. Artificial rupture of membranes was deemed inappropriate due to disengagement of the fetal head. Intravenous (IV) Pitocin was initiated around 15 h after admission. Soon after initiation of oxytocin, she developed a fever (Tmax 38.0 °C), right upper quadrant pain, as well as an intermittent Category II FHT with late decelerations. An evaluation for fever of unknown origin was initiated. Lab studies were obtained at this time and notable for large blood on urinalysis, 51–100 white blood cells on urine microscopy, hemoglobin of 7.8 g/dL and platelet count of 118 × 10^9 /L. Lactate dehydrogenase (LDH), which was obtained due to concern for atypical HELLP syndrome , was markedly elevated at 1518 U/L. AST was 78 U/L, and total bilirubin was normal at 0.3 mg/dL. In addition to atypical HELLP syndrome, urinary tract infection (UTI) and chorioamnionitis were considered as diagnoses. One dose of ceftriaxone was administered for suspected UTI before the decision was made to broaden antimicrobial coverage to ampicillin and gentamicin such that any possible intraamniotic infection was treated.On admission, the patient was well-appearing with normal vital signs. Fetal heart tracing (FHT) was reactive. Lab studies obtained on admission were notable for a hemoglobin of 8.6 g/dL and platelet count of 131 × 10At hour 25 of induction, a bedside TAUS was performed due to the unusual and unchanged cervical examination characteristics. It demonstrated a fetus in cephalic presentation as well as a poorly defined mass in the posterior cul-de-sac without flow on color Doppler imaging. The differential diagnosis was broadened to include adnexal mass, cervical fibroid or stool from ongoing constipation. At this point, the FHT deteriorated to persistent Category II with repetitive late decelerations and moderate variability with a normal baseline Fig. , necessiA primary cesarean delivery via Pfannenstiel incision was performed resulting in the delivery of a vigorous female infant with a weight of 3030 g. Hemoperitoneum was identified upon abdominal entry. After delivery of the placenta and hysterotomy closure, uterine atony was noted requiring the use of multiple uterotonic agents. Once uterine hemostasis was achieved, the pelvis was explored.Arising from the right ovary was a solid fibrous mass with associated bleeding from a vascular pedicle. A gynecologic oncologist was enlisted for the procedure. The patient was placed under general anesthesia and an abdomino-pelvic survey was performed. There were no visual signs of metastatic disease on the pelvic peritoneum, viscera, or infracolic omentum and no palpable masses in the upper abdomen. A right salpingo-oophorectomy was then performed as well as biopsies of the posterior cul-de-sac and left ovarian surface. Given the limited availability of frozen pathology, concern for provoking disseminated intravascular coagulopathy, and the uncertain nature of the mass, the procedure was then concluded. Specimens were sent for permanent pathology. The patient’s quantitative blood loss was 4.3 L by the conclusion of the procedure, with 1.5 L attributed to preexisting hemoperitoneum and 2.8 L due to bleeding from uterine atony and continued bleeding from the vascular pedicle of the tumor. She received two units of packed red blood cells (PRBC) intraoperatively. Massive transfusion protocol was not initiated as bedside point-of-care hemoglobin measurements and serial intraoperative measures of prothrombin time, activated partial thromboplastin time, and fibrinogen remained stable.Postoperatively, the patient was placed on ampicillin, gentamicin, and clindamycin for 24 h given her previous fever of unknown origin, and she remained afebrile for the rest of her hospital course. Postoperative alpha fetoprotein (AFP) and inhibin A and B were obtained and were within the reference range . She required a third unit of PRBCs on postoperative day one for symptomatic anemia but had an otherwise uncomplicated postoperative course. Her neonate suffered no apparent birth complications, and both were dismissed to home without prolonged hospitalization. She was subsequently evaluated in the outpatient setting for postpartum endometritis and was treated with oral amoxicillin/clavulanate.Final pathology of the mass demonstrated a 26 × 18 × 9 cm solid mass with histologic features consistent with a dysgerminoma Figs.  and 5. AHere we present a rare case of an ovarian dysgerminoma incidentally discovered at the time of delivery. While other case reports of similar entities exist dating back to the early twentieth century, our case serves as an interesting learning point for several reasons: our patient had adequate prenatal care and imaging documenting a normal appearing right ovary in the first trimester, suggesting that this tumor developed de novo antepartum; she remained asymptomatic from the massive tumor through most of her pregnancy; she had a labor dystocia that is most likely attributable to mass effect or incarceration of the tumor; and she developed a clinically significant hemoperitoneum as a result of trauma to the vascular supply to the mass.Reproductive age women tend to be at relatively higher risk for germ cell tumors, both benign and malignant. Dysgerminomas, a subtype of malignant germ cell tumor, are one of the most uncommon ovarian neoplasms. The incidence is roughly 0.1–1 cases per 100,000 pregnancies , 9.Pregnancies associated with ovarian malignancies require balancing optimal maternal therapy and fetal well-being. In addition, cancer diagnosis may be delayed because of difficulties in distinguishing symptomatology from physiologic changes in pregnancy , 10. TheSonography is crucial in assessing adnexal masses in the first trimester. Technicians will routinely assess the adnexa for corpus luteal cysts, rare heterotopic pregnancy and ovarian and tubal pathology. The overall incidence of adnexal masses ranges from 2 to 10% in the first trimester . Most maOverall, the effects of pregnancy on dysgerminomas are not well studied. Similar to other adnexal masses, there is increased risk of torsion, incarceration, rupture and hemorrhage that can occur during pregnancy. Intrauterine growth restriction was the most commonly identified adverse fetal outcome in one case series . Our casAn additional uncommon sequela in this patient was large volume hemoperitoneum discovered at the time of delivery. Hemoperitoneum stemming from a dysgerminoma, such as was observed in this case, has yet to be described in the literature. However, clinically significant hemorrhage from other adnexal masses has been described , 18, usuDysgerminomas are known to be rapidly growing, and there have been several reports documenting the development of large ovarian germ cell tumors during pregnancy in women with normal first trimester physical exams , 8, 19. Ideally, management of suspected adnexal masses in pregnancy includes observation with surveillance via ultrasound at every trimester and management post-delivery. Surgical intervention should be strongly considered if there are acute complications such as torsion or rupture or if there is a 30–50% size increase at any time during the pregnancy , 5, 12. Overall, a majority of woman diagnosed with ovarian tumors during pregnancy have favorable results with low grade or early stage disease. It is appropriate to consider fertility sparing surgery in these young women with conservation of the contralateral ovary. Overall five-year survival rates approach 96% if the tumor is confined to the ovary , 8, 19. This case demonstrates that dysgerminomas may develop de novo in pregnancy and be an unexpected cause of labor dystocia or other abnormal symptoms. Although rare, adnexal masses should be part of a broad differential diagnosis when faced with abnormal labor progress and symptoms. Prompt identification can lead to appropriate management with an overall favorable outcome.


Acute lower abdominal pain or pelvic pain is a common presenting complaint in women of reproductive age, which can be accounted for by numerous aetiologies. The presentation of lower abdominal pain with associated findings of an adnexal mass on transvaginal ultrasonography and positive beta-human chorionic gonadotropin (β-hCG) (serum and urine) in a sexually active woman of reproductive age is an ectopic pregnancy until proven otherwise. Here, we present a classic case suggestive of an unruptured ectopic pregnancy, with an unexpected finding of a unilateral dermoid cyst intraoperatively in a 33-year-old woman. Findings presented herein suggest that practitioners in our local setting should evaluate patients carefully, and consider neoplasms as a possible source of β-hCG production in sexually active women of reproductive age who present with subacute lower abdominal pain, identified adnexal mass on ultrasonography and positive serum or urine β-hCG readings. Chief amongst these aetiologies include the occurrence of ectopic pregnancy (EP) and the presence of an adnexal mass.2 Ectopic pregnancy refers to the implantation of a fertilised ovum outside the uterine cavity, of which the majority are located in the fallopian tubes;3 other locations include ovaries and the abdominal cavity. The estimated global incidence of EP is 1% – 2% of pregnancies,4 and it is considered to be one of the leading causes of maternal morbidity and mortality.5 In South Africa, EP is reported to occur in 11 of every 1000 reported pregnancies, with an estimated mortality rate of 2%.6 Ectopic pregnancy is the prime differential diagnosis in any woman of childbearing age presenting with positive beta-human chorionic gonadotropin (β-hCG) and an adnexal mass. However, it has been reported that certain neoplasms  can present with similar symptoms.7Acute lower abdominal pain or pelvic pain is a common presenting complaint in women of reproductive age, which can be accounted for by numerous aetiologies.9 accounting for up to 70% of benign ovarian masses during reproductive years, and 20% in postmenopausal women.11 Mature cystic teratoma is usually asymptomatic until it reaches a considerable size, and it manifests as an adnexal mass associated with abdominal heaviness, dull pain or acute abdominal pain (if the tumour undergoes torsion or rupture).12 Here, we present a classic case suggestive of an EP, but with the unexpected finding of a unilateral dermoid cyst intraoperatively, in a 33-year-old woman.Mature cystic teratoma (MCT) of the ovary or dermoid cyst is the most common (90%) germ cell tumour of the ovary,A 33-year-old woman presented at the emergency department of a district hospital at 18:35 with a 4-day history of lower abdominal pain radiating to the lower back. She reported no vomiting or any change in bowel habits. According to the patient, she had prior episodes of abnormal vaginal bleeding, which has since stopped. Her last normal menstrual period was 17 March 2018, which corresponds to a gestation of 7 weeks and 2 days; the patient had no history of prior or present use of any form of contraceptive. Her last confinement had been 5 years ago, and had culminated in an uneventful, normal vaginal delivery. No abnormal findings were made from the review of systems and the rest of the history.On examination, the patient was slightly anxious, with moderate discomfort resulting from her abdominal pain. She was well hydrated and not pale. Her vital signs were normal . Abdominal examination revealed right iliac fossa tenderness with guarding, and no rebound tenderness. No palpable mass or organs were present. Bowel sounds were normal. Vaginal examination revealed a closed, firm cervix without any palpable abnormality. Cervical excitation tenderness was present. A light-brown discharge was observed on the glove. No bleeding was observed. The rest of the systemic examination was normal. A bedside urine β-hCG test that was performed was positive and the transvaginal ultrasonography  revealed an empty uterus with a right ‘adnexal mass’ . No fluiBased on these findings, an initial assessment of unruptured EP was made. The patient was kept in the emergency department for close monitoring. At about 2 h post initial assessment (20:35), the patient’s condition was the same, with normal vital signs. Received laboratory reports revealed a haemoglobin level of 12.2 g/dL and a positive serum β-hCG, with a value of 4362 IU/L  . PatientIntraoperatively, a right ovarian mass, approximately 7 cm × 5 cm, was found . Both faPost-operatively, the patient’s recovery was uneventful, and she was discharged after 3 days. Her follow-up visit 2 weeks later was also uneventful.Permission to conduct the research was obtained from the head of the health facility and a written consent was obtained from the patient.13 The presence of the classical signs and symptoms suggestive of EP, thus, justify the pre-operative diagnosis of non-ruptured EP made in this index case. Similarly, a diagnostic exploratory laparotomy with a high suspicion for unruptured EP is reasonable, given the potential for fatality and as 50% of all ectopic pregnancies are asymptomatic.14 However, it is important for practitioners to be aware that positive β-hCG (serum and urine) can be observed in other malignant and non-malignant conditions.13The presentation of lower abdominal pain with associated findings of an adnexal mass on transvaginal ultrasonography and positive β-hCG (serum and urine) in a sexually active woman of reproductive age is an EP until proven otherwise.15 It affects a younger age group (mean patient age of 30 years),16 which corresponds with the age of the patient in the index case (33 years). The unilateral occurrence of MCT on the right ovary, as seen in the index case, corroborates prior findings that state that MCTs are mostly unilateral and occur more frequently on the right side (72.2%).17 Whilst most MCTs can be diagnosed with ultrasound, the ultrasound diagnosis is complicated by the fact that these tumours may have a variety of appearances.16 The three main pathognomonic ultrasound findings of MCT include a cystic lesion with a dense echogenic tubercle (Rokitansky nodule) projecting into the cyst lumen;18 a diffuse or partially echogenic mass with the echogenic area usually demonstrating sound attenuation owing to sebaceous material and hair within the cyst cavity;20 and multiple thin, echogenic bands caused by hair in the cyst cavity.16 The diagnosis of MCT on computed tomography and magnetic resonance imaging is fairly straightforward,21 however, these facilities are lacking in most rural district hospitals in South Africa and, indeed, Africa. In resource-poor settings, serial serum β-hCG assay can be used as a pointer to prompt the consideration of other differential diagnoses to EP, as opposed to doing a single assay, as in the index case. If β-hCG levels increase by less than 50% during a 48-h period, there is usually a non-viable pregnancy associated, whether intra- or extra-uterine.23 Ectopic pregnancy should be suspected when a β-hCG plateau is reached early in the pregnancy (i.e. before 9–11 weeks).23 Mature cystic teratoma can be associated with complications from rupture, malignant degeneration or (most commonly) torsion.16Mature cystic teratoma is the most common neoplasm of the ovary and it is composed of well-differentiated derivations from at least two of the three germ cell layers .In conclusion, careful evaluation of patients and consideration of neoplasms as a source of β-hCG production in the presence of subacute lower abdominal pain, and identified adnexal mass on ultrasound in sexually active women of reproductive age is essential in our local setting.


Abdominal examination revealed a palpable pelvic mass that was firm and non-tender. The patient underwent an abdominal computed tomography scan which demonstrated a well-defined oval-shaped homogeneous fat attenuation mass lesion within the uterine wall with no evidence of invasion. Such findings were suggestive of uterine lipoma. The patient underwent a total hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination of the specimen confirmed the diagnosis of pure lipoma. After six months of close follow-up, the patient had no active complaints. Pure uterine lipoma is an exceedingly rare benign neoplasm of the uterus. It may present with an abdominal mass and abnormal genital bleeding. Awareness of the clinical and radiological features of this tumor is crucial to avoid unnecessary surgeries in asymptomatic patients.Abnormal genital tract bleeding is a commonly encountered complaint in general practice. It has a wide range of etiologies and the spectrum depends on the reproductive status of the patient. While it represents a small proportion of genital tract bleeding, endometrial carcinoma is the main concern in postmenopausal women with abnormal genital bleeding. However, the majority of cases are due to benign etiologies. We present the case of a 65-year-old woman who presented to the outpatient department complaining of vaginal bleeding and lower abdominal pain for the last two months. The patient did not report any use of hormonal replacement therapy. Her last Pap smear was five years ago and it yielded no abnormal cells. On examination, the patient appeared obese with a body mass index of 35 kg/m Abnormal genital tract bleeding is a common presenting complaint in family medicine and gynecology clinics. The etiology of genital tract bleeding depends largely on the patient’s age and reproductive status . PostmenWe present the case of a 65-year-old woman who presented to the outpatient department complaining of vaginal bleeding for the last two months. She reported that the bleeding was small in amount and did not occur daily. The bleeding was associated with lower abdominal pain. The bleeding was not related to the sexual intercourse. She did not report any changes in her urinary or bowel habits. There was no history of anorexia, weight loss, or fever.The patient reached menopause at the age of 53 years. Her last Pap smear was five years ago and it yielded no abnormal cells. The patient did not report any use of hormonal replacement therapy. She was sexually active with her husband. The patient had three spontaneous vaginal deliveries with the last being 35 years ago. The past medical history was remarkable for asthma and glucose-6-phosphate dehydrogenase deficiency. She had no history of surgical procedures. She was a retired school teacher. She never smoked or consumed alcohol. Her family history was unremarkable.2. The vital signs were within the normal limits. Abdominal examination revealed a palpable pelvic mass that was firm and non-tender. The speculum examination showed a normal vagina and cervix. Digital rectal examination was normal. The hormonal analysis revealed a normal level of prolactin (10 ng/mL), thyroid-stimulating hormone (2.5 mU/L), and normal thyroid hormones levels. Further, a basic laboratory investigation revealed anemia with a hemoglobin level of 10.2 g/dL (Table On examination, the patient appeared obese with a body mass index of 35 kg/mrolactin 0 ng/mL, The patient underwent an abdominal computed tomography scan for better evaluation of the palpable lower abdominal mass. The scan demonstrated a well-defined oval-shaped homogeneous fat attenuation mass lesion within the uterine wall with no evidence of invasion. Such findings were suggestive of uterine lipoma Figure .The findings were discussed in the multidisciplinary oncology meeting. The decision for a total abdominal hysterectomy was planned. The patient agreed on having the surgery. Subsequently, the patient was prepared for a laparotomy operation. During exploration, the uterus was enlarged and the ovaries were atrophic. Total hysterectomy and bilateral salpingo-oophorectomy were performed. No complications occurred during the surgery. The skin incision was closed and the patient had an uneventful recovery. Histopathological examination of the uterus confirmed the diagnosis of pure uterine lipoma Figure .Postoperatively, the patient had complete resolution of the abdominal pain. She was discharged on the fourth postoperative day. After six months of close follow-up, the patient had no active complaints.We present the case of a postmenopausal woman with pure uterine lipoma that manifested as abnormal genital tract bleeding. Uterine lipoma is one of the lipomatous groups of tumors of the uterus that include pure lipoma, lipofibroma, angiomyolipoma, liposarcoma, and others. Such a group of tumors is uncommon with an incidence of less than 1 per 1,000 women . HoweverSeveral hypotheses have been suggested to provide an explanation for the development of uterine lipomatous tumors. The most widely accepted hypothesis proposes that such tumors arise as a result of metaplasia of the smooth muscles into adipose tissue . HoweverThe typical location of uterine lipoma is the corpus, as in the current case. However, the uterine lipoma may arise in the subserosal or submucosal location. Ultrasound examination and computed tomography scan may provide a clue to the diagnosis . MagnetiAs in the present case, uterine lipoma usually develops in postmenopausal women aged between 50 and 70 years . SurgicaPure uterine lipoma is an exceedingly rare benign neoplasm of the uterus. It may present with an abdominal mass and abnormal genital bleeding. Awareness of the clinical and radiological features of this tumor is crucial to avoid unnecessary surgeries in asymptomatic patients. However, surgical resection may be required in symptomatic patients with an excellent prognosis.


Combined hamartoma of the retina and retinal pigment epithelium is a rare benign ocular tumour in children, composed of glial cells, vascular tissue, and sheets of pigmented epithelial cells. Although generally thought to be congenital, acquired cases are known to exist. It usually presents with reduced visual acuity and/or strabismus and it can be associated with several syndromes, including Neurofibromatosis Type 2. There is no consensus on the management of combined hamartoma of the retina and retinal pigment epithelium.We present a case, including MRI features, of a 4,5-years-old girl with a combined hamartoma of the retina and retinal pigment epithelium. A 4,5-years-old girl was referred by her paediatrician for a brain MRI because of a new ocular motility disorder affecting her right eye. The girl has already been examined ophthalmologically from an early age because of a relative amblyopia of her right eye. At that time, she was diagnosed with Bergmeister’s papilla. Bergmeister’s papilla is a harmless variant of the papilla formed by a posterior remnant of the hyaloid artery presenting as an epipapillary membrane. The patient was otherwise healthy.T1W and T2W fs, axial T2W, coronal and axial post-contrast T1W fs). It revealed a plaque-shaped lesion immediately in front of the papilla of the right eye. The lesion was about 6 mm wide, wider than the width of the papilla, and less than 1 mm thick  was made .The radiological differential diagnosis of unilateral papillary or peripapillary mass or disk swelling in the first decade of life is broad and also includes the pathologies mentioned below:Optic nerve drusen: they are limited to the papilla and can calcify.Neoplasia: it is important to distinguish the benign CHR-RPE from malignant chorioretinal lesions, in particular retinoblastoma and choroidal melanoma, as misdiagnoses could lead to unnecessary enucleations. Retinoblastoma and melanoma are usually mass-like lesions and not plaque-shaped lesions and show contrast enhancement. Retinoblastoma generally shows calcifications in ultrasound.1Infiltrative pathologies: leukaemia is a common cause of infiltrative disease in children. Look for an abnormal signal of the bone marrow. Neurosarcoidosis presenting with optic nerve infiltration is very uncommon in children. Look for basilar meningitis, and/or pulmonary disease.1Optic neuritis: optic neuritis in prepubescents is usually bilateral. The most commonly identified cause of neuroretinitis in the first decade of life is Bartonella .Increased intracranial pressure: papilledema is usually bilateral. MRI can depict additional findings like widened perioptic spaces, flattened globe, or partially empty sella.2,3 Punctate foci of calcification have been reported in longstanding disease. Variations in the relative proportions of these components contribute to a heterogeneous clinical appearance. While classically thought to be congenital, there are reports of acquired cases.4 It was first described in 1973.CHR-RPE is a rare, benign, ocular tumour of the retina and retinal pigment epithelium. It consists of a proliferation of glial and vascular elements in combination with sheets of pigmented epithelial cells.5,6 It can occur in the macula (17%), juxtapapillary (76%), or in the peripheral retina (7%).7 Visual acuity varies with the location of the lesion. When located in the macula, it can cause significant vision loss.6 The majority of CHR-RPE occurs sporadically. However, it has been reported to occur in association with neurofibromatosis Types 1 and 2, tuberous sclerosis, Gorlin syndrome, branchio-oculo-facial syndrome, nasopharyngeal angiofibroma, and Poland syndrome.8–14 One author has even recommended to screen children with CHR-RPE for NF–2.CHR-RPE is almost always solitary and unilateral. It usually presents during childhood (median age 7.5 year) with reduced acuity (40%) and/or strabismus (28%).An ophthalmologist with paediatric experience will be able to diagnose a CHR-RPE. Because of its rarity and variable clinical appearance, misdiagnoses are common and include melanoma, retinoblastoma, Bergmeister’s papilla (as in our case), congenital hypertrophy of the RPE, or vascular anomaly. Early stages of this tumour can mimic disk swelling.The diagnosis cannot be made using radiological imaging alone. We believe that radiology is primarily useful to rule out other causes and to look for any findings of the above-mentioned associated syndromes that remain hidden from the ophthalmologist.15 Our patient received no treatment. An ophthalmologic check-up is planned every 3 months due to the associated strabismus. At the last routine check-up in July 2020, there was no change in the fundoscopic findings.There is no established consensus on the management of CHR-RPE. Surgical interventions (vitrectomy and membrane peeling) can be considered when the child is of amblyopic age, or when the visual acuity declines significantly. A visual improvement rate of 60% has been reported after surgery. Unfortunately, the epiretinal membrane often recurs and subsequent surgery tends to be increasingly less effective due to permanent architectural changes.CHR-RPE is a rare benign ocular tumour in children.CHR-RPE can occur in association with several syndromes, including neurofibromatosis Type 2.On MRI, it seems to be a plaque-shaped lesion, unlike the more mass-like retinoblastoma and melanoma.CHR-RPE is almost always unilateral, unlike papilledema.


Schistosomiasis is a parasitic infection that commonly affects the gastrointestinal and genitourinary tracts. Cerebral schistosomiasis is rare, and few operative cases have been reported in the literature. Diagnosis is usually challenging due to the similarity of the lesion to many other brain conditions. Treatment usually requires surgical resection combined with the use of antiparasitic agents, which often results in good outcomes and excellent prognosis.Schistosoma mansoni infection. Orally administered praziquantel was initiated at a dose of 20 mg/kg twice a day for a total of 3 days along with oral administration of corticosteroids for 2 weeks. The patient improved postoperatively without residual weakness and with no further convulsions.A 24-year-old, previously healthy Afro-asiatic man presented to our neurosurgical outpatient clinic complaining of headache and an attack of convulsions. On examination, he had bilateral lower limb weakness more on the right side. Laboratory investigations including stool and urine general test results were unremarkable. Magnetic resonance imaging of the brain was performed and showed an intra-axial left parietal mass; a granulomatous lesion was suggested in the differential diagnoses. The patient underwent craniotomy and total resection of the lesion. Histopathology confirmed the presence of active cerebral Cerebral schistosomiasis is a rare but important consideration in the list of differential diagnoses of cerebral space-occupying lesions. This is of particular importance in in endemic areas like Sudan. In order to reach a diagnosis, careful social and occupational history need to be obtained and correlated with the clinical, laboratory, and radiological findings. Surgical resection along with the use of proper antiparasitic agents usually provides the best clinical outcomes. Schistosoma japonicum [Schistosoma mansoni reported in the literature [Schistosomiasis is estimated to affect more than 200 million people worldwide, who are infected by contact with contaminated water . Centralaponicum , but theterature . We repoA 24-year-old, previously healthy Afro-asiatic man presented to our neurosurgical outpatient clinic complaining of headache for 3 months, which was followed by one attack of generalized tonic–clonic convulsions, which prompted him to seek medical advice. He reported no other associated signs or symptoms. Upon general examination, the patient looked unwell, but no pallor, jaundice, or cyanosis was observed. His vital signs were all within the normal range. On neurological examination, he was conscious, oriented to time, place, and person, with a Glasgow Coma Scale score of 15 out of 15 and normal papillary reaction and size bilaterally. The patient had power grade 4+ in both the upper and lower right limbs, with normal tone and reflexes in all joints. Systemic review was unremarkable. Laboratory investigations including stool and urine general test results were unremarkable, so no further cerebral spinal fluid analysis was pursued. Initial plain head computed tomography (CT) showed a focal area of high density within the left parietal region. An MRI of the brain was then performed and showed a fairly well-defined 1.8 × 1 cm lobulated, cortical-based intra-axial lesion within the left posterior parietal region. The lesion demonstrated homogeneous enhancement and had associated moderate perilesional vasogenic edema with only a mild localized mass effect. No other focal lesions were seen (Fig. Schistosoma mansoni ova with marked mixed inflammatory infiltrate composed of granulomas and eosinophils, all features consistent with active cerebral schistosomiasis (Fig. Magnetic resonance spectroscopy, although nonspecific, demonstrated a choline peak suggestive of cell membrane turnover that can be seen in a number of different conditions including neoplasms, demyelination, inflammation, and gliosis. Correlating this with the patient age and history, an inflammatory lesion was thought to be more likely Fig. . The patsis Fig. . Oral adsis Fig. . Marked Schistosoma japonicum the most common species affecting the human nervous system [It is estimated that more than 200 million people worldwide are infected with schistosomiasis after contact with contaminants . Five sps system . Contacts system . After ds system . This prs system . The eggs system . The cers system .Schistosoma japonicum commonly causing cerebral lesions, and Schistosoma mansoni and Schistosoma haematobium commonly causing spinal cord lesions. Schistosoma mansoni and Schistosoma haematobium are unusual causes of cerebral mass lesions [et al. reported four patients with cerebral Schistosoma mansoni infection and reviewed a few cases that were reported then in the literature [Schistosomiasis of the central nervous system occurs very rarely, with  lesions . Pittellterature .Schistosoma japonicum, but an increasing number of cases due to Schistosoma mansoni have been reported in the literature [Central nervous system manifestations are a result of the inflammatory response to egg deposition in the brain and spinal cord, and are usually seen in patients with recent infection with no evidence of systemic illness . Supra- terature , 6.Schistosomiasis of the spinal cord is a rare condition but is well reported in the literature, especially in sub-Saharan African countries, where several case reports and series have been published. Spinal cord schistosomiasis may present clinically by myelopathy, radiculopathy, or both .et al., where all patients underwent regular blood tests, serological investigations, and radiological examination, among which two underwent surgical intervention due to expansion of the lesion with no response to medical management [In Sudan, a case series was reported in which 5 of 200 patients with spinal cord compression were found to have schistosomiasis and underwent surgery and medical treatment, with excellent outcome; diagnosis of those who underwent surgery was confirmed only after histopathological examination . Anothernagement .Schistosoma japonicum eggs in the brain were first described by Tsunoda and Shimamura in 1906 [et al. reported two neurological cases of Schistosoma japonicum among 12 English sailors who went swimming in the Yangtze River [Operative cases of cerebral schistosomiasis are very unusual and have been reported in the literature on rare occasions.  in 1906 . In 1936ze River .Patients have been incorrectly diagnosed as having brain tumors, specifically gliomas, due to radiological findings consistent with glioma on CT and MRI . Heteroget al. reported what they called an arborized enhancement pattern with central linear enhancement, which may be significant for cerebral schistosomiasis [et al. concluded that diffusion-weighted MRI with apparent diffusion coefficient values may be a useful tool in the diagnosis of cerebral schistosomiasis [Sanelli somiasis . Huang esomiasis . A combisomiasis .Schistosoma infection is a challenging task. Kato-Katz thick-smear stool examination, which is the most practical laboratory examination for the investigation, can determine the presence of eggs in feces [ et al. reported the first case of cerebral schistosomiasis due to Schistosoma haematobium, which was diagnosed by molecular methods; polymerase chain reaction assay is a promising method for definitive diagnosis and species identification in cases of cerebral schistosomiasis when Schistosoma ova in urine or stool specimens can be identified [Diagnosis of cerebral in feces . Imai etentified . Histopaentified .Schistosoma subtypes [The therapeutic strategy in patients with new-onset seizures should be based on the type of seizures and on the epilepsy syndrome. Long-term antiepileptic drug treatment is typically not indicated . The tresubtypes .Surgical management of cerebral schistosomiasis is safe and highly effective in cases where the diagnostic laboratory and radiological findings are inconclusive, leading to difficulty in initiating appropriate medical management. Surgically, total resection of the lesion is the best choice for confirming diagnosis and alleviating symptoms. Medical treatment should be started after surgery and confirmed diagnosis; oxamniquine and praziquantel are effective antiparasitic drugs. These drugs, used alongside corticosteroids, kill the adult worms and reduce the granulomatous inflammation, respectively.


Echinococcus. The most prevalent and serious complication of hydatid disease is intrabiliary rupture, also known as cystobiliary fistulae. In this study, a sporadic case of biliary obstruction, cholangitis, and septicemia is described secondary to hydatid cyst rupture into the common bile duct and intraperitoneal cavity.Hydatid cysts are fluid-filled sacs containing immature forms of parastic tapeworms of the genus A 21-year-old Iranian man was admitted to the emergency ward with 5 days of serious sickness and a history of right upper quadrant abdominal pain, fatigue, fever, icterus, vomiting, and no appetite. In the physical examination, abdominal tenderness was detected in all four quadrants and in the scleral icterus. Abdominal ultrasound revealed intrahepatic and extrahepatic biliary duct dilation. Gallbladder wall thickening was normal but was very dilated, and large unilocular intact hepatic cysts were detected in segment IV and another one segment II which had detached laminated membranes and was a ruptured or complicated liver cyst.Intrabiliary perforation of the liver hydatid cyst is an infrequent event but has severe consequences. Therefore, when patients complain of abdominal pain, fever, peritonitis, decreased appetite, and jaundice, a differential diagnosis of hydatid disease needs to be taken into consideration. Early diagnosis of complications and aggressive treatments, such as endoscopic retrograde cholangiopancreatography and surgery, are vital. Hydatid disease, also known as echinococcosis, is a serious and problematic health issue worldwide, and this parasitic disease is widespread in most Mediterranean countries, West Asia, South America, the Far East, Australia, and East Africa –3. HumanImaging tools, such as ultrasonography (U/S), abdominal computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), are useful devices to diagnose the disease. U/S and CT scans are the first diagnostic tools of choice and can be applied under all conditions , 2. Of tA 21-year-old Iranian man presented to the emergency ward of our hospital with 5 days of illness and a history of right upper quadrant abdominal pain, fatigue, fever, icterus, vomiting, and no appetite. He was examined physically, and abdominal tenderness was detected in all four quadrants, and scleral icterus. His blood pressure was normal at 110.70 mmHg and oxygen saturation rate was of 95% on ambient air. Axillary temperature was 38.8 °C. His medical history showed that was being treated with albendasol 800 mg daily for months because of two hydatid cysts in the liver. One of the cysts was located on the dome of liver segment III and the second was on segment VII just over the right kidney  and elevated liver enzymes . The direct and indirect bilirubin measurements were 4 and 5 mg/dL, respectively, C-reactive protein concentration was 11 U/mL , and lipase was 180 IU/L. A prothrombin time of 42 s , activated partial thromboplastin time of 48 s , and international normalized ratio of 5  were also detected in the tests. The remaining laboratory test results were within normal limits. These test results show hepatitis due to albendazole toxicity.In addition to considering these test findings and the patient’s ailments, we also used abdominal U/S to arrive at the diagnosis. Abdominal U/S revealed intrahepatic and extrahepatic bile duct dilation; the gallbladder was dilated but had normal wall thickening. Large intact hepatic cysts were observed in segment IV and another one were in segment II with detached laminated membranes, possibly indicative of a ruptured or complicated liver cyst. An intravenous contrast CT scan was performed for more evaluation and revealed unilocular hepatic cysts with segregated laminated membranes that corresponded to hepatic hydatid cysts on segment II and other unilocular intact hepatic cysts on segment IV Fig. . FurtherThe reason for bile duct dilatation was investigated by MRCP, which showed the rupture of cysts of segment II into the intrahepatic ducts, common hepatic duct, and common biliary duct (CBD). In addition, laminated membranes of the hydatid cyst and daughter cysts were found in the CBD, causing the obstruction Fig. .The patient underwent laparotomy due peritonitis resulting from the rupture of the liver hydatid cyst in the abdominal cavity with a right extensive subcostal incision. During exploration, 500 cc bile fluid was aspirated from the abdominal cavity and sent for analysis. The pancreas was inflamed, and its appearance showed pancreatitis. The liver was carefully inspected; one collapsed infected cystic lesion with a small perforation was present in segment II just over the right kidney.Our approach for surgical treatment began with the aspiration and evacuation of the cyst contents. To explore for any purulent or bile contents, cystostomy and irrigation were performed. Also, fibrotic tissue around the cyst was resected and the site of bile leakage ligated with a non-absorbable suture. Capitonnage, omentoplasty, and insertion of a Foley catheter inside the incision were performed to remove the residual cyst and prevent recurrence. The gall bladder was highly dilated and was full of a white mucous fluid with obstruction of the cystic duct; choledocotomy and drainage of the common bile duct were performed with saline irrigation. Moreover, daughter cysts were removed from the common bile duct and intrabiliary ducts. At the end of the surgery, a T-tube was inserted in the site of choledocotomy and a corrugated drain was fixed. During exploration, another intact cyst was found in segment VII; this cyst was aspirated and the laminated membrane removed; the cavity was then irrigated with betadine 10%. Pricystectomy was performed, and a Foley catheter 18 was put into the remnant cavity and fixed to the abdominal wall. Finally, the CBD (diameter 30 mm) was examined; it was full of laminated membrane, daughter cysts, and debrides of the hydrated cyst. After extraction of all materials from the CBD and subsequent irrigation, a T-tube was placed in the CBD and fixed into place. A Penrose drain was placed in the abdominal cavity, and then the abdomen was closed.Three days after surgery, the levels of bilirubin, amylase, lipase, AST, ALT, WBC, and ALP had decreased. The patient’s general condition (fever and appetite) was good, and he was discharged 10-day post-operation with good condition. Trans-T-tube cholangiography was performed 20 days after the operation with good results and was then removed Figure Fig. 4PusThe complications of a liver hydatid cyst (LHC) are rupture into the biliary duct, abscess formation, and rupture into the pulmonary parenchyma and pleural space , 3–5. PrThe preoperative detection of the consequences of LHC is difficult, but clinical demonstrations and findings of in vitro assays can be suggestive of intrabiliary rupture, as in our case. U/S and CT scans may indicate a minor or huge intrabiliary rupture in the majority of cases, and magnetic resonance imaging is another imaging tool that can facilitate diagnosis. MRCP can show daughter cysts, separation of the membranes, dilated biliary tree, and hydatid cyst material in the biliary system –9. In ouIntrabiliary perforation of the LHC is a scarce event but one with severe consequences. Physicians treating patients referred to medical centers while complaining of abdominal pain, fever, peritonitis, decreased appetite, and icterus should recognize the possibility of perforation of LHC, as opposed to hydatid disease. Early diagnosis of complications and aggressive treatments, such as ERCP and surgery, are vital.


Escherichia coli and Clostridium perfringens. We report the case of a 34-year-old gentleman admitted with a 3-day history of generalized abdominal pain, vomiting and markedly raised inflammatory markers. A computed tomography scan demonstrated acute calculus cholecystitis and an incidental CAP. This was successfully treated with an emergency laparoscopic cholecystectomy. CAPs are reported in the literature as rare and are usually diagnosed after rupture with severe haemorrhage. In this report, we highlight that a non-ruptured CAP identified preoperatively can be safely managed simultaneously with a laparoscopic approach, thus avoiding the need for invasive angiographic procedures or open surgery.Cystic artery pseudoaneurysm is a rare complication of invasive biliary procedures or of acute or chronic cholecystitis and pancreatitis. Emphysematous cholecystitis is an acute inflammatory process of the gallbladder due to gas forming organisms such as  Cystic artery pseudoaneurysm (CAP) is a rare entity with a limited number of cases noted worldwide, with ~25 cases reported by Loizides et al.  . It is et al. . CAP haset al. .Patients with CAPs most frequently present with rupture and therefore often experience symptoms such as haemobilia, haematemesis, melena and severe abdominal pain . HaemobiWe present the case of a young patient presenting with EC and an incidental finding on preoperative imaging an unruptured cystic artery pseudoaneurysm.This 34-year-old European male was referred from A&E after complaining of a 3-day history of generalized abdominal pain, nausea, vomiting and constipation. He was unable to eat and drink due to the intensity of the pain. He was otherwise a fit and well patient with no previous medical history and an open appendicectomy at age 9. He was an active smoker, with occasional alcohol intake and a normal body mass index.On initial examination, the patient was obviously in discomfort with no clinical signs of jaundice. On palpation of the abdomen, he was tender in the epigastrium, with guarding in the right flank and right iliac fossa but no rebound tenderness. No organomegaly was noted and bowel sounds were present. A Lanz appendicectomy scar was noted.9/l), a slightly raised ALP (99 IU/l) however all other blood results were unremarkable. He underwent a computed tomography (CT) abdomen pelvis with contrast, which showed a picture of acute calculous cholecystitis with oedematous walls and air within the walls and the gallbladder itself, raising a suspicion of EC. Incidentally, a 7.6-mm pseudoaneurysm was noted at the level of the anterior branch of the cystic artery (On initial blood tests, he had a raised inflammatory markers (C-reactive protein: 201 mg/l, white cell count: 16.2x10c artery  and 2.<fig id="f2"><bold>Figure 2</bold>

CT abdomen and pelvis with contrast; hyper-enhancing, oedematous gallbladder wall with fat stranding and gas locules consistent with acute calculous cholecystitis; suspected pseudoaneurysm of the cystic artery measuring 7.6 mm.

<graphic mimetype="image" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="rjab625f2.tif"/></fig>in situ.The patient was haemodynamically stable despite the ongoing sepsis, and there was no clinical suspicion of haemorrhage; therefore, we proceeded with an emergency laparoscopic cholecystectomy. The intraoperative findings confirmed gangrenous cholecystitis. A careful dissection at the Calot’s triangle allowed for identification of the CAP. The procedure was performed with the standard four ports technique. The dissection allowed to achieve a critical view of safety and the CAP was pre-emptively excluded with two proximal Hem-o-lok green clips. The intraoperative estimated blood loss was around 300 ml, relating to the severe inflammatory process. A percutaneous through right lateral port was left The patient was monitored in the high-dependency unit for the first 24 hours. His post-operative course was uneventful and was discharged home after completing a course of antibiotics and removal of the drain.The histology report showed extensive acute necrotic cholecystitis with widespread ulceration, haemorrhage, abscesses and eosinophils. Bile cultures were sent and showed no significant bacterial growth.In the majority of cases, CAP is noted to be a complication of biliary surgery. In this case, however, the CAP is thought to be a consequence of acute calculous cholecystitis. A patient with a ruptured CAP usually presents with clinical signs of shock, rarely haemobilia and the Quincke’s triad.Unruptured CAPs are extremely rare, with only two cases previously reported , 7 and mIn this case, the patient presented with an EC which could have led to the CAP. Literature states that this disease is more common in older patients and in presence of concomitant pathologies such as poorly controlled diabetes mellitus, immune suppression and peripheral vascular disease. The patient in this case had no such risk factors identified .The most sensitive way to diagnose EC is by CT due to the presence of intraluminal or intramural gas in the gall bladder and bile ducts. The CT scan can also reveal pre-cholecystic inflammatory changes. Early diagnosis and treatment are essential, since if left untreated, EC can progress to soft tissue gangrene and lead to sepsis and death . In thisBeing a rare entity, there are no official guidelines on the management of CAP. Historically, CAP was managed by open cholecystectomy with ligation of the aneurysm. Some authors reported cases of ruptured CAP treated with coeliac arteriography, selective embolization and coiling . Our casIn conclusion, CAPs are rare, with unruptured CAPs being even more of a rare entity. To our knowledge, excluding our case, there were only four cases with unruptured aneurysms . HistoriNone declared.None.


Chondroid syringomas of the nose are rarely encountered. We present a novel case of a patient who developed a chondroid syringoma of the nose after paramedian forehead flap reconstruction. Furthermore, we discuss complete excision by external rhinoplasty approach.A). Scars due to a childhood surgery, including paramedian forehead flap transposition, were noticeable, with no apparent direct relation with the swelling. Fine needle aspiration cytology reported the presence of well–differentiated, cartilaginous proliferation, but no definite diagnosis could be made. Magnetic resonance imaging showed a homogenous tumor  of 17 × 17 × 13 mm3 with irregular borders, not infiltrating deeper structures (B).A 52-year-old Caucasian woman with a medical history of frontonasal dysplasia and several nasal reconstructive procedures in childhood presented with a slowly progressive, painless swelling of the nasal tip. Symptoms started spontaneously, approximately 4 months earlier. Besides blue discoloration of the skin and a progressive nasal obstruction, there were no other symptoms. Physical examination revealed a subcutaneous deformity of the nasal tip, expanding into the right nasal vestibule , A. Scarructures , B.Fig 1To avoid visible scar formation at the nasal tip, without compromising tumor exposure, an external rhinoplasty approach was used. An inverted-V, midcolumellar incision, connected to marginal incisions, allowed meticulous, blunt elevation of the skin's soft tissue envelope from a fairly thick, bluish tumor capsule .Fig 2ExtThe underlying nasal tip cartilage was slightly eroded. Pending a final diagnosis, the reconstruction of the cartilage and restoration of the tip projection caused by tumor volume loss was left for secondary surgery. Three months following the surgery, the patient was very satisfied with the obtained cosmetic and functional aspects of the nose and was not motivated for secondary rhinoplasty .Fig 3A, Histology revealed a dermal-based lesion composed almost entirely of hyaline nodules . HoweverThe term chondroid syringoma was introduced by Hirsch and HelwigSmall chondroid syringomas in the nose have been previously described, with varying  clinical presentations, including 1 malignant counterpart extending into the paranasal sinus.Especially in a patient with a history of extensive reconstructive nasal surgery, it is important to choose a surgical approach that avoids additional visible scaring without compromising tumor exposure and radical dissection. The external rhinoplasty approach meets these criteria and should be considered as an alternative to direct  transcutaneous tumor exploration.None disclosed.


Panel A) while brain MRI showed no obvious abnormalities in the basal ganglia region. Contrast-enhanced computed tomography showed renal and splenic infarction (Panel B). Moreover, a transoesophageal echocardiogram showed a mobile mass attached to the aortic valve moving back and forth between the ascending aorta and the left ventricular outflow tract . Based on these findings, we concluded that ischaemic stroke due to cardiac mass was the underlying cause of the hemichorea in this patient. During the hospitalization, the patient had an exacerbation of involuntary movements. Repeat echocardiography revealed the reduction in the size of the mass and brain MRI showed acute multiple cerebral infarctions. Therefore, we decided to surgically remove the residual mass to prevent further embolic events. Histopathological examinations with haematoxylin–eosin staining revealed papillary fibroelastoma (Panel D), a rare primary cardiac tumour, with organized thrombus (Panel E). After the surgery, we started anticoagulation with warfarin for the prevention of thrombotic event. His hemichorea disappeared 6 months after the onset of symptoms.A 74-year-old man presented to our hospital with acute onset of right hemichorea. He had no medical history of hereditary disease, inflammatory, or endocrine disorders that could be associated with involuntary movement. Although the patient had no clinical findings suggestive of infective endocarditis, it was not possible to accurately differentiate between tumour, thrombus, and sub-clinical endocarditis. Brain diffusion-weighted magnetic resonance imaging (MRI) revealed multiple cerebellar infarctions  Brain magnetic resonance imaging showing cerebral infarction. (Panel B) Contrast-enhanced computed tomography showing renal and splenic infarction. (Panel C) Echocardiogram showing a mobile mass attached to the aortic valve. (Panels D and E) haematoxylin–eosin staining showing papillary fibroelastoma (Panel D) and organized thrombus (Panel E).(Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.


Lactating adenoma is a rare benign breast lesion that most often presents as a small (up to 3 cm), solid, well-circumscribed, solitary, painless, mobile, lobulated mass. The highest incidence occurs in primiparous women (20 to 40 years old) during the third trimester of pregnancy. However, in the rare case presented herein, in addition to its giant size , this lactating adenoma is distinctive due to the presence of multiple nodules, poorly defined ultrasonographic margins, worrisome radiologic features, growth since early pregnancy, presence of infarction and association with chronic mastitis. From the clinical-radiologic perspective, the differential diagnoses included abscess associated with puerperal mastitis, phyllodes tumor, and galactocele. Biopsy was performed, and pathologic examination revealed the classic characteristics of lactating adenoma with multiple infarcted areas, leading to an unexpected confirmed case of giant lactating adenoma. This nodule usually grows slowly and may or may not be palpable.,Biopsy is the current gold standard test used to diagnose lactating adenoma and should not be delayed until after delivery.A 20-year-old, primiparous woman presented during her third postpartum month with firm right breast enlargement. She was exclusively breastfeeding. She noted that the enlargement began during the first trimester of her pregnancy. On physical examination, a bulky and firm mass in the right upper lateral quadrant was palpated to be more than 10 cm. There were no signs of inflammation in the overlying skin. There was a fistula extruding pasty secretions which were assumed to be from an abscess resulting from puerperal mastitis. Adjacent to the fistular ostium, there was a rubbery mobile mass measuring 3 cm on palpation.Right breast ultrasonography showed a hypoechoic and heterogeneous mass in the upper lateral quadrant with poorly defined edges measuring 8.8 x 5.9 cm and an adjacent nodule measuring 6.3 x 3.3 cm described as an atypical lymph node enlargement given a BI-RADS 5 classification, which indicates a high suspicion of cancer.Clinically, the working diagnosis was a phyllodes tumor. Other differential diagnoses included abscess associated with puerperal mastitis and galactocele. Therefore, resection of the lesions was performed. Gross examination of the surgical specimens showed two masses; the larger  weighed ,Lactating adenoma is a nodular lesion formed of tubules and acini surrounded by myoepithelial cells and lined by vacuolated epithelial cells, containing abundant intraluminal secretion. It usually spontaneously regresses and is rarely accompanied by axillary lymphadenopathy.,Lactating adenoma is often a diagnosis of exclusion, after ruling out other benign or malignant causes of a breast mass. In this setting, these entities include fibroadenoma (although lactating adenoma consists of a benign growth of tubules and acini,,After the diagnostic biopsy, the treatments range from medication to surgery, depending on the case. Pharmacologic treatments are based on prolactin inhibitors such as bromocriptineWe present a rare case of lactating adenoma which was highly suspicious for malignancy at clinical presentation and ultrasonography. The dominant mass with satellite nodules, necrotic center, ill-defined borders and related lymphadenopathy were interpreted as BI-RADS 5 category on ultrasonography. Biopsy unexpectedly revealed benign-appearing lactating adenoma. The presence of multiple nodules, inflammatory edema, and necrosis due to ischemic central area of rapid enlarging mass contributed to the high suspicion of malignancy before biopsy was performed.


Different hypotheses have been proposed to decipher the origin of PIMs, such as ectopic arachnoid cap cell entrapment during birth or after trauma. Surgical resection is the treatment of choice of such lesions.Predominantly intraosseous meningiomas are rare entities that include true primary intraosseous meningiomas (PIM), as well as meningiomas that may show extensive bone involvement, such as We present a case of a 65-year-old man with an enlarging mass in the parieto-occipital region that grew slowly and progressively over 13 years, following head trauma during a motor vehicle accident. One year prior to presentation, he started experiencing daily holocranial headaches and blurry vision. CT and MRI studies revealed a permeative midline calvarial lesion measuring 14 cm in greatest dimension with extensive periosteal reaction, extension into the subcutaneous soft tissues, subjacent dural thickening and intracranial extension with invasion of the superior sagittal sinus. The favored pre-operative clinical diagnosis was osteosarcoma. The abnormal calvarium was excised and histopathological examination confirmed the diagnosis of a predominantly intraosseous calvarial meningioma, WHO grade I.The present case highlights the importance of histopathologic diagnosis in guiding therapeutic decisions and reiterates the necessity of considering PIM or meningiomas with extensive intraosseous component in the differential diagnosis of calvarial masses, even when imaging suggests a neoplasm with aggressive behavior, such as osteosarcoma. ImagingA 65-year-old man presented with a chief complaint of daily, persistent holocranial headaches and blurry vision. Upon review of systems, the patient manifested having a cranial mass located in the parieto-occipital region for the past 13 years , which hThe mass grew slowly and progressively over the years. It had never caused him any significant discomfort until approximately one year prior to presentation, when he started experiencing daily headaches which worsened with time and developed blurry vision. The patient's medical history also included essential hypertension, and he had no pertinent surgical, family or social history. On physical examination, an abnormally shaped head was noted due to a mass in the calvarium, as well as bilateral papilledema. There were no neurological deficits or changes in the skin overlying the cranial mass. The mass was not tender to palpation. Laboratory tests were within the normal reference range.Computed tomography (CT) of the head showed a large midline permeative calvarial lesion measuring 14 × 11.7 × 5.4 cm, with extensive periosteal reaction, subjacent dural thickening, extension into the subcutaneous soft tissues and intracranial extension into the bilateral parietal extra-axial space .CT-Angiography revealed invasion and occlusion of a 9.5 cm segment of the superior sagittal sinus. There was no evidence of infarction. Digital subtraction angiography reported a highly hyper-neovascular destructive bone tumor with exuberant blood supply from the bilateral occipital, superficial temporal, and middle meningeal arteries and pial supply from the posterior internal frontal branches of the left anterior cerebral artery.Magnetic resonance imaging (MRI) post-gadolinium fat-saturated T1 sequence showed a large intraosseous mass with demonstration of intracranial extension, invasion into the superior sagittal sinus and regional dural thickening and enhancement . The favThe patient underwent super selective embolization of dural supply using n-butyl 2-cyanoacrylate (NBCA) and bilateral parietal circumferential craniectomy to excise the abnormal calvarium, followed by cranioplasty and reconstruction with titanium mesh.An ovoid fragment of flat bone was received for pathologic examination. The outer surface of the specimen was nodular and had attached soft tissue, while the inner surface appeared flattened, irregular, and hemorrhagic. Sectioning revealed an ill-defined intraosseous mass expanding the bone. No areas of necrosis were grossly identified .Microscopic examination of H&E-stained sections revealed a predominantly intraosseous meningioma with overall features of meningothelial-type meningioma, WHO grade I, composed of cells with eosinophilic cytoplasm and regular, ovoid nuclei with fine chromatin and small nucleoli arranged in syncytia and whorls, with extension into soft tissue .en plaque meningioma with extensive bone invasion, or possibly a primary intradiploic (intraosseous) meningioma.Brain invasion was absent. Few mitotic figures were identified reaching up to 2 mitoses per 10 HPF. Atypical features were focally present, including a minute focus of incipient necrosis and an area of small cell change, and some cells showed mildly enlarged nucleoli. However, the findings were considered insufficient for a diagnosis of atypical meningioma, WHO grade II. The Ki-67 proliferation index was estimated to be less than 5% in average; however, it was noted that it was higher than expected for a usual WHO grade I meningioma reaching up to 10% in the most proliferative areas. The gross and microscopic histopathologic features were those of an ,Extracranial meningiomas are rare entities that arise outside the dural compartment. different nomenclatures have been used to describe them, including ectopic, extradural, calvarial, cutaneous, extraneuraxial or intraosseous meningiomas.5en plaque meningioma with extensive bone invasion, or possibly a primary intraosseous meningioma.In our case, the patient presented with a large destructive osseous mass invading the overlying soft tissue and intracranial structures, with prominent periosteal reaction and exuberant vasculature concerning for a malignant process. Although the pre-operative diagnosis was concerning for osteosarcoma, histopathological examination confirmed the diagnosis of a predominantly intraosseous calvarial meningioma, WHO grade I. The gross and microscopic features, taken together with the imaging findings, were those of an There have been different hypotheses proposed in the origin of primary extradural and calvarial meningiomas.en plaque meningioma with extensive invasion into the overlying calvarium. What is noteworthy about this case is that meningiomas with extensive intraosseous component, either due to bone invasion or primary intraosseous origin, may mimic bone malignancies such as osteosarcoma on imaging, even when these are benign neoplasms (WHO grade I meningiomas).As mentioned previously, it is also possible that the findings represent an Our case highlights the importance of histopathologic diagnosis in guiding therapeutic decisions and reiterates the necessity of considering this entity in the differential diagnosis of calvarial masses, even when imaging is suggestive of aggressive behavior. Therapeutic options for intraosseous calvarial meningiomas include surgical resection as the treatment of choice, with radiotherapy in case there is evidence of rapid disease progression.


Mycobacterium tuberculosis. It may show wide variability of clinical symptoms and imaging appearance, ranging from asymptomatic with a normal radiographic examination to severe joint pain along with joint destruction, osteomyelitis, and abscess formation. This article presents radiographic and MR imaging appearance from a case of tuberculous septic arthritis with large abscess formation mimicking soft tissue tumor.Tuberculous septic arthritis is an infection that occurs inside the joint or synovial fluid and joint tissues caused by We reported a 32-year-old female with a slowly enlarging lump on her right proximal thigh within the last 4 months along with slowly progressing joint pain. Both radiographic and MR images showed destruction of the femoral head and acetabular roof, with a formation of large rim-enhanced abscess that extending superficially and distally until mid-thigh. The patient underwent open drainage surgery and excisional biopsy. Histopathological examination showed chronic granulomatous inflammation caused by tuberculous infection.MR imaging combined with radiographic and clinical information played a very important role in the diagnosis of tuberculous septic arthritis with abscess, and to differentiate it from soft tissue neoplasms. Tuberculosis; Septic arthritis; Infectious arthritis; Abscess In Indo2We reported a 32-year-old female patient who came to the hospital after being referred from another hospital to have further treatment for a soft tissue tumor of her right thigh. She complained of a slowly enlarging lump on her right proximal thigh in the last 4 months, with intermittent sub febrile temperature and mild but slowly progressing pain. She was unable to walk unsupported. Physical examination showed a large fusiform soft tissue mass in the right thigh with a diameter of 84 cm, limited range of motion, moderately firm in palpation, and tenderness of the right hip . In the 2.1An AP radiograph of the right femur was obtained, showed a large lobulated soft tissue mass on the lateral side of the proximal femoral region and was assessed as a soft tissue tumor . HoweverLaboratory test showed microcytic hypochromic anemia, increased white blood cells (WBC) count, , increased c-reactive protein (CRP) , increased erythrocyte sedimentation rate (ESR)  and increased lactate dehydrogenase (LDH) . Other laboratory findings were unremarkable.2.2The large lobulated cystic mass may be consistent with a large abscess formation, and its connection with the abnormality of the right hip may support the diagnosis of chronic infection. Other potential diagnoses related to fluid-filled mass in musculoskeletal lesions were true cystic lesions (such as seroma) and cystic-appearing solid neoplasm (myxofibrosarcoma and myxoid liposarcoma that contain high mucin component).2.3The patient underwent open drainage surgery and excisional biopsy and the specimens were sent to the Pathology Department.2.4The histopathology examination showed chronic granulomatous inflammation caused by tuberculous infection . The pat3Joint destruction with adjacent tumor-like mass has several differential diagnoses, including tuberculous septic arthritis, malignant soft tissue tumor, and pyogenic septic arthritis. Their clinical appearance may look similar, especially with the formation of a large painful mass. It becomes important to differentiate infection from the formation of tumor-like abscess from malignant soft tissue tumor, as they have completely different therapy. Malignant soft tissue tumors should be evaluated with core biopsy so that the clinicians can give appropriate chemotherapy, whereas infection would need immediate abscess drainage, antibiotics and debridement procedures. Delayed management may cause further destruction of the joint and results in irreversible disability, and worsened prognosis.The potential pitfall in the radiographic interpretation, in this case, is the large size of the soft tissue mass, which may divert the reader's attention from the hip joint abnormality. Another potential misinterpretation is whether these two findings are two separate entities or whether they are associated. Without MR imaging, this can be quite challenging since the extent of the mass is quite huge compared to the degree of hip joint destruction.Tuberculous septic arthritis is a chronic disease with long progressive clinical and radiological changes. Saraf SK et al  has intrFluid-filled mass in the musculoskeletal system may have several differential diagnoses, including true cystic lesions (abscess and seroma) and cystic-appearing solid neoplasm (myxofibrosarcoma and myxoid liposarcoma that contain high mucin component) . Seroma Both cystic appearing solid neoplasm and tuberculous septic arthritis may show the same painful mass-forming lesion, with no apparent local infection signs such as redness or warmth on the lump, but MR imaging and blood examination may help to differentiate them. Cystic-appearing solid neoplasm may show heterogeneous signal intensity with inhomogeneous enhancement but without increased leukocyte and CRP level, whereas tuberculous abscess formation will show thin and smooth wall enhancement with the increased number of leukocytes and CRP. Therefore, tuberculous abscess formation is more likely than cystic-appearing solid neoplasm in this patient.Staphylococcus aureus. As the pathogen produces proteolytic enzymes, pyogenic septic arthritis usually has an acute onset, more rapid, and more progressive [Pyogenic septic arthritis can affect all age groups with no specific range of age. The most common pathogen is gressive . It alsogressive  showed bM. tuberculosis does not produce proteolytic enzymes like pyogenic pathogens, it shows less inflammation process and relative joint space preservation compared to pyogenic septic arthritis which is characterized by a more aggressive course, prominent inflammation, and progressive joint space loss [MR imaging and clinical manifestation may help differentiate pyogenic from tuberculous septic arthritis. As ace loss . The mosThe patient had open drainage surgery and excisional biopsy, and histopathology examination showed chronic granulomatous inflammation caused by tuberculous infection. Histopathology examination and good response of clinical condition after the anti-tuberculosis drug combination administration made the diagnosis of tuberculous septic arthritis in this patient.4The presented case was confirmed as tuberculous septic arthritis with large soft-tissue abscess formation. Tuberculous septic arthritis should be considered as one of the differential diagnoses in slow-progressing monoarticular joint pain, especially in endemic countries. As the disease progresses slowly and may cause irreversible joint destruction, early diagnosis is crucial to improve the patient outcome. MR imaging, combined with the radiograph and clinical information, played an important role in the diagnosis of tuberculous septic arthritis and differentiation to pyogenic septic arthritis or other cystic-appearing neoplasms.All authors listed have significantly contributed to the investigation, development and writing of this article.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.•The case presented shows variability of clinical symptom and imaging appearance, ranging from asymptomatic with the radiographic presentation could mimicking other abnormalities such as pyogenic septic arthritis and soft tissue tumor lesion.•The patient with monoarticular joint pain that has slow progress symptoms, especially in endemic countries, tuberculous septic arthritis should be considered as one of differential diagnosis•MR imaging can be beneficial to differentiate pyogenic from tuberculous septic arthritis with the most significant imaging characteristic to differentiate tuberculosis from the pyogenic abscess is the abscess wall.No additional information is available for this paper.


Introduction. Hepatic adenoma is an uncommon benign liver tumor presenting as solitary lesions or even rarely as hepatic adenomatosis. Large lesions carry a risk of rupture, hemorrhage, and malignant transformation. This case report aims to increase awareness about risk factors for hepatic adenomas, considering the increasing prevalence of obesity and the widespread use of oral contraceptive pills. Case Presentation. A 20-year-old obese female who was taking oral contraceptive pills for seven years presented to the emergency department with vomiting and abdominal pain caused by gastroenteritis. On imaging, multiple hepatic adenomas, including two lesions 6 and 9 cm in diameter, were incidentally found. During the hospitalization, the patient suddenly developed acute anemia and rupture of the largest lesion, which was promptly treated with arterial embolization. Discussion. Obesity and exposure to hormones are well-known risk factors for hepatic adenomas. The incidence of hepatic adenomas is steadily increasing because of the prevalence of obesity, especially among females. Lifestyle interventions for weight loss and discontinuation of oral contraceptive pills are considered a conservative treatment of hepatic adenomas. Large lesions possess the risk of malignant transformation and rupture and require surgical excision. Hepatocellular or hepatic adenomas (HAs) are benign tumors of presumable epithelial origin that occur in less than 0.004% of the population at risk , 2. TheiWe present a case of an obese young female in whom hepatic adenomatosis was found incidentally. Three days after the discovery, the patient developed a rupture of the largest lesion and acute anemia, which led to an emergent, but prompt embolization and partial control of bleeding.3 and transaminitis with aspartate transaminase of 267 and alanine transaminase of 333 U/l.A 20-year-old woman presented to the emergency department for the evaluation of the acute onset of epigastric and chest pain, shortness of breath, and vomiting that started the same day after eating a tuna sandwich. Her medical history was significant for hypothyroidism, depression treated with sertraline, and dysmenorrhea. She was taking OCPs for the past seven years. The body mass index was 34, vital signs were prominent for hypertension 164/81 mmHg, and tachycardia 99 bpm. A physical exam revealed palpable hepatomegaly. Laboratory data were remarkable for leukocytosis of 16,000/mmThe patient was tested for SARS-CoV-2 infection, considering the ongoing pandemic. The polymerase chain reaction test returned negative. The differential diagnosis also included viral hepatitis, viral or food-borne gastroenteritis, and pulmonary embolism, considering the history of prolonged hormonal treatment. Computerized tomographic (CT) angiography of the chest was negative for pulmonary embolism but noted multiple large hyperenhancing liver masses. The patient was diagnosed with gastroenteritis, and symptomatic treatment was continued. However, the incidental finding of liver masses prompted further investigation. Blood work, including viral hepatitis panel, carcinoembryonic antigen, and cancer antigens 19–9 and 125, were within normal limits. The magnetic resonance imaging (MRI) of the liver was performed to differentiate between possible liver neoplasms, abscesses, hemangiomas, and adenomas. It showed hepatic steatosis and multiple masses involving both lobes. The MRI findings indicated that one of those lesions was an inflammatory hemorrhagic lesion of the hepatic dome, measuring 9.0 × 8.5 cm with severe mass effect and flattening of the intrahepatic inferior vena cava. Another one was a nonhemorrhagic lesion 5.9 × 5.1 cm, inseparable from the dominant mass . There wAfter three days at the hospital, the patient developed acute anemia with a drop in the hemoglobin level from 11.5 to 8.7 g/dL. The CT scan of the abdomen showed an increase of the largest adenoma to 9.5 cm in diameter, thus confirming the rupture. The emergent transarterial embolization of the lesion was performed, considering rapid expansion and life-threatening hemorrhage risk . The CT The patient had a follow-up CT scan of the abdomen two months after embolization. It showed a decrease in the size of the dominant lesion with a complete resolution of the hemorrhagic component . The optExposure to hormones, including OCPs and anabolic steroids, is a known risk factor for HA. It was proven that the use of OCPs for five to seven years carries a 5-fold risk of HA, and after nine years, the risk becomes 25-fold . The injThe modern-generation OCPs are safer and have less impact on the risk of HA. However, the incidence of HA has been steadily growing, driven by the increasing number of overweight and obese female patients . Also, pThe definite diagnosis of the nature of adenomas is usually made by performing a biopsy of the lesions. In our case, a biopsy was not performed; however, the MRI identified early arterial enhancement without portal washout and a hyperintense signal band on the periphery of the lesion. That finding was strongly suggestive of the inflammatory nature of the adenomas in the patient .HA can result in spontaneous hemorrhage in 20% of the cases and malignant transformation to hepatocellular carcinoma in 5% . The risIn conclusion, the combination of hemodynamic compromise and obesity or the history of exposure to hormones in a female should always raise suspicion for the possibility of a ruptured HA and prompt the necessary workup and management.


Laparoscopic sleeve gastrectomy (LSG) is a widely accepted and adopted procedure to achieves weight loss in morbid obesity. Situs inversus (SI) is when the body's visceral organs are not in the normal position with reversal of anatomical orientation. Patients with obesity and SI can be challenging to diagnose and manage. We present a case of a 23-year-old male who has SI totalis with Kartagener syndrome who underwent LSG to treat morbid obesity. Furthermore, we conducted a comprehensive review of the current medical literature. We conclude that LSG can be safely performed in SI. However, it is recommended to leave such cases to more experienced surgeons. In addition, it is advisable to consider few unconventional technical operative methods before surgery. Nevertheless, more data are needed to better study LSG in SI patients, which can be difficult given the rare nature of SI. Situs inversus (SI) is a congenital condition characterized by the reversal of visceral organ orientation within the body -4. SitusObesity is a growing health problem worldwide. According to the World Health Organization, more than half a billion adults are obese and around two billion adults are overweight in 2016 . In 2017We present in this paper a case of a 23-year-old male who has SI totalis (SIT) with Kartagener syndrome who underwent an LSG to treat morbid obesity. We present the case and conduct a comprehensive review of the current medical literature with a focus on sleeve gastrectomy cases. We also discuss important clinical points that require attention in such cases.2. The patient had previously failed to lose weight using different dietary and lifestyle modification techniques over an approximately four years period. He provided a history of dextrocardia, bronchiectasis, and chronic sinusitis with no recent flare in the last three months. He denied any history of previous surgery, smoking or alcohol consumption. He elected to have LSG to help with weight reduction.A 23-year-old male patient has morbid obesity with a weight of 146.3 kg and a height of 177 cm. The calculated body mass index (BMI) was 46.7 kg/mThe patient was evaluated by a multidisciplinary bariatric surgery team, cardiology, pulmonology, and anesthesiology. He was cleared for the planned surgery. A full assessment was conducted preoperatively including physical exam, complete blood count, biochemical profile, thyroid function test, electrocardiogram, and pulmonary function test (PFT). Additionally, imaging studies including chest x-ray, transthoracic echocardiogram, ultrasound of abdomen, computed tomography (CT) scan of sinuses, chest, abdomen, and pelvis were performed. His blood workup was normal, the electrocardiogram revealed right axis deviation Figure , and his   He was admitted the night before surgery per pulmonology recommendation for preoperative monitoring. LSG was performed with the patient in the reverse Trendelenburg and French position (split-leg supine). The surgeon stood between the legs. The abdomen was accessed using veress needle technique inserted in the right upper quadrant at a mirror image of the palmer’s point after infiltration of local anesthesia. Pneumoperitoneum was achieved successfully and was maintained at 13 mmHg of intra-abdominal pressure. The veress needle was then removed and a 5-mm optical trocar was placed in the left lumbar region of the abdomen about 10-15 cm below the costal margin to avoid injuring the malpositioned liver. This was done under direct visualization using a 5 mm/zero-degree laparoscopic camera. Diagnostic laparoscopy revealed that all abdominal organs were in reverse orientation . The mean operative time was ~75 minutes (range 28-202) but four authors did not report this information [Key information extracted and summarized in Table ormation ,18,20,29ormation . The meaormation ,21,29. Pormation ,25,27-29ormation . Only thormation ,18,29. Iormation . This waormation ,21,26,30SI cases can go undiagnosed in their adulthood especially if they have no associated anomalies or heart defects. However, SI can be diagnosed incidentally while performing routine imaging or electrocardiogram for an unrelated problem. Patients presenting to the surgery clinic may fail to mention that they have SI either because they think it is not relevant or because they are not aware of it. Surgeons need to pay attention and take a thorough history and ask the patient if they were told before that they have an unusual condition. Also, family history may help but not always as SI can happen due to sporadic genetic mutations. If the localization of the symptoms does not make sense then this should trigger a high clinical suspicion of SI. A careful physical exam can reveal the congenital condition especially if the patient has dextrocardia with heart sounds more prominent in the right chest.Imaging such as ultrasound or plain chest x-ray will easily discover the condition in case the diagnosis was missed in the physical exam. Nevertheless, SI can present in different degrees and make it more difficult to diagnose even radiologically. It can be complete which is called SIT. SIT involves all the body organs in a mirror image orientation of the normal body. In SIT type the diagnosis should not be difficult. In contrast, it can be partials, ambiguous, or hetrotaxy based on the organ involved, a pattern of lateralization, the body cavity involved, and absence of body viscera or organs in some cases ,3,4. HenIt is particularly important to be able to identify SI patients not only for diagnostic purposes but also for the planning of clinical care and surgical approach. These conditions can be associated with other diseases and defects that can affect the patient health. Congenital heart diseases are not uncommon especially if dextrocardia is present. This can include atrial or ventricular septal defects, an anomaly of great vessels, coronary sinus absence, double-inlet/outlet ventricle, and pulmonary valve and veins defects ,3,31. ThSurgical planning should start with early referral to an anesthesia clinic for preoperative assessment. SI can raise a couple of anesthetic-related concerns and issues ,33. FirsSurgeons need to pay attention to several points prior to taking a SI patient for surgery. LSG has been proven to be safe in SI -30,17-24In SI, the reversal of the body viscera orientation can be challenging to any surgeon who is planning LSG. Identification of anatomic landmarks and surgical dissection can be challenging. Port placement will be modified and most of the dissection will be from the right side of the body because of the stomach position. In contrast, Salerno et al. presented a successful LSG in SI with no alteration of port placement or surgical technique . AdditioOne major challenge is related to cognitive adaptation of the reversed anatomy during surgery with a suggested solution including a thorough review of preoperative radiological imaging  and a seDifferent surgical positions can be utilized in SI patients undergoing LSG. Nonetheless, the French position used in our case seems to be the most preferred. The French position is believed to provide easy access to the umbilical area and can possibly minimize the effect of reverse anatomy ,24,27. MSI patients with morbid obesity can be safely managed and treated. Attention is needed to clinical hints in history, examination, and imaging to identify SI and avoid misdiagnosis. Management can be challenging to the anesthetist and the surgeon especially if associated conditions are present, such as Kartagener syndrome or congenital cardiac anomaly. Careful planning and cooperation between the surgical teams and different specialties are key. LSG can be safely performed in SI. However, it is recommended to leave such cases to more experienced surgeons. In addition, it is advisable to consider few unconventional technical operative methods before surgery. Finally, more data are needed to better study LSG in SI patients, which can be difficult given the rare nature of SI.