Patients with conversion disorder (CD) present with weakness or unexplained movement disorder that may evolve from inciting psychological events, but presentation with rigid deformity is rare. Only one case of CD presenting as foot deformity with atraumatic rigid psychogenic equinovarus has been reported previously. Here we describe a rare case of psychogenic equinovarus in a physically healthy 10-year-old boy. He had noticed left equinovarus deformity upon waking abruptly but had no history of preceding trauma and no relevant medical history. Computed tomography (CT) images revealed dislocation of the left Chopart joint complex, but clinical examination did not suggest an organic neurologic disorder. On further history taking, he reported that he was under psychological stress because of being required to play baseball against his will. When he was given permission to withdraw from this stressful situation, the equinovarus improved without the need for surgical invention. This report highlights the importance of early and accurate diagnosis of psychogenic equinovarus, so that unnecessary surgery can be avoided. This is the first report of psychogenic equinovarus caused by dislocation of the Chopart joint complex that was confirmed with CT. Conversion disorder (CD) is essentially a psychogenic condition with symptoms that cannot be traced to an identifiable organic disorder and are incompatible with known anatomy and physiology . SymptomRigidity and contractures are rare in CD , 6 and rIn this report, we describe a rare case of a physically healthy 10-year-old boy who presented with rigid equinovarus caused by dislocation of the Chopart joint complex in association with psychological stress that was diagnosed early and improved spontaneously without surgical invention.A physically healthy 10-year-old boy, who weighed 32 kg (just below 50 percentile) at a height of 1.34 m (just above 50 percentile), noticed sudden atraumatic left foot deformity on waking up in the morning. There was no relevant past medical history. A visit to a local doctor was arranged promptly, and he was referred to our department for further examination and treatment within 2 days.On physical examination, there was slight tenderness and swelling over the dorsal aspect of the left midfoot. The left forefoot was rigid and held in an equinovarus position . Almost Detailed history taking revealed that the boy had been under psychological stress. He had been playing baseball but was doing so reluctantly to please his mother. He wanted to tell his mother and the baseball team coach of his wish to quit baseball but felt unable to do so. Furthermore, his parents were divorced, and his father had remarried and started a second family. Considering all the events in his social history, we concluded his foot deformity was psychogenic equinovarus accompanied by CD. Therefore, we opted for conservative treatment rather than surgical reduction under general anesthesia.When the boy woke up on the morning after visiting our hospital, the left rigid equinovarus deformity had disappeared. However, it returned 2 days later, and then resolved completely after another 2 days. Subsequently, the clinical course was uneventful, with no return of the fixed deformity after he was allowed to quit playing baseball. He continues to have no pain or discomfort in his left foot and has no limitations on physical activity.CD is much more likely to involve paralysis or weakness than rigidity or contracture , 6. TherWomen are 2–10 times more likely to develop CD than men , and theSymptoms of CD are usually self-limiting and do not lead to any lasting disability, although patients with psychogenic tremors or seizures, concomitant medical illness, or pending litigation issues generally have a less favorable prognosis –14. In oIn one series, 22% of children were reported to have undergone surgery needlessly before their symptoms were accurately diagnosed as being related to CD . AlthougAs for diagnosis of psychogenic equinevarus, although neurologic examinations including electromyography are usually within normal limits , 12, 16,Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-4). Although that name refers to the hypothesis based on psychoanalytic etiology and has not been accepted by either nonpsychiatrists or patients [A limitation of this case report is its short follow-up duration. Careful longer-term follow-up of other cases would be necessary in the future. Another limitation is the name of CD in patients , 19. Thepatients .In conclusion, we encountered a rare case of rigid psychogenic equinovarus in a physically healthy 10-year-old boy. The patient interview, including a psychiatric consultant, revealed underlying psychological stress and led to an early and accurate diagnosis. Therefore, this deformity was successfully managed conservatively without surgical invention. While not overlooking the possibility of coexistent organic disease, we should keep in mind psychological conflict as a potential cause of conversion reactions.


Focal nodular hyperplasia (FNH) is the second most common benign hepatic tumor and is very rarely complicated by hemorrhage or rupture. Although thought to be extremely rare, there have been several reports of hemorrhage caused by ruptured FNH. Herein, we report the case of a patient with ruptured FNH, who subsequently developed hemorrhage during follow-up.A 32-year-old man was admitted to our department for an asymptomatic hepatic tumor in segments 4 and 5 (S4/5), which measured 8 cm in diameter and observed to project from the liver. Imaging and pathologic examination of a biopsy specimen confirmed the diagnosis of FNH. Three years after the diagnosis, the patient was readmitted to our hospital because of sudden onset of upper abdominal pain. Dynamic abdominal computed tomography revealed ascites around the tumor with high-density areas that were considered to represent hematoma caused by ruptured FNH. Transcatheter arterial embolization (TAE) was performed to stop the hemorrhage. One month after TAE, S4/5 of the liver was resected; macroscopic findings revealed that a large part of the tumor was composed of necrotic tissue and hematoma. Pathological examination using hematoxylin–eosin staining and immunohistochemical examination indicated a final diagnosis of FNH rupture and hemorrhage.Although a well-established diagnosis of FNH usually requires no treatment or surveillance, careful examination remains necessary when the FNH is large and projects from the liver because of the possibility of rupture and hemorrhage. Focal nodular hyperplasia (FNH) is the second most common benign hepatic tumor after cavernous hemangioma –3. AlthoA 32-year-old man was admitted to our department because of a hepatic tumor. Although the patient was asymptomatic, his previous medical history included chronic alcohol consumption for the past 8 years. Dynamic abdominal computed tomography (CT) scan revealed an 8-cm mass that projected from segments 4–5 (S4/5) of the liver. The tumor exhibited contrast enhancement, mainly on the border, from the early phase until the late phase. The tumor contained a low-density area that was considered as a central stellate scar Fig. . DynamicThree years after diagnosis, he was readmitted to our hospital because of sudden onset of upper abdominal pain without any preceding traumatic events. His hemodynamic status on admission was nearly stable, except for tachycardia (117 beats per minute). Further physical examination revealed a palpable induration with tenderness and peritoneal signs on the epigastrium. Laboratory test results on admission revealed no anemia  and an increased white blood cell count . The serum levels of C-reactive protein (30.2 mg/dl), aspartate aminotransferase (256 U/l), and alanine aminotransferase (491 U/l) were also elevated. Dynamic abdominal CT scan showed a small amount of ascites around the tumor. Most of the tumor was observed as a low-density area, but there were high-density areas, which were considered as hematoma around the tumor Fig. . These fAlthough extravasation was not obvious on dynamic CT and the hemodynamic status of the patient was almost stable, the possibility of continuous hemorrhage could not be ruled out because of the presence of hematoma around the tumor, severe abdominal pain, and tachycardia. Although the tumor had been initially diagnosed as FNH, we deemed that hepatic angiography was necessary for reassessment and accurate diagnosis of the hepatic lesion because of the extreme rarity of a ruptured FNH. Hepatic angiography showed patent arterial branches of the S4 and S5 without a spoke-wheel pattern, but with extravasation.Transcatheter arterial embolization (TAE) of the arterial branches of S4 and S5 was performed to stop the bleeding Fig. . One monFNH accounts for approximately 8% of all primary hepatic tumors, with an estimated prevalence of 0.9% in the general population . FNH occMost FNHs are incidentally discovered with few clinical clues . Only 20Microscopically, FNH is a confluent mass of several small nodules of benign-appearing hepatocytes, partially or surrounded by fine bands of fibrous tissue containing proliferating bile ductules and vessels. It lacks a capsule and grows in an expansive manner to compress the adjacent hepatic parenchyma, which may exhibit a pattern of sinusoidal congestion –34. The Several studies reported that FNH does not have an aggressive or malignant course , 19, 22.Spontaneous rupture occurs in 3–26% of hepatocellular carcinoma (HCC) cases, and it is regarded as a life-threatening condition –45. SomeIn conclusion, although majority of FNH cases are asymptomatic and require no treatment, spontaneous rupture may occur in some patients during the follow-up period. Although ruptured FNH is extremely rare, careful examination is necessary for a large FNH that projects from the liver because of the risk of spontaneous rupture, which can present as sudden onset of abdominal pain.


Ehlers-Danlos Syndrome refers to a spectrum of connective tissue disorders that have a variety of clinical manifestations. In this case, we present a spontaneous diaphragmatic rupture in a patient with type III Ehlers-Danlos Syndrome. The patient presented with worsening shortness of breath after failure of medical therapy for a presumed pneumonia. A CT scan was obtained which showed diaphragmatic rupture with splenic herniation which was repaired in the operating room via thoracotomy. It is important to include diaphragmatic rupture in the differential diagnosis for patients with connective tissue disease and acute onset tachypnea and pain, as this complication has the potential for significant morbidity without prompt surgical intervention. Ehlers-Danlos Syndrome (EDS) refers to a spectrum of inherited connective tissue disorders affecting the skin, joints, and blood vessels. Abnormal collagen formation or deficiency leads to excess joint mobility, cutaneous fragility, and poor wound healing. The hypermobile type (EDS type III) primarily presents with hypermobile joints and mild skin manifestations. We present a case of spontaneous diaphragmatic rupture in a patient with EDS type III.A 27-year-old woman with EDS type III, depression, gastroesophageal reflux, and hypothyroid disease was transferred to our institution with a four-day history of left chest and left upper quadrant abdominal pain. Prior to transfer, she underwent treatment for pneumonia. A thoracentesis for a left parapneumonic effusion was attempted; however, upon obtaining blood, a thoracic CT scan  was perfEDS is a group of inherited disorders characterized primarily by hyperextensible skin and hypermobile joints, caused by abnormal collagen forms or density. The incidence is estimated at 1 in 5,000 births. Classification is based primarily upon expression of tissue involvement, mode of inheritance, and chemical analysis. Classic  and hypermobile  types comprise approximately 90% of the cases. Classic EDS is characterized principally by skin involvement (hyperextensibility and fragility), with joint hypermobility being more common with the more severe classic form (type I). Hypermobile EDS (type III) has predominantly joint hypermobility with mild to moderate skin involvement and absence of tissue fragility. In type III, a tenascin X deficiency (extracellular matrix glycoprotein that regulates the assembly of collagen fibers) causes reduced collagen density with fragmented elastic fibers. The vascular type (EDS type IV) often has a shortened life span due to life-threatening complications, including sudden death from visceral or great vessel rupture  from arterial aneurysm, valvular prolapse, and spontaneous pneumothorax. The other types of EDS are generally more benign, and these individuals rarely present with life-threatening complications [Spontaneous diaphragmatic rupture from strenuous activity  is a rare surgical emergency. A left-sided rupture is more common, and the defect tends to be located peripherally. Additionally, approximately 25% of cases have a concomitant chest wall defect. These ruptures are associated with visceral organ herniation (in order of frequency): stomach, colon, greater omentum, small intestine, spleen, and liver [The management of diaphragmatic rupture is surgical, but no widely accepted opinion regarding the optimal approach exists. While some authors advocate performing a thoracotomy for wider exposure of the diaphragm, others advocate a laparotomy, which provides better exposure for management of potential complications  . The diaHowever, in the presence of colonic contamination, the abdomen should be copiously irrigated, and an autologous tissue flap (omentum or latissimus dorsi flap) can be considered . SurgicaWhile this is one of only a handful of cases presented worldwide, it is also the first ever reported case of spontaneous diaphragmatic rupture in patient with EDS type III –9. It is


Our article reports a case of a 35-year-old man with cardiac mass, who underwent a wide range of imaging methods, including cardiac magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT). Contrast-enhanced MRI images revealed “sun ray” pattern in the mass. Final histopathological diagnosis of angiosarcoma was confirmed during autopsy. To our knowledge, our case is the second direct observation of this MRI diagnostic pattern and the first one that allows a comparison with PET/CT findings. Primary malignant tumors of the heart are very rare with angiosarcoma being the most frequent one. As with other malignancies, its timely and correct diagnosis is the most important for the prognosis of patients. Unfortunately, despite the technical development and increasing clinical availability of echocardiography, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT), only some of the tumors are detected in the stage allowing curative resection. Modern surgical treatment, chemotherapy and radiotherapy, however, have not reversed the overall poor prognosis of patients with cardiac angiosarcoma. In this paper we present a case study of a patient with angiosarcoma of the heart with emphasis on imaging methods, especially MRI.A 35-year-old Caucasian male came to the hospital to seek medical care because of abdominal pain, mild dyspnea, and cough. He was examined in the emergency room and a chest x-ray and an abdominal ultrasound were performed. The chest x-ray revealed double contour and enlargement of the left ventricle with silhouette-sign . Small p2-weighted double inversion “dark blood” turbo spin echo (T2-w TSE) images  and T1-weighted double inversion “dark blood” TSE (T1-w TSE) images  in standard cardiac planes. Immediately after administration of Gd-DOTA 0.2 ml/kg, we performed T1-w TSE images with the same setting as mentioned above, T1-w TSE with fat saturation  and early-enhancement single-shot inversion-recovery steady-state free precession (SS-IR-SSFP) . Late-enhancement images using inversion-recovery steady-state free precession (IR-SSFP)  were acquired after 10 minutes. Late-enhancement magnitude and phase sensitive inversion recovery (PSIR) images are part of the routine scanner protocol. In accordance with echocardiography, MRI confirmed a cauliflower mass protruding to the right atrium with extension toward right ventricle, right appendage, and diffuse obliteration of pericardial cavity around the ventricles  was seen both on T1-w TSE and late-enhancement IR-SSFP images, especially PSIR images  and protocol included non-contrast-enhanced electrocardiogram (ECG)-gated balanced steady-state free precession (SSFP) cine sequences , ECG-triggered Tntricles . In cinerintense , 4. PattR images . AdditioCardiac angiosarcoma was suspected based on demographic data, tumor location, metastatic spread and visible “sun ray” pattern; in the differential diagnosis, we considered primary cardiac lymphoma, because it also often involves right-sided cardiac chambers or pericardium.Finally, 18-fluoro-2-deoxy-D-glucose PET/CT of the torso was performed using Biograph 16 Hi-Rez scanner , confirming previous morphological findings in the heart and the chest. Regions of increased tracer uptake corresponded to areas of gadolinium enhancement on MRI images. Furthermore, increased tracer uptake was detected in pulmonary nodules and enlarged mediastinal lymph nodes .Despite very swift management of diagnostic procedures, clinical status of the patient deteriorated rapidly and he became unable to undergo biopsy. Patient died of right sided heart failure within 1 week after admission.No histology was obtained pre-mortem, thus no specific oncological therapy was applied. Post-mortem autopsy confirmed presence of hemorrhagic sponge-like tissue filling pericardial cavity and adhering to the parietal and visceral layer of pericardium , and alsPublication of the case was approved by local ethical committee; informed consent to use patient’s data was waived.1 The tumor occurs more often in men than in women (in ratio around 2:1), the average age of patients is around 40 years.1 The most frequent localization of the tumor is the free wall of the right atrium (about 60% of cases) or together with involvement of the right ventricle or the adjacent pericardium (about 20% of cases).1 Isolated involvement of the pericardium, the right ventricle, or the left atrium is rather rare (4–6.5% of cases).1 Obliteration of pericardial cavity by tumor or fibrous tissue is present in 31–43%.1Angiosarcoma is the most common type of primary malignant tumors of the heart.1Unfortunately, diagnosis of angiosarcoma is usually late and metastases are present in 66–89% of cases, typically in the lungs, liver, lymph nodes, or the central nervous system; other possible sites of metastases include bones, kidneys, and the spleen.Clinical manifestation depends on tumor localization; frequent symptoms include fatigue, malaise, dyspnea, signs of right ventricular failure, and chest or abdominal pain.Our 35-year-old male with abdominal pain and dyspnea can be considered a typical representative regarding age, gender, and clinical manifestation of angiosarcoma.Imaging methods play a crucial role in the diagnosis of malignant tumors. A plain chest x-ray might show pathological changes, such as cardiomegaly and abnormality of heart shadow, mediastinal mass, pleural effusion, or signs of dissemination into the lungs. Plain chest x-ray was performed in our patient because of cough and dyspnea and the revealed abnormal left ventricle contour prompted further imaging studies. Transthoracic echocardiography is a readily available method enabling detection of a pathological cardiac mass and evaluation of its relationship to cardiac ventricles, valves, and the pericardium.2 but CT does not allow further tissue characteristics.Generally, tomographic imaging methods usually display angiosarcoma as irregular lobulated cauliflower formation involving free wall of the right atrium, possibly infiltrating also the surrounding pericardium or the free wall of the right ventricle. In the CT image, the tumor appears as a low-attenuation right atrial mass,3 Recommended MRI protocol should include balanced SSFP cine images in standard cardiac planes, T1- and T2-weighted double inversion recovery “dark blood” TSE images, spectral presaturation fat suppression images, and gadolinium-enhanced black blood TSE.3 Contrast-enhanced T1-w TSE can be performed immediately after the contrast media administration,5 or alternatively, T1-w spoiled gradient-echo first-pass perfusion3 or early-enhancement SS-IR-SSFP6 can be performed. It is recommended to add late-enhancement IR-SSFP after 10 minutes.6 Angiosarcoma typically appears iso- to hyperintense in T1-w TSE images and hyperintense on T2-w TSE.4 Generally, it could be stated that angiosarcomas are mostly strongly inhomogeneous and their signal characteristics depend on the content of hemorrhage, vessels, or necrosis. After contrast media administration, angiosarcomas typically show strong and irregular or rim enhancement. In 1994 Yahata et al. observed enhancing lines radiating from the epicardium to parietal pericardium and called this type of enhancement “sun ray appearance.”7An MRI represents an important tool in the evaluation of cardiac tumors, their anatomic definition, tissue characterization, and functional impact.1-w TSE, we used the same plus early- and late-enhancement IR-SSFP. The “sun ray” sign was seen on the T1-w TSE images , as well as lymphoma that often affects the right atrium free wall and pericardium.11 Differential diagnosis of cardiac angiosarcoma and lymphoma using MRI is addressed in very recent paper comparing series of seven angiosarcomas and five lymphomas.12 Authors describe different type of enhancement in the two groups—six out of seven sarcomas revealed enhancing rim with unenhancing necrotic central part, whereas the enhancement of all lymphomas was rather homogeneous. Other possible distinguishing features mentioned in the paper are age (patients with sarcomas were younger), involvement of the right appendage , and extension of tumor toward the right ventricle . Despite advances in imaging techniques and their increasing clinical availability, most patients are diagnosed at an advanced stage and the vast majority of patients die within 12 months since diagnosis.1An increasing number of angiosarcomas have been studied with PET/CT. This hybrid method allows evaluation of both morphology and metabolism of tumors and may aid in differentiation between benign and malignant tumors, furthermore it is also very suitable for detection of distant metastases and follow-up of patients after treatment.We can conclude that our patient was a typical case in terms of gender, age, and tumor localization. Unfortunately, he also confirmed a quick spread and generally poor prognosis of cardiac sarcomas. The finding was detected by chest x-ray, confirmed by echocardiography and further specified using cardiac MRI and PET/CT. Suspicion of angiosarcoma was raised based on the tumor localization, the presence of distant metastases, and “sun ray appearance” on the contrast-enhanced MRI images.


Dear Editor,A 50-year-old male patient, diagnosed with multiple myeloma 10 months prior andundergoing chemotherapy, presented to the emergency department with abdominal pain.Laboratory tests revealed slightly elevated pancreatic enzymes. Subsequently,contrast-enhanced computed tomography (CT) of the abdomen showed diffuse, markedenlargement of the pancreatic parenchyma, with homogeneous uptake of the iodinatedcontrast medium in the portal phase . Theini-4. The most common site of extramedullary involvement isthe upper respiratory tract (80%); however, other sites, such as the gastrointestinaltract, genitourinary tract, reticuloendothelial system, thyroid, lungs, skin, andtesticles, can also be involved.Multiple myeloma is characterized by proliferation of malignant plasma cells originatingfrom the bone marrow and accounts for 10% of all hematological malignancies.Extramedullary plasmacytoma accounts for 5% of all plasma cell tumors and primarilyaffects males, the mean age at presentation being approximately 55 years. They can beprimary, occurring as solitary masses without bone marrow involvement, or secondary,occurring as part of a multiple myeloma, the latter being the more commonpresentation-6, ours thereforerepresenting only the second such case reported. The most common site of presentation isthe pancreatic head, in most cases resulting in abdominal pain and obstructivejaundice-4. The radiological findings of pancreatic plasmacytomaare not highly specific. In the focal presentation, the solid mass is homogeneous orheterogeneous, multilobulated, with variable enhancement; in the one previously reported case with a diffusepresentation, there was diffuse volumetric enlargement of the pancreas with lobulatedcontours and predominantly homogenous uptake in the portal phase, similar to what was observed in thecase reported here.There have been few reports of extramedullary plasmacytoma affecting the pancreas. Of theapproximately 25 cases described, most have involved a focal mass and only one hasinvolved diffuse infiltration of the pancreas. In the case reported here, given the diffusepresentation, the main diagnostic hypotheses were pancreatitis and lymphoma. Lymphomawas excluded because of the clinical and laboratory findings, which indicated thatpancreatitis was the most likely diagnosis. However, based on the history of multiplemyeloma and the persistence of symptoms, the possibility of pancreatic infiltration byplasmacytoma was considered. Treatment for extramedullary plasmacytoma involves thecombination of local radiation, chemotherapy, and, in selected cases, surgery.Although CT is the method of choice for the investigation of pancreatic plasmacytoma, itis not capable of excluding diseases such as adenocarcinoma, lymphoma, and metastasis,histopathology therefore being fundamental for the diagnosisPlasmacytoma of the pancreas is a rare entity and continues to be the subject of manystudies. In patients with multiple myeloma and focal or diffuse enlargement of thepancreas, the hypothesis of plasmacytoma should be considered, thus avoiding delayeddiagnosis.


Hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma is a life-threatening and rare condition in western countries with an incidence of less than 3% because of early detection of cirrhosis and neoplasm. Here, we describe a case of a 66-year-old male patient with altered mental status with hemorrhagic shock. Computed tomography scan of abdomen revealed hemoperitoneum and mass in liver. Patient underwent resection of liver tumor and biopsy revealed multinodular hepatocellular carcinoma. A high degree of suspicion is required where severe anemia and hemoperitoneum can be a first presentation for hepatocellular carcinoma especially in patients with chronic hepatitis C infection. Early diagnosis is crucial since mortality rates remain high for untreated cases. Hepatocellular carcinoma (HCC) is a hypervascular tumor with a high tendency for vascular invasion and can produce growth factors that induce neoangiogenisis. It is one of the most common types of cancer in the world accounting for about 500,000 of new cases diagnosed yearly , 2.Spontaneous rupture of HCC was previously considered as problems of large tumor; however, small tumors with aggressive behavior are also at high risk. Symptoms may vary depending on location of tumor. Although rupture of deep tumors can present with asymptomatic or pain, a peripheral tumor can lead to hemoperitoneum with hemorrhagic shock in severe cases . In the A 66-year-old male with past medical history of chronic alcoholic and chronic hepatitis C (not sure if it was treated or not) was brought in by Emergency Medical Service (EMS) because of drowsiness and fatigue for 1 day. He denied any history of trauma.Vital signs were pulse rate of 123 beats/minute, respiratory rate of 23 breaths/minute, and blood pressure of 82/55 mmHg. Physical examination revealed drowsy and pale patient that responded only to painful stimuli. Abdomen examination showed distended, tense abdomen with hypoactive bowel sounds. No organomegaly was found on palpation. Cardiovascular and chest examinations were within normal limits. No external bleeding source was identified.9/L, hemoglobin of 5 g/dL, hematocrit of 15%, platelet counts of 120,000/μL, mean corpuscular volume of 90.2 fL, absolute reticulocyte count of 63 K./μL , haptoglobin of 68 mg/dL, bilirubin of 1.5 mg/dL, aspartate transaminase (AST) of 50 IU/L, alanine transaminase (ALT) of 103 IU/L and alkaline phosphatase of 90 IU/L, ammonia of 34 μmol/L, and tumor marker alpha fetoprotein level of 2556 ng/mL . Serum electrolytes, coagulation profile, amylase, and lipase were within normal limits. Baseline hemoglobin was 14.7 g/dL and hematocrit was 44% in 2011. Occult blood was negative.laboratory tests showed white blood cells of 17.4 × 10Chest X-ray was unremarkable. Abdominal ultrasound revealed free peritoneal fluid and computed tomography (CT) scan of head showed no acute hemorrhage or infarct. CT scan of abdomen and pelvic revealed hemoperitoneum in the abdomen and pelvis and heterogeneous mass-like density abutting the gallbladder and lower right hepatic lobe Figures , and 3.Patient was admitted to the intensive care unit (ICU) and treated with 4-litre bolus of normal saline intravenously and transfused a total of 4 units of pack red blood cells (PRBC). Patient underwent bland transcatheter arterial embolization (TAE). Microcatheter was used along with polyvinyl alcohol (PVA) particles injected into the hepatic artery. A sliding CT scanner system with interventional radiology features (IVR-CT) was used to take CT images during arterial infusion of contrast agents (CT during angiography). A mass was found to be exophytic from the edge of segment 5 of liver adjacent to the gallbladder bed. A small lesion in segment 4A of the liver was also identified. Laparoscopic resections of segments 5 and 4A along with mass and cholecystectomy were performed.Pathology report revealed that a tumor is segment 5 poorly differentiated 5.3 cm multinodular hepatocellular carcinoma with extensive microvascular invasions. It had approximately 85% necrosis and fibrosis. The tumor in segment 4A was 1.6 cm moderately differentiated multinodular hepatocellular carcinoma with extensive microvascular invasion. Background liver had portal and periportal fibrosis and focal fibrous septum formation. Hematoxylin and eosin (H & E) stained slides revealed evidence of background hepatitis C and grade 2 and stage 2 and multinodular poorly differentiated hepatocellular carcinoma, which was ruptured as evidenced by surrounding blood Figures . Some ofPatient condition improved along with stable vital signs. He tolerated diet gradually and was discharged from the hospital. Patient was called one week later after discharge and he denied any symptoms of postembolization syndrome such as nausea, pain, or fever. He was recommended follow-up with hematology and oncology clinic but was lost to follow-up.Spontaneous rupture of HCC is more prevalent in male with average age of around 45–75 years . It is aThe symptoms can range from severe abdominal pain to anemia, hemorrhagic shock, and eventually death if left untreated. Kanematsu et al. published a study that states that increased tumor size and extent of extrahepatic protrusion are correlated with an increased risk of rupture of HCC . HoweverManagement is dependent on hemodynamic status and resuscitation remains the first step in patients with shock. TAE is the first choice of treatment in unstable patient with active intra-abdominal hemorrhage with a success rate of 90% . It imprComplications include repeated spontaneous rupture and intraabdominal HCC dissemination; however, it is not a contraindication for resection of primary tumor . PrognosThe incidence of ruptured HCC is a rare phenomenon accounting for <3% of HCC patients in western countries while incidence is higher in Asian countries in 2.3–26% of all HCC cases –15. The It is important to distinguish blood from simple fluid depending on amount of Hounsfield unit (HU) in CT scan images. The attenuation of fluids that have similar density as water such as bile, urine, and intestinal contents ranges from 0 to 15 HU . HoweverIn conclusion, spontaneous rupture of HCC is a rare condition in western countries because of early detection of cirrhosis and neoplasm. However, a high degree of suspicion is required where severe anemia and hemoperitoneum without history of trauma can be a first presenting sign for HCC. Early diagnosis is crucial since mortality rates remain high for untreated cases.


Objective: Infantile digital fibromatosis is a rare benign childhood tumor, infrequently cited in the literature. Hallmarks include nodular growths exclusive to fingers and toes and the presence of eosinophilic cytoplasmic inclusions on histology. This article aims to exemplify diagnoses of infantile digital fibromatosis and possible treatment options. Methods: A computerized English literature search was performed in the PubMed/MEDLINE database using MeSH headings “infantile,” “juvenile,” “digital,” and “fibromatosis.” Twenty electronic publications were selected and their clinical and histological data recorded and used to compile a treatment algorithm. Results: A 9-month-old male child was referred for a persistent, symptomatic nodule on the third left toe. A direct excision with Brunner-type incisions was performed under general anesthesia. The procedure was successful without complications. The patient has no recurrence at 2 years postsurgery and continues to be followed. Histological examination revealed a proliferation of bland, uniformly plump spindle cells with elongated nuclei and small central nucleoli without paranuclear inclusions consistent with fibromatosis. Conclusions: Asymptomatic nodules should be observed for spontaneous regression or treated with nonsurgical techniques such as chemotherapeutic or steroid injection. Surgical removal should be reserved for cases with structural or functional compromise. As a rare entity, available literature describing diagnostic criteria and treatment options for IDF is proportionally scarce. Reye1Histopathological diagnosis is usually based on a few characteristic findings: cellular proliferation restricted to the dermis; interlacing fascicles extending to the epidermis; and tumor cells surrounding the adnexal structures.,11-6,15,Treatment of IDF has also been varied, owing to a paucity of data on remission rates and different treatment modalities. Numerous case reports have demonstrated success with either surgical excision of nodules or a more conservative observational approach. Surgical intervention has been widely effective, although recurrence remains a problem in up to 61% to 74% of cases.2Here, we describe a case of IDF in a 9-month-old male child presenting with a painful nodule on the dorsum of his left third toe, summarize case management, and review the available literature to provide a management algorithm for IDF .A 9-month-old otherwise healthy male child was referred for evaluation of a spontaneously occurring nodule on the dorsal aspect of the third toe proximal and middle phalanges, noticed 2 months earlier. On examination, the nodule was hard and ill-circumscribed, with significant blanching and thinning of the overlying skin. The nodules were reported to be tender, and the family noted increasing discomfort with shoes. A similar lesion had developed 2 weeks prior to evaluation over the middle phalanx of the same toe. The patient's hands and the rest of the feet were otherwise normal. The patient's medical history was negative for trauma, infection, or signs of excoriation. Family history was otherwise unremarkable, except for a history of Irish and Scottish descent on both parental histories. Radiographs of the lesions demonstrated no bony erosions, osteophytes, or any other radiographic evidence of bony pathology or involvement. Because of the overlying skin compromise secondary to the compressive effect of the nodules, and the discomfort and irritation with shoe fit and friction, the patient's family elected to undergo operative intervention at 11 months of age.A direct excision of the lesions with Brunner-type incisions was performed under general anesthesia. The lesion was noted to abut and was adherent to the underlying dermis from which the extirpation was performed. The procedure was successful without complications. The patient is now 33 months of age, has no recurrence at 2 years postsurgery, and continues to be followed . Histolo-3,1,3,6,8,11,14,15,18-25,5,7,8,18,19,21,Reye1The differential for IDF includes juvenile aponeurotic fibroma, pachydermodactyly, keloids, terminal osseous dysplasia, and pigmentary defects.10In a histopathological review of 12 patients with 18 tumors, Reye described IDF nodules as frequently less than 1 cm in diameter, causing flattening of rete ridges, acanthosis, and compression atrophy despite an intact epidermis. Interlacing bundles of fibrocellular material were found within the dermis. Individual cells demonstrate few mitotic figures, and lightly eosinophilic inclusion bodies can be located near one pole of the nucleus with hematoxylin-eosin staining. Treatment with phosphotungstic acid–hematoxylin stains these characteristic inclusions deep purple, allowing more ready identification. Reye examined 40 sections from pediatric fibrosarcomas and other benign fibromatoses with identical staining techniques without identifying paranuclear inclusions, confirming IDF as an independent entity.,24,These characteristics have since been reiterated and elaborated upon by Laskin et al.20,2-4,10-14,22,34,2,6,Given the rarity of IDF, there is an inherent challenge in diagnosis and attempting to define a treatment protocol. Surgery was previously considered the primary therapy for IDF but is now advocated as a therapy of last resort for cases that present with symptoms such as pain or joint deformity.2,6,Nonsurgical approaches to treatment of disabling lesions have included intralesional triamcinolone injections of 0.5 to 2 mL at 10 mg/mL with 1 to 3 injections over the course of 5 to 40 months, which showed promise in a pilot study.9The authors propose a management algorithm for patients diagnosed with IDF. When a nodular lesion clinically consistent with IDF is discovered in a pediatric patient, the risks and benefits of operative management versus observation should be considered. None of the injection treatment methods have been explored in large studies, to date, leaving surgery as the most accepted treatment of symptomatic lesions. However, in the subset of asymptomatic patients with relatively large-sized tumors (>2×2 cm), preemptive treatment with intralesional triamcinolone or 5-fluorouracil should be considered when tolerated.Infantile digital fibromatosis is a rare childhood disease of benign myofibroblast tumors occurring on both upper and lower digits. Nodules that are asymptomatic should be watched over time for spontaneous regression or may be treated with chemotherapeutic agents, steroids if they become large or unwieldy. Surgical treatments should be reserved for cases with structural or functional compromise to minimize trauma and the associated risk of recurrence.


Abdominoperineal resection (APR) is one of the surgical techniques performed for the distal rectal cancer. The perineal herniation is one of the complications of APR surgery. In this report, we aim to demonstrate a rare case of small bowel evisceration and strangulation secondary to the transvaginal herniation evolved in the late stage after perineal hernia repair following laparoscopic APR. Abdominoperineal resection (APR) is one of the techniques performed in the surgical treatment of the distal rectal cancer . The perA 67-year-old female patient with a locally advanced distal rectal adenocarcinoma (cT3N+) underwent laparoscopic abdominoperineal resection after short-term radiotherapy. A vaginal resection or repair was not required for the patient as she did not have any intraoperative problems. The patient with the pathology test result of pT2N0 received adjuvant chemotherapy. No complication was observed in the third and sixth month controls; however, the perineal hernia was detected at the ninth month. The abdominal computed tomography (CT) imaging taken without valsalva maneuver revealed no pathological findings except perineal hernia . The patThe patient was placed on a Jackknife position. The perineal defect was revealed by dissecting the hernia vesicle through posterior approach. After the hernia content was reduced into the abdomen, the double-sided synthetic patch was placed over the defect and fixed to the levator ani muscle laterally, the vagina anteriorly, and the coccyx posteriorly with the 2/0 polyprolene sutures. The patient was discharged without any complication.The patient had no complaints related to the perineal hernia during the follow-up using CT imaging . The patThe perineal herniation has been reported as 1–13% after the classical APR surgery . The larThe perineal herniation may be reconstructed through transabdominal or transperineal approach. Although the transperineal approach is a less invasive procedure, there are some disadvantages such as the poor exposure, the inadequate mobilization of the muscles, and the difficulty in competing with the adhesions compared with the transabdominal approach . In addiIn this case, a recurrent perineal herniation through vagina has occurred, and a portion of the small intestine eviscerated and strangulated after one year of the transperineal hernia repair following the abdominoperineal resection. It may be claimed that the transvaginal herniation occurred due to the chronic protrusion of the abdominal viscera to the weakened vaginal wall due to the loosening of the pelvic structures, the advanced age, and the previous surgeries. The intraoperative findings such as well-placed previous mesh material far from current vaginal defect and no relevant intra-abdominal adhesions may support the reason mentioned above. However, the anchoring suture placed in the vagina in the former perineal repair may be another reason for transvaginal herniation.


Giant cell tumour (GCT) of bone arising from a phalanx of a finger is extremely rare. Only two percent of all reported GCTs are found in the hand, which show a higher rate of recurrence as compared to those occurring at a more proximal location. Here we report a rare case of giant cell tumour of proximal phalanx of the ring finger in a 20-year-old male, which was treated with extended curettage and bone grafting. After two years of follow-up, the patient was asymptomatic with complete functional recovery and no signs of recurrence. Giant cell tumour is an uncommon benign osseous tumour usually seen at the epiphysis of a long bone after skeletal maturity. It is defined as a benign but locally aggressive neoplasm . Only twA 20-year-old male patient presented with pain and swelling of the left ring finger base since five months without any history of trauma or constitutional symptoms. On examination, a fusiform swelling in the proximal phalanx of the left ring finger was noted, which was tender, firm in consistency, and had normal overlying skin without any scar or adherence to the underlying tissue. The adjacent metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints had normal ranges of movements.Radiographs showed an expansile lytic lesion involving the base and proximal half of the proximal phalanx shaft with a thin cortical rim Figure . There wThe differential diagnosis at this stage was giant cell tumour, enchondroma, and aneurysmal bone cyst. After giving a written informed consent, the patient underwent extended curettage of the lesion with chemical cauterization by phenol, and the void was filled with autologous cancellous bone graft taken from the iliac crest Figure . A biopsPostoperatively, active and passive range of movement exercises of the digits and wrist were begun. After gaining functional range of movement at MCP and PIP joints, gradual hand strengthening was initiated. The patient was instructed to refrain from contact sports and lifting heavy objects for three months. During further follow-ups his grip strength was normal with good functional recovery. At two years follow-up there was complete healing of the lesion with no evidence of recurrence Figure .Giant cell tumour of the bone is benign and locally aggressive with an uncertain biological behaviour. Most giant cell tumours occur in patients between 20 to 40 years of age . The mosPain and swelling are usually the first symptoms of GCT, especially when it occurs over the extremities like the hand due to its proximity to the surface. The pain is usually insidious at onset with progressive worsening of symptoms. In a few cases, the tumour may grow quickly, with thinning and destruction of the bone cortex and invasion of the adjacent soft tissues. However, a pathological fracture at the lesion may result in acute pain -4.Giant cell tumour has typical radiographic features such as an epiphyseal eccentric location, expansile and lytic lesion with thinning of the cortex. However, there is absence of internal calcifications, marginal sclerosis, or periosteal reaction . ComputeEnneking first described the staging of GCT of the bone, subsequently followed by Campanacci who gave the radiological classification. Three stages of the local tumour which correlate to the aggressiveness and risk of local recurrence are depicted. Campanacci's Grade 1 is a cystic lesion (latent) with sclerosed margins. Grade 2 (active) is the most common type where the cortex is thin but there is no extension into the surrounding soft tissue. In Grade 3, the cortex is perforated and the tumour is large in size, destroying the cortex and invading the surrounding tissues. The highest rate of recurrence is observed in tumours that are in Grade 3 -5.Grossly, GCT of the bone is brown in colour, solid, with areas of necrosis and haemorrhage. Histologically, the neoplasic tissue shows highly vascularised stroma interspersed with oval or fusiform cells, with multinucleated giant cells of the osteoclast type . MitoticDifferential diagnosis includes benign lesions like aneurysmal bone cyst, brown tumour of hyperparathyroidism, giant cell reparative granuloma, early stages of metastatic disease, and multiple myeloma. Radiologically, they may appear similar to GCT, but it is the histological examination that can differentiate these tumours -5.Primary modality of treatment of GCT is surgical , 6. The Amputation, although it reduces the recurrence rate, is cosmetically disfiguring and causes loss of functionality of the limb. Resection with reconstruction of the base of the proximal phalanx for articulation with the metacarpus can be done with a bone graft, polymethylmethacrylate (PMMA) cement or prosthesis, which reconstructs the functional and structural integrity of the metacarpophalangeal joint .Medical therapy and radiotherapy can alter the management of GCT of bone, especially in multifocal and metastatic disease and in cases of local recurrences. As radiotherapy is associated with malignant transformation, it should also not be used as the primary procedure. Medical therapies like bisphosphonates and denosumab, as an adjuvant therapy for giant cell tumour of bone, have demonstrated a lower local recurrence rate with more promising results in stage III diseases .In the present case, extended curettage with phenol application and bone grafting procedure was carried out in accordance with clinical condition and radiological findings. The patient had regular follow-up for two years during which no signs of recurrence were seen and the patient had complete functional recovery.With the appropriate surgical technique, the rate of recurrence varies from five percent to 10%  and the GCT in the hand is a rare, benign, locally aggressive tumour. It evolves earlier than GCT in other locations. The diagnosis is based on the clinical, radiological, and histopathological findings with primary treatment being surgical. Each case should be assessed individually to ensure adequate treatment, aiming to prevent recurrences and functional limitations. In view of the comparative rarity of a tumour arising from the phalanges of the ﬁnger and the higher rate of recurrence after curettage, the contrary outcome observed in this case makes it worth reporting.


This study reports two cases of conjunctival granuloma with necrosis caused by an exposed suture in the upper palpebral conjunctiva masquerading as ocular surface squamous neoplasia.Two patients presented with chronic conjunctival ulcerative and granulomatous lesions on the superior bulbar conjunctiva that repeatedly recurred after the mass was removed. The pathologic findings revealed the absence of malignant cells and presence of many lymphocytes, plasma cells, and histiocytes. There was no evidence of acid-fast bacilli or fungal organisms. When a past history of blepharoplasty was established, microscopic examination revealed occult exposed suture tips. After the sutures were removed, the granuloma with necrosis was resolved within a month.For all conjunctival lesions in the superior bulbar conjunctiva, a thorough examination of the ocular adnexae which includes eyelid eversion should be performed. There should be a suspicion of foreign body or exposed suture material especially when there is a non-healing ulcer. Ocular surface squamous neoplasia (OSSN) of the conjunctiva is considered the most common malignancy of the ocular surface , 2. BecaMeanwhile, the complications associated with exposed sutures following upper blepharoplasty are vertical cornea abrasions, eyelid edema, papillary changes in the upper tarsal conjunctiva, and recurrent blepharoptosis . As far A 43-year-old woman in good health was referred for evaluation of a superior bulbar conjunctival necrotic lesion in the left eye. She presented with ocular pain and a foreign body sensation in the left eye that had lasted for 1 year. She said that she had no history of trauma or surgery.The slit-lamp examination revealed moderate injection and a 2.2 mm round ulcerated zone with granuloma in the center of the superior bulbar conjunctiva Fig. . There wBacillus species were cultured. After topical antibiotics that treated Gram-positive bacteria were administered, conjunctival necrosis decreased, but the granulomatous lesion remained. The pathologic findings showed CD3+ T cells, CD20+ B cells, CD68+ macrophages, and Ki-67+ positive cells in 1% of the parabasal area, which was diagnosed as inflammatory conjunctivitis, but there was no evidence of malignancy , Periodic acid–Schiff (PAS), and acid-fast bacilli (AFB) to rule out mycobacterial conjunctivitis or conjunctival malignancy. Systemic evaluations revealed no abnormal findings. AFB staining revealed no acid-fast bacilli, and GMS and PAS staining revealed no fungal organisms, although ncy Fig. . To reduncy Fig. . After rncy Fig. .A 25-year-old woman was referred for evaluation of a superotemporal bulbar conjunctival mass in the left eye. At a previous ophthalmic clinic, she had complained of a foreign body sensation. On suspicion of OSSN, a conjunctival biopsy was performed that revealed no malignant (Ki-67+) cells but an inflammatory lesion that contained CD3+ T cells and CD20+ B cells. She was treated with a topical steroid and topical antibiotics for 8 months, but the lesion persisted. When the patient was referred to our clinic, a slit-lamp examination revealed a granulomatous mass and calcium deposits in the center of a granuloma along with vascular injection on the superior bulbar conjunctiva Fig. . The corIn various Far East Asian countries, double-eyelid blepharoplasty is a popular aesthetic surgery. A current popular method in Far East Asian countries is non-incision buried suture blepharoplasty because of cosmetic advantages, short operative and recovery times. Surgical technique of non-incision blepharoplasty is as follows. After turning the upper eyelid inside out, 7–0 nylon suture is passed through the same point through the upper tarsus margin from the conjunctiva to the skin . In the Usually, foreign bodies or exposed sutures on the palpebral conjunctiva of the upper lid cause vertical abrasions on the cornea, and foreign body-associated corneal lesions are easily diagnosed by this observation. However, our patients presented with conjunctival necrosis and granuloma, which were very unusual findings for exposed sutures on the upper lid. One case did not even feature cornea abrasions. The reason for this unique conjunctival presentation may be presumably related to the location of the exposed or broken suture; deep-seated sutures near the fornix appear to irritate the conjunctiva more than the cornea. The reason of the deep seated location of the exposed or broken sutures is that the loosened sutures may be migrated to the deep fornix or the sutures may be placed on superior fornix if the patients had blepharoptosis component. Because of the deep location near the fornix, the suture appeared to be less mobile despite the blinking movement of the lid, and the tip of the suture appeared to persistently irritate the corresponding area of the upper conjunctiva where the suture made contact. This could cause necrosis and granulomatous inflammation rather than epithelial linear abrasions.+ cells were not observed as same as the 1st case. Considering that the granulomatous changes was observed in 2nd case, we can presume that macrophages might also be involved in the chronic wound healing process in the 2nd case. Taken together, the histologic features are similar in two cases, showing chronic inflammation.After any mechanical injury, various inflammatory responses are activated with many types of cells including immune cells , endothelial cells, keratinocytes and fibroblasts . HistoloNecrotic granulomatous lesions resemble OSSN or tuberculous conjunctivitis and thus require appropriate suspicion of OSSN or infectious conjunctivitis. No involvement of the limbus and relative young age may lower the possibility of malignancy, and no systemic involvement of tuberculosis may reduce the possibility of tuberculous conjunctivitis. Taken together, in a young patient who has undergone upper blepharoplasty, chronic necrotic granulomatous conjunctival lesions in the superior bulbar area should be considered possible suture-related inflammation as well as possible OSSN or infectious conjunctivitis. Very careful examination of the palpebral conjunctiva through the fornix may ward against unnecessary biopsies of suture-related granulomas.Blepharoplasty for cosmetic reasons has grown more prevalent in Asian countries. Thus, surgeons in Asian countries should be aware of this blepharoplasty-related complication, which can masquerade as OSSN or infectious conjunctivitis.


Histology revealed an abundance of plasma cells; immunohistochemistry was positive for CD138 expression and lambda chains, and negative for CD20. Comprehensive imaging studies and panendoscopy of the ENT tract confirmed solitary disease involvement. Following additional systemic work-up, a diagnosis of extramedullary plasmacytoma was rendered. The patient underwent definitive radiotherapy using intensity-modulated radiation therapy . Serial PET/CT showed the stepwise resolution of abnormal FDG uptake and resolution of the cricoid cartilage lesion. With 22 months of follow-up, the patient remains free of disease. We describe the rare case of SP presenting as a FDG-avid hypermetabolic soft tissue mass in the cricoid cartilage, which should be considered in the differential diagnosis of laryngeal tumors. Of note, SP is radiosensitive; favorable outcome can be expected once treated with doses of 40–50 Gy. FDG PET/CT is helpful in diagnosis and response assessment for this disease.Solitary plasmacytoma (SP) is an extremely rare form of hematologic malignancy that can be classified as solitary bone plasmacytoma or solitary extramedullary plasmacytoma. Here, we report a patient who presented with progressive shortness of breath and foreign body sensation in his throat. Fluorodeoxyglucose positron emission tomography/computed tomography ( Multiple myeloma (MM), a malignant plasma cell tumor, accounts for approximately 1.8% of all cancers and 15% of hematologic malignancies . SolitarA 77-year-old man who grew up in Sicily presented with progressive shortness of breath and foreign body sensation in his throat to an outside emergency department while traveling to Arizona. Other symptoms included intermittent cough of whitish sputum, intermittent wheezing, and dyspnea on exertion. Outside chest X-ray and CT of the chest revealed thickened soft tissue beneath the vocal cords. A prior chest CT from April 2014 showed no laryngeal lesion. A dedicated CT of the larynx performed in March 2015 with intravenous contrast then demonstrated an expansile soft tissue mass arising in the posterior half of the cricoid cartilage with mild airway narrowing measuring 3.3 cm × 1.7 cm × 2.2 cm. No infiltration of adjacent soft tissues, trachea, or arytenoid cartilage was detected, nor was focal calcification observed . He tolerated the treatment well; the acute toxicity noted was grade 1 voice change. He had no unanticipated events during his RT course; however, he developed likely radiation-induced subclinical hypothyroidism , for which he was treated with levothyroxine. This RT-related complication is not unexpected in view of the thyroid’s immediate vicinity to the larynx; therefore, baseline thyroid function tests prior to RT initiation and subsequent continued testing should be considered to detect transient or permanent dysfunction , MRI of spine and pelvis, and FDG PET/CT (PET/CT) as second-line imaging techniques . PET is The histologic differential diagnoses of a monoclonal cell population with plasmacytic features includes plasma cell neoplasms, such as plasmacytoma, plasma cell myeloma, monoclonal gammopathy of uncertain significance, and smoldering myeloma , as wellThe etiology of SEMP remains unknown; however, viral pathogens (particularly Epstein–Barr virus) and chronic irritation from inhaled irritants associated with its diagnosis have been reported . While sWe describe the rare case of SP presenting as an FDG-avid hypermetabolic soft tissue mass in the cricoid cartilage, which should be considered in the differential diagnosis of laryngeal tumors. Whereas updated guidelines for treatment, risk stratification, and prognostic criteria for patients with MM have been established, determination of a concise approach for patients with SP has been hampered, largely due to the rare occurrence and limited literature. Of note, SP is radiosensitive; favorable outcome can be expected once treated with doses of 40–50 Gy. FDG PET/CT is helpful in diagnosis and response assessment for this disease.Written informed consent was obtained from the patient for publication of this case report and accompanying images.SK and HS assembled, analyzed, and interpreted the patient’s imaging data. IG performed the biopsy. RG undertook the histologic analyses. JaY and JmY provided the treatment and continue with the patient’s follow-up. All authors contributed to writing the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hydatic cyst is a zoonotic disease caused by Echinococcus granulosus. It is a public health problem in Tunisia and remains endemic. It occurs in intra-abdominal organs in 10–15% of the cases, particularly in the liver representing the most common affected organ. The aim of the case is to highlight the scarcity of this appendicle origin and to consider it among the differential diagnosis of any intra-abdominal cystic lesion.A 45-year-old Tunisian woman, with no past medical history, was admitted for a pelvic cystic mass. The clinical manifestation as well as the imaging findings were toward a lateral uterine mass. Our patient underwent appendectomy and resection of the mass. The patient had no recurrence at 2 years of follow-up.An extrahepatic hydatid cyst should be recognized among the differential diagnosis of any intra-abdominal cystic lesion. Treatment should be based on surgical excision. Due to the risk of recurrence, a close follow-up is mandatory. Hydatidosis is a zoonotic disease caused by the larval stage of tapeworm Echinococcus granulosus . The lifCysts are mainly found in the liver (63%), succeeded by the lungs (25%), muscles (5%) and bones (5%) . The invWe present a case highlighting the importance of considering appendical hydatic cyst among the differential diagnosis when facing a case of intra-abdominal cystic lesion in endemic countries.A 45-year-old Tunisian woman, with no past medical history, was admitted for a pelvic mass. She had no associated history of vomiting, fever, jaundice or weight loss. On physical examination, the patient was anicteric and afebrile. The abdominal palpation found a bloating in the right iliac fossa. Her gynecological examination showed a right pelvic mass in the recto-uterine pouch. Her blood tests were normal. The abdominal ultrasound revealed a suspicious cystic mass of 9 cm in diameter, located at the right side of the uterus. The right ovary was not seen. The thoracic-abdominal pelvic scan showed a heterogeneous right lateral rectal mass of 9 cm.Tumor markers, including CA 125, alpha fetoprotein, Beta human chorionic gonadotropin (hCG) hormone, carcinoembryonic antigen (CEA) and CA19–9 were tested and found within the normal range. With nonspecific signs and symptoms, wide radiological image findings, an anatomical contiguity, and the absence of a clinical history of a previous hepatic echinococcal cyst, a preoperative diagnosis of pelvic tumor was suggested.Our patient was scheduled for an exploratory laparotomy. Three cystic masses were observed intra-operatively: the first one was 4.5 cm in diameter and was closely located to the appendix; the second one measured 2 cm in diameter and was attached to the uterovesical pouch; and the third cyst was of 6 cm in diameter, and was detected laterally to the right of the rectum. The rest of the abdominal cavity was normal.An appendectomy and a complete resection of the cysts were conducted. The frozen section showed the presence of hydatic cysts, which were later confirmed by the histopathological examination. The operation ended with peritoneal cleansing with a hypertonic saline solution. Our patient had an uncomplicated postoperative course and was discharged from the hospital on the third postoperative day.Our patient was then referred to a general surgery department to undergo an appropriate follow-up. We also took the opportunity to integrate her in the breast cancer screening program. Two years after treatment, our patient remained under follow-up and demonstrated no evidence of recurrent hydatidosis.The liver is the most common affected organ. Other intra-abdominal organs are less concerned and represent only 10–15% of the cases [The clinical manifestation of the hydatic cyst varies widely and it is associated with nonspecific radiological images, which lead to difficulties in making the correct diagnosis , as in tA hydatic cyst develops increasingly inducing compression and irritation of the adjacent organs, which adds difficulties in diagnosing this pathology . When loFor the abdominal localization, the ultrasonography represents an important imaging examination as it may show the characteristic aspect of this cystic lesion, and may help in making the correct diagnosis .et al. conducted this procedure and showed successful results, considering it safe and simple, but antihelminthic drugs should be administrated postoperatively [Surgical excision is the preferred treatment . An en bratively .The overall local recurrence rate of hepatic disease ranges between 10 and 12% , thus a The involvement of the appendix, especially as a primary localization of the hydatid cyst, is a rare finding. This pathology is associated with nonspecific clinical manifestation and different radiological images. Surgical excision remains the preferred treatment. A close follow-up is highly recommended to detect further recurrence.


Introduction. Vitelline artery remnants are rare causes of intra-abdominal bands leading to bowel obstruction. These bands may be associated with Meckel's diverticulum. Double inferior vena cava (IVC) is a rare presentation and is usually identified incidentally. Case Presentation. A sixty-year-old male presented with progressive vomiting for five days and he was clinically diagnosed with intestinal obstruction. Plain X-ray abdomen showed evidence of small bowel obstruction. CT scan of the abdomen revealed dilated small bowel loops with a small outpouching in the distal ileum with a band like structure attached to it. In the CT, left sided patent IVC draining into the left renal vein was identified. Left external iliac vein was in continuity with the left IVC. Left internal iliac vein was draining into the right IVC. Exploratory laparotomy revealed a Meckel's diverticulum with a band identified as the vitelline remnant attached to its apex and inserting at the anterior abdominal wall near the umbilicus. Discussion. Meckel's diverticulum with vitelline bands, although rare, should be borne in mind in adult patients with intestinal obstruction. Identification of this anomaly can be difficult in imaging studies. Presence of double IVC should be mentioned in the imaging findings to prevent possible catastrophic complications during surgery.  Meckel's diverticulum is the commonest congenital anomaly in the gastrointestinal system, though being most often detected as an incidental finding. Incomplete obliteration of the omphalomesenteric duct is considered as the cause for this anomaly. However, apart from Meckel's diverticulum, there is a spectrum of anomalies that arise as a result of complete or incomplete obliteration of the omphalomesenteric duct. These include umbilicoileal fistula, omphalomesenteric duct sinus, omphalomesenteric duct cyst, and fibrous connection of the ileum to the umbilicus . As the A 69-year-old previously healthy male patient presented with a history of vomiting for five days' duration. The vomitus contained clear fluid initially, which later became brownish in colour. He had developed absolute constipation for three days. He had noticed gradual abdominal distension during this period. He had not undergone any abdominal surgeries in the past.On examination, his abdomen was distended and there was mild tenderness in the lower abdomen. The examination of the respiratory system did not reveal any abnormalities. Biochemical investigations were unremarkable. With the clinical diagnosis of intestinal obstruction, he was referred for imaging studies.Plain X-ray abdomen was performed in the supine position and it revealed grossly distended small bowel loops with absent rectal gas . There wUltrasound scan of the abdomen revealed fluid filled aperistaltic bowel loops. Central abdomen was distended and presence of bowel gas hindered evaluating the deeper structures. Pancreas appeared normal. There was no free fluid in the abdomen. Liver, spleen, and both kidneys were normal on ultrasound. The superior mesenteric artery appeared normal at the origin and showed normal colour and spectral flow pattern. The portal vein was normal.CT abdomen showed grossly dilated jejunal and ileal loops. The appendix was identified separately. There were no fat strandings or fluid collections around the appendix. Distal ileal loops appeared collapsed. There was a soft tissue density band like structure extending from the collapsed ileal loops anteriorly .However, its insertion site was not identified. There was no CT evidence of appendicitis. The cause for the small bowel obstruction was not identified on CT. However, as the patient had no previous surgeries, the possibility of a congenital band was highly suspected. The presence of a soft tissue density linear band led to the preoperative suspicion of a congenital band. Furthermore, Meckel's diverticulum was not considered on CT images.There was a tubular retroperitoneal structure in the left side of the aorta which was extending up to the left renal vein. It was in continuity with the left external iliac vein and was identified as the left IVC. Right IVC was also noted. Left IVC was smaller in caliber than the right IVC .Left internal iliac vein was seen crossing the midline to drain into the right common iliac vein .Patient underwent exploratory laparotomy. There was a Meckel's diverticulum with fibrous band extending to the anterior abdominal wall . The sizMeckel's diverticulum is the result of incomplete obliteration of the vitelline or omphalomesenteric duct and is the commonest congenital anomaly of the gastrointestinal system . It is lMost of the instances, this anomaly is asymptomatic and the lifetime risk of developing complications is between 4% and 6% . FurtherSmall intestine obstruction due to persistent vitelline-intestinal duct is extremely rare, especially in adult patients, and very few cases were reported in the literature . Thus, aAnatomical variation of the inferior vena cava occurs in 0.4–4% of the population . FormatiThe importance of identifying the left IVC is that it can be mistaken for lymph node mass. It is also important to inform the referring surgeon regarding this anomaly to avoid catastrophic complications during surgery . AlthougReports on association of double IVC and congenital gastrointestinal anomalies are scarce. One case report was found in the literature stating duplication of inferior vena cava and malrotation of gut in the same patient . HoweverIn conclusion, although not common, Meckel's diverticulum should be borne in mind when elderly patients present with intestinal obstruction. Identification of this anomaly can be difficult in imaging studies. Presence of double IVC should be mentioned in the imaging findings as this will prevent catastrophic complications during surgery. It is important to communicate the presence of a double IVC to the operating surgeon, in order to avoid forceful interference during the surgical procedure.


Myopericytoma is reported to occur mainly in the skin and superficial soft tissue of the extremities. In contrast, occurrence in the urinary bladder is extremely rare.h-caldesmon.We describe a 75-year-old Japanese man who developed a submucosal tumor at the right trigone of his bladder that led to interference with the discharge of right ureteral calculus. No invasive growth was observed by magnetic resonance imaging. Transurethral resection was successfully performed; histopathological analysis revealed perivascular proliferation of spindle-shaped to oval-shaped, cytologically bland tumor cells with eosinophilic cytoplasm. On immunohistochemical examination, the tumor cells were positive for alpha-smooth muscle actin, desmin, CD34 and Cystoscopic and pathological findings were compatible with a diagnosis of myopericytoma of the urinary bladder. Mesenchymal tumor in the bladder accounts for less than 1 % of all bladder neoplasms .Myopericytoma is a benign mesenchymal neoplasm composed of cytologically uniform presentation ranging from oval to spindle-shaped cells with a myoid appearance showing multilayered, perivascular concentric growth , 3. MyopIn the present case report, we review our experience with a case of myopericytoma occurring in urinary bladder, and report the clinicopathological features.A 75-year-old Japanese man was referred for sudden asymptomatic gross hematuria. Ultrasonography and abdominal X-ray suggested bladder calculus, and computed tomography (CT) was performed. CT showed intramural right ureteral calculus (1.8 cm in diameter) and a well-circumscribed hypervascular mass measuring approximately 2.1 cm at the right trigone of his urinary bladder Fig. . HydroneOn gross examination, the resected surface of the mass specimens was solid, firm, and tan-white to yellow without apparent necrosis and hemorrhage.h-caldesmon, and CD99 was weakly and focally expressed  classification (of tumor of soft tissue and bone) . Myoperiet al. , the majOn histopathologic examination, morphological features were consistent with myopericytoma. On immunohistochemical examination, the majority of the findings were also consistent; however, unusual intense immunoreactivity was observed in CD34. Although, myopericytoma is reported to be negative for CD34 in most cases, one case of strong and three cases of partial reactivity have been reported in the kidney , 7, 9.Myopericytoma shares several morphologic and immunohistochemical features with myofibroma, angioleiomyoma, and glomus tumor , 3. HoweMyopericytoma is generally considered a benign tumor with favorable clinical course, although local recurrence has been reported in a small number of cases –10. HoweWhile myopericytoma commonly occurs in skin and superficial soft tissue, it is extremely rare in the urinary bladder. We treated a 75-year-old Japanese man with submucosal tumor adjacent to the right ureteral orifice. The tumor may have interfered with the discharge of ureteral calculus. Cystoscopic and pathological findings prompted the conclusion that the tumor was the urinary bladder counterpart of myopericytoma.


Reverse takotsubo cardiomyopathy is an uncommon cardiomyopathy characterized by reversible regional wall motion abnormalities in the basilar segment of the left ventricle. This happens in the absence of any coronary artery pathology. Although it shares some pathogenic mechanisms with its more common variant, takotsubo cardiomyopathy, differences exist in terms of echocardiographic features, demographics, clinical manifestations, laboratory features, and prognosis. Cases of postoperative reverse takotsubo cardiomyopathy are less described in the literature. Herein, we report a case of reverse takotsubo cardiomyopathy in a 44-year-old woman occurring after exploratory laparotomy. It is usually characterized by depressed function or akinesis of the mid and apical segments of the left ventricle along with hyperkinesis of the basal walls.1 On the other hand, reverse TTC (r-TTC), or inverted TTC, has been recognized as a variant with a hypocontractile ventricular basal segment along with a hypercontractile apex.2 Cases of r-TTC following surgery seems to be unusual and rare.4 In this article, we report a case of r-TTC in a patient who underwent exploratory laparotomy for small bowel obstruction.Takotsubo cardiomyopathy (TTC), also called “broken heart syndrome,” “transient apical ballooning,” and “stress cardiomyopathy,” is an acute cardiac syndrome that mimics myocardial infarction and characterized by transient cardiac wall motion abnormalities. This occurs in the absence of any coronary artery obstruction or acute plaque rupture.Video 1; available in the online version of the article). Therapy with a β-blocker and an angiotensin-converting-enzyme inhibitor was initiated and the patient was discharged on postoperative day 8 with a persistent LVeF of 30%. A follow-up cardiac magnetic resonance imaging was done 14 days later after discharge revealed an improvement in the myocardial function with an LVeF of 54%. A repeat echocardiography also showed normalization of the LVeF.A 44-year-old female patient with a known history of multiple sclerosis (MS) maintained on immunomodulatory agents presented to our emergency department with abdominal pain, nausea, and vomiting. Her past surgical history was only remarkable for appendectomy and partial small bowel resection. The patient was diagnosed with small bowel obstruction after a computed tomography (CT) scan of her abdomen was performed. She was admitted to the surgical service subsequently. However, her clinical status deteriorated and she underwent exploratory laparotomy on the next day. One day after surgery, she started experiencing shortness of breath. Her physical examination was otherwise unremarkable. An electrocardiogram was remarkable only for sinus tachycardia. A CT angiography of the chest for suspected pulmonary embolism was performed and was unremarkable. Serum troponin-T levels done were elevated and peaked at 2.19 ng/mL (reference range: <0.05 ng/mL). CT angiography of the coronary arteries was normal with a calcium score of zero. Echocardiographic examination done revealed a hyperkinetic apical wall along with a hypokinetic basilar wall of the myocardium suggestive of r-TTC with a left ventricular ejection fraction (LVeF) of 30% (5The pathogenesis of both TTC and r-TTC is not well understood. Several mechanisms were postulated. The most widely accepted underlying etiological mechanism behind both types is sympathetic nervous system overactivation. Among the various neurochemical substances associated with cardiac wall motion abnormalities, epinephrine and norepinephrine seem to be the most crucial. This catecholamine surge is believed to mediate a vascular dysfunction leading to coronary artery vasospasm, microvascular dysfunction, hyperdynamic contractility, and direct myocardial toxicity via free radicals formation.5 This has been also proven by 123-meta-iodobenzylguanidine myocardial scintigraphy that implied more myocardial sympathetic innervation in the apex.6 This might explain the myocardial stunning affecting the apical wall in TTC. However, it does not explain the hyperkinetic apical wall motion in r-TTC, neither the hypokinesis of the basal wall. It has also been postulated that as catecholamine levels subside after a surge, a quicker apical recovery might happen leading to r-TTC pattern.6 Nevertheless, this again does not explain the hypokinesis observed in the basal wall.Furthermore, there seems to be a role in protein signaling within the myocardial cells that mediates a paradoxical negative inotropic effect to protect against the intense activation of β-adrenoceptors. This effect is greatest at the apical myocardium where the β-adrenoceptor density is highest.7 Song et al8 and Ramaraj et al9 observed that in r-TTC patients are usually younger, tend to have a lower LVeF, and sustains a quicker myocardial recovery in comparison to TTC. Moreover, since the basilar part of the ventricle is the main involved region in r-TTC, which has more myocardial tissue, cardiac biomarkers are usually more elevated in comparison to TTC.9Additionally, it is worth noting that certain clinical features differ between TTC and r-TTC.1013 Biesbroek et al11 and Kozu et al12 both reported r-TTC in association with new MS lesion occurrence. They have speculated a possible role for demyelinating brain lesions interfering with sympathetic nervous system regulation. On the other hand, Peller et al10 reported r-TTC in a patient with stable MS, which is similar to our case; however, our patient had the complication after surgery and without any acute electrocardiogram changes, in comparison to the previous cases. It is unclear in our case whether MS had a role in triggering r-TTC or whether surgery itself was the sole stress triggering factor.In the literature, most reported cases of r-TTC occurred after physical or emotional stress. Although surgery is considered a form of stress, it is less described. Nevertheless, it remains unclear whether r-TTC occurring after surgery is secondary to physical or emotional stress solely, or whether there is a role for anesthetic agents in triggering this cardiomyopathy. Furthermore, TTC and r-TTC have been reported in several neurological diseases such as subarachnoid hemorrhage, seizure, and ischemic stroke but rarely in MS patients.Reverse takotsubo cardiomyopathy is a rare type of stress-induced cardiomyopathy that is described mainly following neurological insults. Cases of r-TTC following surgery are less described in the literature. We presented a case of r-TTC in a patient with stable MS who underwent exploratory laparotomy for small bowel obstruction.


Primary osteosarcoma of the bone with rhabdoid features is a rare malignant tumor of bone, not previously described in the literature. Here we report a 69-year-old female who originally presented with a right femur pathologic fracture. Radiographs of the injury showed an aggressive-appearing lesion of the distal femur. Initial biopsy was done, which was not diagnostic; additional advanced imaging studies were performed, which failed to show any other site within the body with detectable disease process. Accordingly, the patient underwent radical resection of the distal femur and reconstruction with endoprosthesis. Histopathology obtained from the operative specimen showed osteosarcoma with rhabdoid features. Two months after surgery, the patient is symptom-free and doing well; she is currently pending adjuvant chemotherapy. Although rhabdoid features have been described in extraskeletal osteosarcoma, this appears to be the first mention of osteosarcoma of bone with rhabdoid features in the literature. Primary osteosarcoma with rhabdoid features is a rare, previously undescribed malignant neoplasm of bone with histologic features of both primary osteosarcoma and those of rhabdoid cells. Osteosarcoma is mesenchymal neoplasm which accounts for 15% of all primary tumors of bone . PrimaryRhabdoid tumors have been divided into three classes, based upon anatomic location: malignant rhabdoid tumor of the kidney, extrarenal extracranial rhabdoid tumor, and atypical teratoid rhabdoid tumor involving the central nervous system . RhabdoiExtraskeletal osteosarcoma with rhabdoid features has been previously described twice in the literature, first in the scalp by Pillay et al.  and lateAn otherwise healthy 69-year-old female presented to our emergency department with five days of acute right thigh pain and inability to ambulate after a low-energy fall from standing height. Prior to her acute presentation, the patient suffered from approximately 1 month of progressive knee and thigh pain; however she did not seek any medical care during that time period for her insidious lower extremity pain. The patient denied any constitutional symptoms, weight loss, or presence of other alarming symptoms during the time period leading up to her fracture. Initial radiographs of the right femur showed a pathologic fracture associated with an aggressive-appearing lesion in the distal femur. The associated lesion was a markedly expansile, poorly geographically defined lytic lesion measuring approximately 9 × 6.7 cm in the metaphysis of the distal femur. The films also revealed associated periosteal reaction with disorganized bone formation and cortical destruction laterally; the pathological fracture could be observed at the proximal extent of the lesion . Due to Given the lack of osteoid-producing cells seen on original histopathology, the differential diagnosis at that time did not feature osteosarcoma. Taking into account the presence of rhabdoid cells, the working diagnosis at that time was established as metastatic carcinoma of unknown origin with rhabdoid features, versus rhabdoid sarcoma of the thigh with local spread to the femur. Therefore, the patient was referred for chemotherapy; however, she experienced issues with payment due to the expiration of her insurance, and she was unable to initiate chemotherapeutic treatment. The patient's leg remained in a long leg cast, and she was lost to follow-up for a brief period of time. One month later, she again presented to the emergency department, now with severe pain, inability to ambulate, balance problems, and high fall risk. Due to the patient's unclear diagnosis, her inability to obtain chemotherapy, and the few reasonable treatment options in this setting, the decision was made to treat patient with right distal femur radical resection and reconstruction with an endoprosthesis . The proGross pathology of the surgical specimen showed the presence of new, disorganized bone formation ; and hisThe most common malignancy of bone is metastatic, particularly in the elderly population, which would have made a metastatic lesion a likely probability in our patient. However a thorough workup via CT and PET imaging showed no other lesions in the patient's body. Furthermore the imaging revealed multiple characteristics of osteosarcoma, such as a sunburst pattern of periosteal reaction, new disorganized bone formation extending into adjacent tissue, cortical destruction, and the location of the lesion. Nonetheless, malignancy of unknown primary source was still felt to be the most likely diagnosis after the patient's needle biopsy, given the findings of rhabdoid cells and lack of any finding of osteoid matrix .The working diagnosis was revised however, after histopathology obtained from the surgical specimen showed the presence of osteoid matrix and matrix-producing cells. As in the original needle biopsy sample, eosinophilic rhabdoid cells with their characteristic nuclei and nucleoli and cytoplasmic inclusions were prominently featured and clearly identified under the microscope Figures  and 5. HThe question remains however: is this a primary osteosarcoma of bone? The incidence of osteosarcoma is bimodal; the second, smaller peak appears in adults greater than 65 years of age . Our patThis patient's diagnosis, primary osteosarcoma of bone with rhabdoid features, is an apparently novel diagnosis, not yet described in the literature. Unlike the bimodal distribution observed in osteosarcoma, rhabdoid tumors are almost exclusively pediatric tumors. Typically, rhabdoid tumors are found in the central nervous system or in the kidneys . There h


A 29-year-old male with acquired immunodeficiency syndrome presented with a week of left eye blurriness, which then progressed to complete vision loss. On exam, the left pupil was nonreactive to light, and fundoscopy showed significant optic nerve edema. CT and MRI of the left orbit showed a mass lesion compressing the posterior aspect of the sclera with diffuse thickening and contrast enhancement of the retrobulbar portion of the left optic nerve. The lesion demonstrated low T1 and intermediate T2 intensities and heterogeneous contrast enhancement and measured 17.4 mm x 15 mm x 10.6 mm. Anterior orbitotomy with exploration and biopsy were performed. Immunohistochemical studies confirmed diffuse large B-cell lymphoma and a workup showed no systemic involvement. Plans for treatment with chemotherapy and radiation were initiated. Even though rare, primary orbital NHL should be in the differential for relatively acute blindness without other symptoms, especially in patients with AIDS. Primary orbital lymphoma is a rare condition and site for non-Hodgkin’s lymphoma. The most common type of NHL is diffuse large B-cell lymphoma. NHL can have extra-nodal presentation in 25% to 35% of patients. However, extra-nodal lymphoma of the head is very rare . Even thNon-Hodgkin’s lymphoma is a heterogeneous group of malignant lymphomas that reflect the development stages of lymphocytes, with the majority arising from a B-cell origin. Even though primary orbital lymphomas represent 1% of NHLs and 8% of extra-nodal NHLs, POLs make up about half of adult primary orbital malignancies , 5]. Un. Un5]. UThe mean duration of symptoms of a POL at presentation is approximately 18 months (range: 10 days to 10 years), which is significantly greater than our patient’s duration of one week . TatsugaCT scans generally shows a well-defined, homogenous, high-density mass that is nodular and has distinct margins . MRI usuDiagnosis of POLs is accomplished by tissue studies and imaging. Standard treatment for DLBCL includes R-CHOP with or without radiation. R-CHOP is safe for AIDS patients and can be combined with HAART therapy. It is rare for the presenting symptom of a POL to be complete blindness without other symptoms of mass effect. We describe a case of a primary orbital NHL causing complete blindness in the left eye of a 29-year-old male with AIDS after a week of blurriness. A 29-year-old Hispanic male presented with a week of blurriness in his left eye that progressed to complete vision loss. He was HIV positive for 6 years with a latest CD4 count of 100 and a viral load of 617 copies/mL on HAART therapy. He noted fevers and chills, but no other symptoms. On examination, the left pupil was fixed with no response to light. A reverse relative afferent pupillary defect was present in the right eye. The left optic nerve was edematous with blurring of margins. A CT scan showed enhancement of the retrobulbar optic nerve of the left eye with an adjacent, discrete soft tissue enhancement bordering the posterior globe Figure 1 . Two weeHistology of the mass showed tissue diffusely infiltrated with large, dysplastic lymphocytes with vesicular nuclei (Figure 3A Even though rare, primary orbital NHL should be in the differential for subacute blindness especially in patients with AIDS. After imaging and diagnostic biopsy, patients should be immediately staged and treated. For DLBCL, the standard treatment includes R-CHOP with HAART for AIDS patients.BCL: B-cell lymphomaCD: cluster of differentiationCT: computerized axial tomographyDLBCL: diffuse large B-cell lymphomaHAART: highly active antiretroviral therapyMALT: mucosa associated lymphoid tissueMRI: magnetic resonance imagingNHL: non-Hodgkin’s lymphomaPOL: primary orbital lymphomaR-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine, prednisoneInformed consent was obtained from the patient, and this report is HIPAA-compliant.The authors declare that they have no competing interests.


Portal vein thrombosis (PVT) refers to thrombosis that develops in the trunk of the portal vein including its right and left intrahepatic branches and may even extend to the splenic or superior mesenteric veins. PVT due to Cytomegalovirus (CMV) infection is a rare complication, scarcely described in English literature. We present a case of a 58-year-old immunocompetent patient with PVT and small bowel ischemia. A 58-year-old immunocompetent female presented to the emergency department with abdominal discomfort, fever, and increasing chronic fatigue. Cytomegalovirus (CMV) IgM antibodies had already been tested by her general practitioner, and the result was consistent with an acute CMV infection. The treatment was symptomatic and consisted of analgesics and antipyretics.Five hours later, the patient was readmitted to the emergency department with severe abdominal pain. Her clinical examination revealed abdominal defense, percussion pain, and rebound tenderness. Blood tests showed disturbed liver function and confirmed CMV infection. Abdominal ultrasound showed slight splenomegaly, but the clinical degradation with development of an acute abdomen required prompt contrast-enhanced abdominal CT, which demonstrated thrombosis of the superior mesenteric vein, the right portal vein, part of the left portal vein, and the distal splenic vein Figures , 2, 3. DThe patient was transferred to the nearest University Hospital for systemic thrombolysis . However, it had to be discontinued due to a large cervical hematoma at the central line site. Treatment with heparin was tried after the bleeding stopped, but it had to be discontinued due to digestive tract bleeding. Gastroscopy excluded esophageal varices and gastric ulcers.The patient developed a secondary episode of acute abdomen with peritonitis due to secondary small bowel necrosis. Surgical resection of the small bowel and an extensive right hemicolectomy was performed (80–100 cm remaining bowel). The patient was discharged after three weeks.Portal vein thrombosis (PVT) usually occurs in association with cirrhosis or malignancy of the liver. There are however non-cirrhotic cases based on one or more features of Virchow’s triad: reduced portal blood flow, vascular endothelial injury, or a hypercoagulable state. Venous thromboembolism due to acute CMV infection is a well-known complication in immunocompromised patients. However, in immunocompetent patients, it is often underestimated or not considered. According to a recent prospective study by Paran et al., the reported incidence rate is 6.9 percent . Our patA contrast-enhanced CT scan is the gold standard to promptly diagnose PVT. Arterial phase usually provides little information; the diagnosis can only be reliably made during the portal venous phase. CT findings include demonstration of the thrombus itself, presenting as a well-defined intraluminal filling defect with central low attenuation, which may be surrounded by enhanced venous walls. Accompanying collateral circulation, engorgement of mesenteric veins, and mesenteric edema may be present. Bowel wall thickening is the most common manifestation of venous bowel ischemia. The combination of low attenuation in the superior mesenteric vein, thickening of the small bowel wall, and the presence of ascites make bowel infarction very likely.Various causative mechanisms have been considered as the reason for CMV-associated thrombosis. However, the currently most accepted theory is that CMV transiently induces production of antiphospholipid antibodies . PhosphoOur case illustrates that venous thromboembolism caused by an acute CMV infection may occur in immunocompetent patients. The importance of a contrast-enhanced CT scan to allow for early diagnosis and therapy is illustrated.


Cancer of the urethra is very rare with an age-adjusted incidence of only 0.6 per million women in Europe. The etiology is multifactorial and the incidence increases with age, with the highest rates in patients 75 years or older. We herein describe a 58-year-old woman referred to our unit due to pollakisuria and repeated lower urinary tract infections. The gynecological examination revealed a suspect area in the anterior wall of vagina. Subsequently, ultrasound examination, MRI, and PET-CT scan followed by vaginal biopsies revealed a urethral adenocarcinoma. Urethral cancer is very rare. The annual age-adjusted incidence rate for women is 1.5 per million in the United States and only 0.6 per million women across Europe . The 5-yThe ethology is multifactorial. Thus, recurrent urinary tract infections, sexual-transmitted diseases, and urethral stricture seem to increase the risk of urethral carcinoma . Also, HWe herein present a rare case of a 58-year-old woman with urethral adenocarcinoma.In November 2016, a 58 year-old woman was referred from her general practitioner to our Gynecological Department. Her main complaints were up to 16–18 micturitions a day and repeated bladder infections despite continuous antibiotic treatment with either Pivmecillinam (Selexid®) or Nitrofurantoin. She had a feeling that she could not empty her bladder.Due to the organization of our outpatient clinic, a nurse with a special interest in incontinence initially saw the patient. At this visit an uroflowmetry showed obstruction, a voiding time of 78 sec, and residual urine of 190 ml.Input and output tables showed daily intakes of 1700–1800 ml and a total urine production of 1310–1860 ml. At her first visit the patient was instructed to perform double or triple voiding, and further she was recommended local treatment with estrogens (Vagifem® or Estring®).After one month, she was referred to the outpatient clinic to see an urogynecologist. She was in pain and was not able to empty her bladder properly through the night. Moreover, during the previous months, she had some abnormal bleeding from the vagina and blood-stained urine.A gynecological examination was performed which revealed a palpable solid mass located in the anterior wall of the vagina.The anterior and posterior vaginal wall presented without prolapse. Uterus was well suspended and the cervix appeared normal. After examination, a small area in the anterior wall of the vagina was seen to bleed.Transvaginal ultrasound showed a bladder containing a total of 250 ml urine, a normal uterus with a thin endometrium of 1,4 mm, and two normal adnexa.The solid area was located in close contact with the anterior wall of the vagina and the urethra was measured to be 29 × 28,8 mm on ultrasound.Due to the urinary retention and pain, an attempt to apply a urinary catheter was done; however, this was not possible due to obstruction. Blood samples from the bleeding area in the anterior wall of the vagina and from the urethra were sent to the pathologist for further examination. An urologist was contacted and an ultrasound-guided suprapubic catheter was placed.The patient was further examined having a cystoscopy with biopsies, a MRI scan, and a PET-CT scan, revealing a urethral adenocarcinoma measuring 4 × 4,5 cm with suspected lymph node affection of the iliac vessels on the left side .In January 2017, 19 lymph nodes were removed laparoscopically. All 19 lymph nodes were normal without any malignancy. The finale staging diagnosis was a large T3, M0, N0 tumor . Due to Urethral cancer is very rare with an annual age-adjusted incidence rate for women being 1.5 per million in the United States and only 0.6 per million women across Europe . PatientMRI scan is used for local staging of the tumor, while imaging for regional lymph node metastases involves either MRI-CT or (PET-) CT scan. In women, the proximal 1/3 of urethral drains into the pelvic lymph nodes and the distal 2/3 drains into the superficial or deep inguinal lymph nodes. Finally, a CT scan is used for assess the possible presence of metastases in the abdomen and thorax . In a stTreatment consists of surgery, radiotherapy, chemotherapy, brachytherapy, and often a combination of these. Previously, Derksen et al. reported an overall survival rate of stages 0–II, stage III, and stage IV of 67, 53, and 17%, respectively. Moreover, Dalbagni et al. found that the 5-year overall survival was 32%, while Visser et al. reported the 5-year relative survival rate for cancer of the urethra to be 54% [Urethral cancer can present with different nonspecific symptoms from the urinary tract. Awareness of urethral cancer is important in daily clinical practice as it may present also in women under the age of sixty.