Introduction: Recreational and sport activities, traffic accidents and human behaviour represent the main causes of trauma in young people. Case presentation: This report describes a case of a 15.2-year-old male who suffered uncomplicated crown fracture and avulsion of tooth 11 and uncomplicated crown fracture of tooth 21 due to a bicycle accident. Tooth 11 was dry stored and it was replanted 18 h after the trauma. The root was planed to remove the necrotic periodontal tissue, the pulp was extirpated before replantation and a flexible splint was applied to tooth 13 to tooth 23 for 3 weeks. A replacement root resorption of replanted tooth was suspected at the 3-month radiographic control and suffered a dramatic increase later; minimal infraocclusion, about 1 mm, was observed due to its ankylosis. Sixteen years after the trauma the patient was scheduled for an orthodontic and implanto-prosthetic rehabilitation. Conclusion: Delayed replantation usually has a long-term poor prognosis, so it is very important to promote awareness regarding emergency management modalities in dental traumatology especially among parents, school teachers, and coaches that are usually present at the site of the accident.  Traumatic avulsion of teeth is a very serious assault on the gingiva, the periodontal ligament and the pulp. It occurs with a range from 0.5 to 3% of injuries in permanent teeth, most often in children and adolescents, because a relatively resilient alveolar bone provides only minimal resistance to extrusive forces .Recreational and sport activities, traffic accidents and human behavior, such as risk-taking children, children being bullied, emotionally stressful conditions, obesity, and attention-deficit hyperactivity disorder, represent the main causes of trauma in young people. Oral factors, particularly increased overjet with protrusion and inadequate lip coverage, amplify the risk of traumatic dental injuries .Pulp and periodontal healing depends on the stage of tooth development, time, and type of extra-alveolar storage, therefore, a tooth with an open apex has a greater potential for pulpal revascularization and tissue regeneration because it may contain a rich blood supply and stem cells ,4; and pRecall visits allow for an early diagnosis and treatment of complications like pulp necrosis or root resorption that may occur long after the trauma. A case of a 15.2-year-old male who suffered a facial trauma following a bicycle accident is reported with a 16-year follow-up.A healthy 15.2-year-old male arrived at the dental office coming from the Hospital Emergency Unit 18 h after a facial trauma due to a bicycle accident. Intraoral examination revealed avulsion of tooth 11 and an uncomplicated crown fracture of tooth 21 .The fragment of tooth 21 was discovered inside the swollen and lacerated upper lip. No other oral injury was detected clinically. Examination of the avulsed tooth showed an uncomplicated crown fracture and necrotic periodontal ligament cells due to the prolonged dry storage. After the parents’ informed consent, the root of the avulsed tooth was planed to remove the necrotic periodontal tissue, and was then filled with gutta-percha and sealer after pulpectomy .The fractured crown was restored with composite resin. A local anaesthetic was administered to remove the contaminated coagulum from the socket prior to pushing back the tooth with a gentle pressure. A functional splinting with an orthodontic 0.014-inch braided stainless steel wire and composite resin was positioned from tooth 13 to tooth 23  and leftThe splint was removed 3 weeks later and the fractured crown of tooth 21 was restored with composite resin .The importance of recall visits was emphasized to the patient and the parents, so the patient was scheduled for a follow-up according to the International Association of Dental Traumatology (IADT). Due to the prolonged extra-alveolar dry storage (about 18 h) and the age of the patient, ankylosis and infraocclusion of tooth 11 were expected. A replacement root resorption of the replanted tooth was suspected at the 3-month radiographic control , and draFinally, 16 years after the trauma  the patiThe prognosis of avulsed teeth is inevitably affected by appropriate first aid at the site of injury. Immediate replantation is the best practice for avulsed permanent teeth. If it is not feasible, the teeth must be stored in the mouth of the patient inside the lip or cheek or in a container with saliva for a short period of time, no longer than 30 min. Saliva is a hypotonic solution; its osmolality (60–70 mOsm/kg) is much lower than the physiologic one, causing cell swelling, which stretches the cell membrane, and potentiates the effect of bacterial products and toxins present in itself. As saliva is always available, it should be considered as a temporary medium to avoid dry storage. A combination of brief storage in saliva is recommended, with subsequent storage in a physiologic medium, rather than storage in saliva only. The ideal biological medium is Hank’s Balanced Salt Solution (HBBS), but its availability near the site of an accident is doubtful. HBBS has a pH balanced at 7.2, an osmolarity of 320 mOsm/kg, and preserves viability, mitogenicity and clonogenic capacities of periodontal ligament cells for up to 24 h. Based not only on periodontal ligament cell viability, but also on practical considerations such as low cost and high availability, milk is one of the most commonly used and recommended storage media. It has a pH of 6.5–7.2 and an osmolarity of 270 mOsm/kg. Being a gland secretion, milk contains epithelial growth factor, which stimulates the proliferation and regeneration of epithelial cell rests of Malassez, and activates the alveolar bone resorption. Pasteurized and refrigerated fresh milk with lower fat is preferable. It can effectively store the tooth for up to 6 h, although 3 h is considered the threshold storage time, and it is as effective as HBBS for up to 1 h. . MoreoveDelayed replantation usually has a long-term poor prognosis. The follow-up of a replanted tooth observed in the present case has rarely been described in literature. The possibility of a very long survival encourages dentists to attempt this procedure to fulfill the esthetic, functional, and psychological needs of the patients who are in late adolescence or adulthood when they sustain their injury. Conversely, immediate replantation at the site of the accident or correct maintenance of an avulsed tooth in a physiologic storage medium are resolutory for treatment outcome. Therefore, it is very important to promote awareness regarding emergency management modalities in these severe and unexpected injuries, not only among emergency healthcare professionals, but especially among parents, school teachers, and coaches that are usually present at the site of the accident, through direct education, via press or by mass media campaigns.


The best approach for resecting epidermoid cysts is still controversial. We describe a case of an epidermoid cyst in which laparoscopic resection was performed successfully.63 × 55-mm well-defined cystic mass was incidentally detected by computed tomography in the presacral cavity of a 50-year-old woman during evaluation for upper abdominal pain. Magnetic resonance imaging showed a cystic tumor with a low signal intensity on T1-weighted images and, high signal on T2-weighted images in the left dorsal side of the rectum. This tumor was diagnosed as a developmental cyst, and laparoscopic resection was performed. Resection of the tumor was performed with negative margins. This tumor was histopathologically diagnosed as an epidermoid cyst. There was no evidence of malignancy, and no postoperative event or signs of recurrence occurred 6 months postoperatively.In our patient, there was no difficulty in the field of view and forceps operability during laparoscopic surgery. Furthermore, it is possible to perform laparoscopic surgery with minimal damage to the muscles, nerves, and rectum, leading to the preservation of anal function.Laparoscopic resection of an epidermoid cyst may be a better option in carefully selected cases with consideration of the tumor size and location. They are mostly benign tumors, but they reportedly have risks of infection, fistula, and malignancy . Therefo2A 50-year-old woman was referred to our hospital for further examination of a cystic tumor in the pelvis that was incidentally detected by computed tomography (CT) during evaluation for upper abdominal pain. She had no past medical and surgical history. On digital rectal examination, a soft mass was palpated outside of the rectal wall. Laboratory findings indicated that the carbohydrate antigen 19-9 level was within the normal limit (11.3 U/ml), but the carcinoembryonic antigen level was slightly high (7.2 ng/ml). A colonoscopy showed no tumorous lesions. Contrast-enhanced CT revealed a 63 × 55-mm well-defined, homogeneous cystic mass in the left dorsal side of the rectum and ventral side of the coccyx. Magnetic resonance imaging (MRI) showed a unilocular cystic tumor with a low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and high signal intensity on diffusion-weighted images . The tumThe patient was placed in the lithotomy position. Access to the tumor was gained with by using a 10-mm umbilical port with the Hasson technique, followed by four 5-mm ports in both the right upper/lower and left upper/lower quadrants. The uterus was fixed to the anterior abdominal wall with sutures. The tumor was placed along the left lateral side of the rectum , located at the caudal level (below S4), and has not invaded surrounding structures, a sacral approach is often selected  cm, loca.In our patient, there was no difficulty in the field of view and forceps operability during laparoscopic surgery. Since an epidermoid cyst is a well-defined lesion, ablation between the tumor and muscle is easy because of the magnifying effect of the laparoscope. Furthermore, it is possible to perform laparoscopic surgery with minimal damage to the muscles, nerves, and rectum, leading to the preservation of anal function. However, a longer operating time may be required.Laparoscopic surgery is considered to be one of the options in terms of its minimal invasiveness, reduced risk of complications, and complete tumor removal. Laparoscopic resection of an epidermoid cyst might be implemented in carefully selected cases with consideration of the tumor size and location.There are no conflicts of interest.There are no study sponsors or sources of funding.No ethics committee approval is required at our institution for a case report involving a single patient.Written informed consent was obtained from patient for publication of this case report and accompanying images.1Koichi Mohri wrote the paper and did data collection and inter-pretation.2Tadahiro Kamiya, Kazuhiro Hiramatsu, Yoshihisa Shibata, Motoi Yoshihara, Taro Aoba, Akira Ito, and Takehito Kato reviewed this article and approved.Not applicable.Koichi Mohri.Not commissioned, externally peer-reviewed.


Sister Mary Joseph's nodule (SMJN) is a metastatic malignancy of the umbilicus usually indicative of advanced, metastatic disease. It is a rare occurrence, but it may be the first sign of abdominal cancer, most commonly an adenocarcinoma metastasis from a gastrointestinal or gynecologic primary malignancy. We present the case of an 82-year-old woman with an acute, 2 cm non-tender mass located at the umbilicus, diagnostic indication of an SMJN. Additional investigations included imaging via ultrasound and a pelvic magnetic resonance imaging (MRI) along with a biopsy and immunohistochemical staining in order to further characterize the mass. Our findings are discussed in the following case report. Sister Mary Joseph's nodule (SMJN) is a rare growth found at the umbilicus that indicates a metastasis from a pelvic or abdominal source. Cutaneous metastases of malignant neoplasms are relatively uncommon, occurring between 0.7% and 9% of autopsy evaluations . An SMJNAn 82-year-old obese woman presented to the dermatology department because of a two-month history of an enlarging umbilical mass that had been bleeding. The patient also complained of menorrhagia for the previous two weeks. Physical examination showed a 2 cm firm, non-tender, protrusive umbilical nodule Figure . LaboratHistological and immunohistochemical examination of the umbilical mass biopsy diagnosed a high-grade serous ovarian carcinoma. Histological/cytological evaluations of all umbilical lesions are mandatory, not only to determine its nature but also to guide the clinician in searching for the possible primary source . FurtherThe patient subsequently underwent a hysterectomy and bilateral salpingo-oophorectomy. The patient declined chemotherapy as she found this treatment approach too aggressive.It is suggested that primary umbilical adenocarcinomas arise from embryologic remnants connected to the umbilicus, such as the omphalomesenteric (OM) duct or the urachus -10. The Diagnosis of SMJN was made. Consideration of the primary differential diagnoses of a patient presenting with an umbilical nodule included an umbilical hernia, endometriosis and a keloid, with other causes including a granuloma, abscess, mycosis, and eczema Table  12]. Al. Al12]. An umbilical hernia occurs when the abdominal musculature fails to close completely in infancy, or excess pressure to the abdominal contents is present, resulting in penetration of intestinal tissue at this location. Adult umbilical hernias usually are a consequence of increases in pressure  combined with the pull of the abdominal muscles and the deterioration of the connective tissue . An umbiEndometriosis results when tissue normally found in the uterine-lining is found outside of the uterus. Umbilical endometriosis is a common manifestation of external endometriosis, representing primary or secondary endometriosis, with a typical presentation that has little variation . This diA keloid is cell growth beyond the boundaries of normal cell division. The exuberant scar tissue in keloids has been attributed to augmented growth factor activity (transforming growth factor-β and platelet-derived growth factor) and alterations in the extracellular matrix  . A keloiTreatment strategies for an SMJN focus on diagnosing the underlying cause of the metastatic tissue. Once discovered, recent studies recommend an aggressive surgical approach combined with chemotherapy as a treatment strategy for an SMJN associated metastasis . Yet as Umbilical masses in adults are rarely seen in day-to-day practice, and physicians must exercise caution when dealing with umbilical lesions. As in this patient’s case, an SMJN can be an important diagnostic and prognostic factor to consider in the assessment of gynecologic oncology patients. Therefore, these nodules should always prompt further investigation into the primary cause of the growth.


Liposarcomas are rare causes of oesophageal tumours, accounting for <1% of tumours. We present a case of a dedifferentiated oesophageal liposarcoma arising from a giant fibrovascular polyp for which resection was performed via a left cervical oesophagostomy with transgastric retrieval of tumour. We also review the existing literature focusing on discussion of resection techniques.To date, 62 cases of oesophageal liposarcoma have been reported in the literature. They usually occur in males (74.2%), with a median age of 66 years (range 38–84 years). Such tumours present most commonly with dysphagia (69.4%); usually arise from the cervical oesophagus (79%), and are well-differentiated. Treatment options include surgery and recently, endoscopic resection techniques such as submucosal dissection (ESD).Giant oesophageal liposarcomas are very rare tumours. Such tumours are usually polypoid, arising from a pedicle. As such, resection techniques have shifted away from oesophagectomy to less invasive means such as endoscopic resection or oesophagostomy. Decision on type of resection technique depends on tumour characteristics and location; with the guiding principle being resection with clear margins in order to prevent local recurrence. They account for <1% of oesophageal tumours and usually arise from the upper oesophagus. We present a case of a dedifferentiated liposarcoma arising within a giant fibrovascular polyp and a review focusing on the resection techniques in the literature. This case has been reported in line with the SCARE criteria .2A 54-year-old Chinese gentleman presented to the hospital for palpitations and exertional dyspnoea over 3 months. He was initially reviewed by a cardiologist and a transthoracic echocardiography performed showed a 3.9 cm × 4.2 cm mass posterior to the left atrium. He was also found to be anaemic with a haemoglobin of 5.9 g/dL. Upon further questioning, he denied any symptoms of dysphagia, abdominal or chest discomfort, reflux/regurgitation and respiratory symptoms. He did however note a loss of weight of 5 kg over the same duration with no loss of appetite.A CT scan of the thorax, abdomen and pelvis was performed which showed a markedly dilated oesophagus with large intraluminal masses extending from proximal thoracic oesophagus to cardioesophageal junction (CEJ). There appeared to be 2 masses in close proximity measuring 4.5 cm × 7.2 cm and 5.8 cm × 14.4 cm, with a stalk arising from the cervical oesophagus. The proximal mass was noted to be predominantly fat whilst the distal mass was of a mixed fat and soft tissue attenuation. There was no invasion of adjacent structures and no enlarged lymph nodes or distant metastases. Oesophagogastroduodenoscopy (OGD) performed showed one giant, pedunculated polyp distending the oesophageal diameter and extending from the cervical oesophagus to CEJ. The polyp also appeared to be bilobed with mucosal ulceration at its distal aspect , Fig. 4.An endoscopic ultrasound (EUS) was also performed, which showed a large submucosal pedunculated multilobed mass with some lobular lipomatous regions (hyperechoic). A vascular stalk was seen at the proximal oesophagus. Core biopsy of the mass however only revealed rare groups of spindle cells with no malignant cells seen.In view of occult bleeding (and resultant anaemia) from ulceration on the distal polyp, resection was advised. Endoscopic resection was deemed not suitable in view of a highly vascular 1 cm stalk and large size of polyp. He subsequently underwent surgical resection and intraoperative findings were that of a large multiloculated heterogenous oesophageal polyp  spanning up to the CEJ. Total polyp length was 24 by 6 cm with the cut end of stalk to base of polyp being 3.5 cm.2.1The cervical oesophagus was mobilised via a left neck skin crease incision. Longitudinal cervical oesophagostomy was performed on the left side and the polyp stalk on the opposite wall was ligated and oversewn with PDS 3/0 for haemostasis. The polyp diameter was deemed too large for transoral retrieval. A 5 cm left upper quadrant abdominal incision was made and a gastrostomy was performed near the greater curve of the stomach. An Applied medical GelPOINT® port was inserted into the stomach to enable trans-gastric retrieval of the giant oesophageal polyp. Both the cervical oesophagostomy and gastrostomy were closed with PDS 3/0 , Fig. 9.The patient’s post-operative recovery was uneventful and he was progressed to diet on POD 3 and discharged well on POD 4. He was well on follow up post-operatively with no evidence of recurrence.2.2Final histology of the oesophageal polyp showed a dedifferentiated liposarcoma arising within a giant fibrovascular polyp, FNCLCC grade 2, measuring 17.5 cm in size. Stalk margin was clear of tumour. FISH (Fluoresence in situ hybridisation) was positive for MDM2. Immunohistochemistry was positive for CD34, SMA and desmin, but negative for STAT 6, ALK-1, S100, AE1/3 and MNF116 , Fig. 113Search in PubMed was performed using the following search string:  and (Liposarcoma) or . All English-language articles and articles from 1983 (first ever case report) to February 2019 were included. The relevant articles found are shown in 4Liposarcomas are soft tissue tumours most commonly found in the retroperitoneum. It is rarely found in the gastrointestinal tract, especially the oesophagus, and it is estimated to account for less than 1% of oesophageal neoplasms. Ever since the first report by Mansour  in 1983,A literature review by Dowli et al.  found thReview of the literature also revealed that the majority of oesophageal liposarcomas are polypoid with the stalk arising most commonly from the cervical oesophagus. These tumours have the potential to grow to large sizes resulting in obstruction. Reported tumour sizes ranged from 4 cm to a maximum length of 33 cm , with thThe mainstay of treatment is resection with clear margins. Open surgery has classically been the standard of treatment, but over the past decade with advances in technology, endoscopic resection has become a viable option for tumour resection. Endoscopic resection confers the benefit of being less morbid and invasive compared with conventional surgery, especially since the majority of such tumours are pedunculated giant oesophageal polyps arising from a single stalk. Endoscopic techniques described in the literature include (a) using a stabilising retraction suture placed with an endoscopic suturing device followed by division of stalk using ultrasonic shears , (b) usiIn cases where endoscopic resection is not an option, surgery would be the definitive mode of resection. Oesophagostomy, oesophagectomy and laparotomy for resection and retrieval of the tumour have been described in the literature. A systematic review by Dowli et al.  of 40 caFollowing complete resection with clear margins, most authors advocate surveillance with OGD and/or imaging such as computed tomography (CT) scans as such tumours have a propensity for local recurrence. The role of adjuvant radiotherapy and is still controversial and can be complicated by side effects such as constrictive pericarditis, radiation pneumonitis and lung fibrosis .5Giant oesophageal liposarcomas are very rare tumours. The majority present with dysphagia and such tumours are usually polypoid and arise from a pedicle at the cervical oesophagus. As such, resection techniques have shifted from oesophagectomy to less invasive means such as endoscopic resection or oesophagostomy. Decision on type of resection technique depends on tumour characteristics and location; with the guiding principle being resection with clear margins in order to prevent local recurrence.No sources of funding.This study is exempt from ethical approval as we have obtained informed consent from the patient and this is a report of the patient’s management previously and does not change his existing management.Informed consent has been obtained from this patient.http://www.researchregistry.com .This is not needed as per Ng YA.Lee J.Not commissioned, externally peer-reviewed.Y. Annalisa Ng: Conceptualization, Visualization, Writing - original draft, Writing - review & editing. June Lee: Writing - review & editing, Supervision. X.J. Zheng: Writing - review & editing. J.C. Nagaputra: Resources. S.H. Tan: Resources. S.A. Wong: Supervision.There are no conflicts of interest for this case report.


Dear Editor,Fibroepithelioma of Pinkus (FEP), also known as fibroepithelial basal cell carcinoma, is a rare cutaneous neoplasm. It has a frequency that ranges from 0.2% to 1.4% in a series of basal cell carcinomas.The patient was 69 years old, male, white, and with a history of bone tumor in the left femur at the age of 17 years. He had undergone a surgical intervention and adjuvant radiotherapy. Years later, he noticed the appearance of red-brown, asymptomatic, slowly evolving papules, restricted to the skin adjacent to the surgical scar, in the area previously subjected to radiotherapy. In 2016, the patient sought dermatological treatment. He exhibited discreetly raised translucent erythematous plaques with pigmented inferior borders, located on the upper lateral aspect of the left thigh. He also exhibited some translucent erythematous papules, located near the surgical scar . The hisFEP affects non-photoexposed areas, commonly in the inguinal and lumbosacral regions.The etiopathogenesis of FEP is controversial.5The histopathological features are fundamental for diagnosis. They are described as peculiar and unmistakable, evidencing thin anastomosing strands of basaloid cells, surrounded by abundant stroma, which form a uniform border with the underlying dermis, resembling a honeycomb.The evolution of FEP is slow. It exhibits low local aggression and little risk of metastasis.In the presented case, the patient had multiple FEP lesions excised and is attending regular follow-up appointments at the dermatology service.This case is reported to emphasize the possibility of other etiologies of basal cell carcinomas, such as previous radiotherapy.None declared.Bruna Anjos Badaró: Conception and planning of the study; elaboration and writing of the manuscript; obtaining, analyzing and interpreting the data; critical review of the literature; critical review of the manuscript.Lucia Martins Diniz: Approval of the final version of the manuscript; conception and planning of the study; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; critical review of the literature; critical review of the manuscript.Ernesto Negris Neto: Obtaining, analyzing and interpreting the data; intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied.Elton Almeida Lucas: Obtaining, analyzing and interpreting the data; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied.None declared.


Oral lichenoid reaction (OLR) is a type IV cell-mediated immune response in the oral cavity. There is an established relationship between various dental materials and OLR, but few cases reports reported the occurrence of a lichenoid reaction in association with the use of a Hawley retainer.A female patient (twenty years of age) has been complaining of a reddish painful area on the tongue, which started one year ago and has been increasing in size over time. The patient completed orthodontic treatment two years ago and has been using a Hawley retainer for orthodontic retention since then. After performing histological analysis and patch test, the lesion was diagnosed as a lichenoid reaction to the Hawley retainer. Topical corticosteroids were prescribed, and the patient was asked to stop using the retainer and followed for six months.It is difficult to diagnose lichenoid lesions and even more challenging to differentiate between OLP and OLR, therefore it is essential to do a full intraoral and extraoral examination. OLL can occur in association with Hawley retainer, which we believe could be because it is made of an acrylic based material. Generally, OLL resolves after removal of the cause. Oral lichenoid reaction (OLR) or oral lichenoid lesion (OLL) is a condition, which is similar clinically and histologically to oral lichen planus (OLP). This term is used to describe eruptions of the oral cavity having an identifiable etiology .The term OLR was first proposed by Finne et al.  in 1982 Clinically, OLR may appear in any of the forms of OLP, namely reticular, plaque-like, erythematous, erosive, bullous, or ulcerative form  . MoreovWhen the previously mentioned clinical and histological features are present in a unilateral distribution in the oral cavity, OLL is the most probable diagnosis. Furthermore, the presence of dysplastic changes on the histological examination favors the diagnosis of OLL .The following case-report presents full clinical and histological analyses of an oral soft tissue contact reaction to acrylic resin-based Hawley retainer in the form of an erosive area on the left and a keratotic area on the right dorsolateral surface of the tongue.A twenty-year-old female presented to the oral medicine clinic at the Faculty of Dentistry, Alexandria University. The patient complained of a reddish painful area on the tongue, that started one year ago and has been increasing in size over time Fig. . The patNo specific findings were found on medical history taking and extraoral examination. Intraoral examination revealed a reddish patch on the left dorsolateral surface of the tongue surrounded by whitish lines. The lesion measured 2 × 3 cm, had normal consistency, smooth surface texture, and normal surrounding tissues Fig. .Fig. 3AThe initial differential diagnoses included erythroplakia (because of the fiery red color), lichenoid contact reaction (because of the Hawley retainer), and geographic tongue (because of the location and age). An incisional biopsy was taken and subjected to histopathological examination to aid in reaching a conclusive diagnosis.The soft tissue section showed keratinized stratified squamous epithelium of variable thickness. Atrophic areas were predominantly present, other areas showed hyperplasia or epithelial proliferation in the underlying lamina propria. Degeneration of the basal epithelial cells and the basement membrane was evident. There was a dense, band-like lymphocytic infiltrate in the lamina propria that obscured the epithelial-connective tissue junction. Additionally, numerous dysplastic criteria such as hyperchromatism, pleomorphism, prominent nucleoli and mitotic figures were evident Fig. .Fig. 5aHistopathological results suggested the diagnosis of OLR. In an attempt to confirm this diagnosis, we performed a patch test by applying grinded acrylic resin, similar to that used in the construction of the Hawley retainer, on the forearm for 72 h and instructed the patient to report any kind of discomfort. After 72 h, there was desquamation, erythema and pigmentation of the skin suggesting a positive patch test, which confirmed our diagnosis Fig. .Fig. 6AWe instructed the patient to discontinue using the Hawley retainer, replaced it by a vacuum retainer, and prescribed topical corticosteroids to decrease patient’s discomfort. Three weeks later, partial resolution of the lesion was evident. We followed the patient for six months with no signs of lesions recurrence Fig. .Fig. 7AIn the presented case a definitive diagnosis was difficult to establish, therefore multiple diagnostic tools were implemented, namely clinical examination, histopathological analysis, and patch testing, which is useful whenever a dental material allergy is suspected .Upon clinical examination, three entities were included in the differential diagnosis; erythroplakia, atrophic LP, and OLR, none of which could be excluded outright based solely on clinical appearance. Using histopathological examination, erythroplakia was excluded as the histopathological features matching those of LP and OLR were evident. Subsequently, the patch test demonstrated a positive result making the diagnosis of OLR more probable.According to the diagnostic criteria proposed by van der waal ; the preAccording to Shirasuna et al. , Dudhia Rashid et al.  reportedNumerous cases of lichenoid reactions or allergy due to self-curing resin were reported, however, lichenoid reactions linked to Hawley retainers were found to be extremely few. Case reports reporting allergic reactions to self-curing resin reported similar clinical presentations as most of them reported unilateral lesions, swelling and redness of the contact area , 17.Tatiana et al.  reportedFurthermore, Alferdo et al.  reportedHawely retainer is the gold standard appliance for fixation and retention after orthodontic treatment. In addition, Hawely retainers are more favorable and more commonly used than vacuum retainers .The presented case had some limitations. Most importantly, the patch test wasn’t performed using commercially available kits which would have given more precise results , 22. AlsIn conclusion, acrylic resin-based Hawley retainers should be used with caution watching out for possible similar adverse reactions. Further studies are required to explain and emphasize the existence of Hawley retainer-associated OLR in orthodontic patients. Establishing the possibility of such an association would necessitate the performance of a patch test for patients receiving this appliance after orthodontic treatment termination.


Aneurysmal bone cysts (ABCs) are an uncommon osteolytic intraosseous bone lesions. ABCs commonly involve metaphysis of long bones and are rarely diagnosed in craniofacial bones. The World Health Organization (WHO) designates ABCs as benign, but locally destructive, rapidly growing masses. ABC can be clinically misdiagnosed as a malignant tumor. In this article, we present a case of a 12-year-old female patient who presented to a maxillofascial outpatient clinic complaining of huge jaw swelling over the past 3 months, which was clinically suggestive of sarcoma. Few reported cases in the English literature describe ABC presented with huge rapidly growing mass causing destructive bony lesion that was clinically mimic sarcoma, which initiates this case report. We also discuss the most important pathologic differential diagnosis of tumors with malignant behavior and review the literature. An aneurysmal bone cyst (ABC) is a benign osteolytic, rapidly growing, expansive, hemorrhagic bone lesion. ABCs favor long bones, such as the femur, tibia up to 50%), and spine 12–30%) [2–30% [1]0%, and sThis is a 12-year-old girl who was referred from an outside hospital as a case of right mandibular and neck mass, which was rapidly progressive for the last 3 months . The patABCs are nonodontogenic, nonepithelial cysts that commonly occur in long bones and the spine. Van Arsdale was the first who described ABCs in 1893. Later in 1942, the term aneurysmal bone cyst was applied by Jaffe and Lichtenstein . Only 2-ABCs can also be categorized according to their clinical and radiological behavior as inactive, active, or aggressive. Clinical presenting symptoms are variable and nonspecific and might include pain, localized swelling, and pathologic fracture. Radiology workup has variable appearing morphology. Typically, it appears as a radiolucent multilocular cyst with ill-defined internal septations. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) might show the classic multiple cysts with fluid-fluid levels . The mosIn conclusion, ABCs are benign osteolytic lesions that commonly appear in the first two decades of life, predominantly involving the mandibular body. Their clinical presentation can be atypical with large destructive mass, mimicking high-grade malignancy. It can cause huge swelling and compression symptoms. ABC should be considered in the differential diagnosis of maxillary bone lesions, and surgical curettage represents the main method of accurate diagnosis.


Isolated spontaneous dissection of the superior mesenteric artery (SMA) is a rare entity that is increasingly becoming recognized due to an improvement in imaging techniques. The pathogenesis of a spontaneous SMA dissection has yet to be fully elucidated. Here, we present the case of isolated SMA dissection in a 65-year-old female who was seen in the emergency room with acute substernal chest and left upper quadrant abdominal pain. She was managed for atrial fibrillation with a rapid ventricular response. She underwent computed tomography (CT) angiogram of the chest, abdomen, and pelvis, which revealed focal dissection involving SMA measuring 2.7 cm in width. Vascular surgery recommended conservative management with low-dose daily aspirin and the optimization of blood pressure control. She subsequently was seen as an outpatient with complete resolution of abdominal pain. Given the low incidence rate, vascular surgery evaluation may be required to determine the best course of management. Treatment needs to be individualized for each patient. Since abdominal pain is a common complaint for which patients are seen in each clinical setting, it is important to highlight this case to create awareness regarding the possibility of isolated SMA dissection as one of the underlying etiologies. Isolated spontaneous dissection of the superior mesenteric artery (SMA) is a rare entity that is increasingly becoming recognized due to an improvement in imaging techniques. Due to its infrequent occurrence, clinical experience regarding the management of isolated SMA dissection is primarily based on outcomes from reported cases in the literature. Given its presentation as acute or chronic abdominal pain, a common but nonspecific complaint encountered in routine practice, it remains essential that all medical professionals be aware of SMA dissection as a possible underlying etiology. Here, we present the case of a patient who presented with chest and abdominal pain and was found to have an isolated SMA dissection.A 65-year-old Caucasian lady with a past medical history of essential hypertension and poorly controlled type 2 diabetes mellitus was seen in the emergency room (ER) with acute onset retrosternal chest and left upper abdominal pain that woke her up from sleep. She described the abdominal pain as sharp, non-radiating, and worsening with respiration. The chest pain was reported as pressure-like in quality. She endorsed nausea, vomiting, and dyspnea. In the ER, her pulse rate was noted to be irregular and high at 155 beats per minute (bpm) and her blood pressure was noted to be 149/108 mmHg.Initial workup showed normal electrolytes and renal function tests as well as elevated blood sugar levels at 392 mg/dL. Lactic acid levels were normal at 1.7 mmol/liter. Hemoglobin A1c was 11.6%. The electrocardiogram (EKG) showed atrial fibrillation (AF) with rapid ventricular response (RVR). A chest X-ray was done, which showed mediastinal widening. This was followed by a computed tomography (CT) angiogram of the chest, abdomen, and pelvis, which revealed a focal dissection involving the superior mesenteric artery (SMA) measuring 2.7 centimeters (cm) in width but, otherwise, the normal caliber of the aorta without dissection or intramural hematoma was noted  was three. Accordingly, anticoagulation was initiated with rivaroxaban. She was discharged home in stable condition on the fifth day of admission and at the two-week outpatient follow-up, she reported complete resolution of abdominal pain.While aortic dissection can extend into branching arteries, spontaneous and isolated dissection of a visceral artery, such as the superior mesenteric artery (SMA) is rare. Based on previously reported cases, isolated dissections have involved the renal arteries, coronary arteries, intracranial arteries, and then the superior mesenteric artery in order of frequency . Among tClinically, manifestations can vary and may be nonspecific; patients may have an acute presentation with abdominal pain, nausea, and vomiting or may report chronic abdominal pain with poor appetite and, possibly, weight loss. Occasionally, patients may be asymptomatic; rarely, patients may present with hemorrhagic shock resulting from rupture of the dissecting artery . Given tA CT angiography is a good initial diagnostic test, as it allows the visualization of a false lumen as well as the intimal flap. It also provides the dimensions of the lesion and may identify signs of acute bowel ischemia-like enhancement of the bowel wall or mesenteric edema . DiagnosTreatment modalities include either conservative management or invasive management. Conservative management comprises anti-platelet therapy, optimizing blood pressure control, anticoagulation, and bowel rest. Invasive interventions include endovascular or surgical repair. In case of a deteriorating clinical condition, such as a lack of improvement in abdominal pain within one to two weeks or the development of complications such as bowel necrosis or aneurysms requiring repair, further invasive treatment strategies can be pursued .Treatment needs to be individualized for each patient, taking into consideration the patient’s symptoms as well as the anatomy of the dissection, particularly the level of reduction in the diameter of the true lumen . Given tIsolated spontaneous dissection of the SMA in the absence of aortic dissection is rare and unsuspected. SMA dissection as a cause of abdominal pain may remain unrecognized if the examining physician does not have a clinical suspicion for this and appropriate imaging studies are not ordered. This makes it essential to highlight this case as a potentially life-threatening cause of acute or chronic abdominal pain. Timely and accurate diagnosis allows correct treatment that is lifesaving.


A 21-year-old man presented with progressive facial disfigurement along with intermittent pain over his prominent mandible and forehead. Examination revealed asymmetrical facial figures especially the forehead and his left side (A). CT skull demonstrated typical features of fibrous dysplasia (FD) including multiple expansile lesions with heterogeneous pattern including radiolucency interspersed with ground glass opacity involving all craniofacial bones (B). No periosteal reaction or soft tissue involvement is noted. Extensive bone survey and hormonal assessments were unremarkable. The patient preferred conservative treatment with pain relief and undergoing regular follow-up. FD is a benign and progressive disorder in which the bone is replaced and expanded by fibro-osseous tissue, leading to fractures and deformities. It may affect a single (monostotic) or multiple (polyostotic) bones. The latter may be associated with endocrine dysfunctions and cafe' au lait spots (McCune-Albright syndrome) or soft tissue myxomas (Mazabraud syndrome). Craniofacial bone involvement has been reported in about one-fourth of the FD case. Its manifestations are varied depending on the involving bones including painless swelling with facial asymmetry, malocclusion, headache, visual or hearing impairment, nasal obstruction or neurological deficit. Diagnosis is based on the clinical ground and typical radiographic findings. Biopsy is reserved for cases suspicious of malignant change or indeterminate diagnosis. Treatment is aimed to alleviate cosmetic or functional problems, ranging from observation, medical treatment with bisphosphonates, to extensive surgery. Regular follow-up is mandatory to detect disease progression or malignant change.


Rare cases are shown to arise from the olfactory or optic nerve, being devoid of myelin sheath. Up to date and according to our best of knowledge, 66 cases have been reported till now. Here we present a review of the literature and a case report of a 56-year-old male with an accidently discovered anterior cranial fossa schwannoma, following a road traffic accident. Tumor was completely excised, using a right frontal approach. Histopathology revealed Antoni-A cellular pattern. Although rare, but olfactory nerve schwannomas should be included in the differential diagnosis in anterior cranial fossa space occupying lesions, and the approach should be designed taking into consideration, this rare entity.Schwannomas are benign tumors, which arise from the Schwann cells of the central or peripheral nerves. They form 8% of all intracranial tumors and most of the cases arise from vestibular division of the 8 Other less common origins are the 5th, 7th, 9th, and 10thcranial nerves. The occurrence of schwannoma not originating from cranial nerves is extremely rare, up to date. Only 66 cases have been reportedSchwannomas are usually benign tumors, which arise from Schwann cells of central or peripheral nerves. They constitute 8% of all intracranial tumors and arise most commonly from the vestibular division of the 8A 56-year-old male patient was presented to the emergency department, one day following a road traffic accident. Full history was obtained and thorough neurological examination was done, the patients Glasgow coma score was 13/15, he had right otorrhea, ecchymosis of both eyes, the right pupil was dilated fixed, and the left one was regular and reactive to light. Patient had history of old orthopedic instrumentation, 30 years ago.CT (computed tomography) scan was obtained, which revealed pneumocephalus, and an incidental finding of a right frontal intra-axial mass with aggressive perilesional edema. Patient received conservative management, including dehydrating measures, antibiotics, and prophylactic antiepileptic. Complete investigations showed fracture maxilla and mandible.α-feto protein were all negative.Two days after admission, patient regained consciousness and re-evaluation showed right sixth nerve palsy, right optic atrophy, and anosmia. We recommended magnetic resonance imaging (MRI) brain with contrast, but it was not possible due to the old fracture and instrumentation, so a CT scan with contrast was done, as shown in.We were not able to identify neither optic nerves, nor the olfactory, at the end of our transcortical approach.Expecting the mass to be intra-axial a right frontal craniotomy with trans-cortical approach was decided. Intraoperatively, palpation of the brain surface revealed no underlying cystic lesion, neither did aspiration, using a brain needle came up with any fluid. We proceeded with the transcortical approach, where a well-defined basal intraparenchymal mass appeared. The mass was reddish, soft in consistency, and was excised completely at the end of the procedure. Postoperative CT scan is shown inHistopathological examination showed benign spindle-shaped cells, with elongated nuclei and fibrillary cytoplasm (Antoni-A pattern), and less cellular, loosely textured tumor areas,Postoperatively, the patient was fully conscious, with improvement of his right sixth nerve palsy, but no improvement occurred in his smell, or right optic atrophy, right sixth nerve palsy, and anosmia.Schwannomas of the anterior cranial fossa are extremely rare, only 66 cases have been reported in literature to date.The origin of this entity is still debatable, since the fact that olfactory nerve lacks Schwann cells and has only oligodendrocytes.Our approach to the tumor was through a right frontal transcortical craniotomy, although the tumor was completely excised and the patient came out with no neurological deficit, yet this was not the ideal approach to this lesion. The cause of this pitfall was absence of the MRI, which couldn't be done due to the previous orthopedic instrumentation and unfamiliarity with this rare entity of anterior fossa tumors. Most reported cases were done through a subfrontal approach, which offers the best surgical corridor to the tumor,We were not able to identify neither the optics nor the olfactory nerve, yet some of the other authors, who adopted a subfrontal approach couldn't identify the nerve also, but no conclusion could be made, whether it was due to the origin of the tumor or was involved in it or just a displacement.Despite being a rare type with 67 cases (including our case), reported worldwide up till now, anterior cranial fossa schwannoma should be included in the differential diagnosis of anterior cranial fossa lesions and further steps toward understanding the exact origin, pathology and pathogenesis of such tumor entities should be achieved.


Spinal cord compression in Wilms' tumor (WT) is an extremely rare event that can have a very poor prognosis if not taken care of rapidly. Most cases reported in the literature involve widely metastatic patient with bone or paraspinal metastases or occasionally intradural metastasis. Here, we present the case of a 3-year-old girl of WT confirmed by biopsy, with spinal cord compression due to the direct contiguous spread of a tumor through 2 vertebral foramina. Abdominal ultrasonography and magnetic resonance imaging performed for an abdominal mass revealed a large heterogeneous tumor near the upper pole of the left kidney. A nodular infiltration extended through the T11-L1 and L1-L2 neural foramina, forming an intraspinal mass that compressed the spinal cord. Major paresthesia subsequently occurred, requiring urgent treatment with corticosteroids and chemotherapy. The evolution was rapidly satisfying. After six courses of chemotherapy, a left nephrectomy was performed. Macroscopic examination identified a large tumor attached to the kidney without renal infiltration. Microscopical examination concluded to a nephroblastoma with regressive changes, of intermediate risk. Evolution at 6 months is satisfactory, with no neurological deficit. The histological aspect of the tumor and the clinical outcome suggest that she had an extrarenal WT that spread through the vertebral foramina and was secondarily attached to the kidney. Childhood renal neoplasm accounts for approximately 7% of all cancers in childhood and are in the vast majority Wilms' tumor (WT) or nephroblastoma , 2. AbouIn the course of WT, spinal cord compression is a very rare occurrence, usually involving skeletal metastases to the vertebral body, intradural or extradural metastases –11.Here, we report the case of a large WT in a 3-year-old patient with secondary spinal compression by direct contiguous spread through 2 vertebral foramina.A 3-year-old girl, with no prior medical history, was admitted in our center with a three-week history of an abdominal mass discovered by her mother. On physical examination, a firm, painless mass in the left flank was palpable. Complete examination showed no other abnormality. In particular, no neurological deficit was detected.Abdominal ultrasonography revealed a large heterogeneous tumor of 69 × 67 ×  97 cm originating from the upper pole of the left kidney, deviating it towards the midline. The mass is located on the periphery of the upper pole of the kidney, and a vascular pedicle seemed to emerge from the renal sinus. No calcification or hemorrhagic component was found. Magnetic resonance imaging (MRI) and computed tomography (CT) showed an encapsulated tumor but with a nodular infiltration of the retroperitoneal fatty tissues. It extended through the T11-T12 and T12-L1 neural foramina, forming an intraspinal mass from T11 to L1 and compressing the spinal cord . AssessmConsidering this extremely unusual clinicoradiological presentation, a posterior transcutaneous needle biopsy was performed, as recommended in the International Society of Pediatric Oncology renal study group SIOP-RTSG 2001 protocol. The histopathologic features revealed a triphasic nephroblastoma, with no anaplastic feature.Meanwhile, the patient started complaining of major paresthesia and leg pain, requiring urgent treatment with corticosteroids and chemotherapy. Due to the neurological threat and the lung nodules, chemotherapy according to the SIOP-RTSG 2001 for stage IV nephroblastoma was administered, including three drugs .The patient's evolution was rapidly satisfying, with the rapid and complete receding of neurological symptoms. The preoperative assessment, after four courses of chemotherapy, indicated a massive regression of the tumor volume by 53%, with measures of 67 × 46 × 77 cm, and a complete disappearance of the intraspinal extension. The lung nodules were no longer detected on CT imaging.After six courses of chemotherapy, a left nephrectomy was performed. Macroscopic examination identified a large tumor attached to the kidney, enclosed in a thick fibrous capsule. The microscopic examination concluded to a triphasic nephroblastoma with regressive changes, of intermediate risk and without capsular rupture, thereby staging it as a stage I of the SIOP-RTSG 2001 classification. The tumor consisted in tumor epithelial component (abortive tubules and glomeruli) surrounded by metanephric blastema and tumor immature spindled cell stroma without any anaplasia or emboli of tumor cells. The histology of the kidney was unremarkable without any nephrogenic rest. Postoperative treatment included 29 weeks of chemotherapy with the same three drugs. After 24 months of evolution, the child is in good health and has no neurological deficit.The occurrence of spinal cord compression in childhood neoplasm ranges from 2.7 to 4% and is most often seen in the terminal phase of a widely metastatic cancer –8 AlthouThe most common tumors causing spinal cord compression are neuroblastomas, soft-tissue sarcomas, followed by osteogenic and Ewing sarcomas, lymphomas, and very rarely leukemia and WT , 4. The In the course of WT, spinal cord compression is invariably explained by skeletal metastasis to the vertebral body, intradural or extradural metastasis, although solitary metastases to the spine have been described –11. MostOnly two cases of spinal cord compression by contiguous spread of a WT through the neural foramina had previously been described , 14. BotOur patient did not have any spinal dysraphism. We hypothesize that she had an ERWT that spread through the vertebral foramina and was secondarily attached to the kidney. Indeed the macroscopic description of this tumor, with no renal capsular effraction, fits the description of an ERWT, even though no nephrogenic rests were found. The best outcome of this patient could be further evidence of the extrarenal origin of this neoplasm.Spinal cord compression is a very rare occurrence in WT, but it can have dramatic functional and vital consequences if not taken care of appropriately. Treatment comprises of immediate chemotherapy and corticosteroids to reduce the tumor size, followed by nephrectomy.While the vast majority of WT cases with spinal cord compression are explained by metastasis to the spinal canal , we report the first case of contiguous spreading from the primary tumor through the neural foramina in a child devoid of spinal dysraphism. This case could be explained by the extrarenal origin of the nephroblastoma.


Intra-articular lipomas are rare and very few cases have been reported in the knee. To the best of our knowledge, here we report the largest lipoma to have ever been observed in the knee. It is crucial to avoid the misdiagnose of lipoma arborescens, which is associated with degenerative joint disease. Lipoma is a homogeneous, ovoid, adipose tissue tumor that is contained within a fibrous capsule and not associated with previous disease.A 48-year-old male, with a soft-tissue tumor on the superomedial aspect of the right knee. Magnetic resonance imaging (MRI) revealed an intra-articular lipoma. The mass was resected by means of a limited arthrotomy.Knee lipoma is an extremely rare disease that must be diagnosed by MRI. Where possible, it should be resolved by arthroscopic resection. To the best of our knowledge, this is the largest lipoma presented within the knee joint, at least in the literature –19.Although lipomas are the most common type of soft-tissue tumor, intra-articular examples are extremely rare. This contrasts starkly with lipoma arborescens, which is a well-established clinical entity that develops in joints secondary to a degenerative process rather than as a neoplasm . As mentA 48-year-old male with no relevant medical history was referred to our service from another hospital with a soft-tissue mass on his right knee. The patient noticed the mass several years earlier, but due to its size and the absence of symptoms, he did not seek medical assistance. The mass progressively increased in size and deep flexion became uncomfortable. No history of previous trauma was reported.Physical examination revealed a mass of soft tissue in the superomedial aspect of the right knee. Upon palpation, the mass was soft, nontender and adhered to deep planes. There was no localized temperature increase or joint effusion. The range of movement was 0–110° with no mechanical symptoms, although deep flexion was painful. There was no evidence of muscular atrophy. Complementary tests and diagnostic imaging: Blood test results were within normal limits. Weight-bearing X-rays of the knees were normal, presenting only radiolucent soft tissue and no signs of degenerative joint disease. T1-weighted (T1-w) and T2-weighted (T2-w) MRI sequences revealed a soft-tissue mass with high signal intensity containing linear structures of low signal intensity . We encountered a soft ovoid mass measuring about 13 × 8.5 cm, with a fibrous capsule Fig. a, that wOutcome and follow-up: The case coursed with a favorable postoperative evolution. The surgical site incision healed without complications, although a keloid scar formed on the skin. The patient suffered from postoperative rigidity that was resolved with physiotherapy sessions. He was discharged without symptoms and with a complete range of motion. Table Lipomas are commonplace soft-tissue tumors, and can be found anywhere in the body . Intra-aDifferential diagnosis should be made to rule out lipoma arborescens, intra-articular liposarcoma, pigmented villonodular synovitis (PVNS) and Hoffa’s disease .Macroscopically, lipoma arborescens has the appearance of villous synovial proliferation of fatty tissue. It is also associated with some clinical conditions such as previous trauma, osteoarthritis and other chronic inflammatory conditions , whereas, intra-articular lipoma occurs de novo without any previous history. On MRI, lipoma arborescens produces “hairy” projections in the synovium with a high signal intensity in T1-w and T2-w sequences, that is saturated on Short-Tau Inversion Recovery Images (STIR) .Low-grade liposarcoma affects middle-aged people. It usually presents as a painless, slow-growing, locally aggressive tumor that rarely metastasizes. Intra-articular liposarcoma is rare. On MRI, it appears as a large lesion with thick septa, accompanied by non-lipomatous soft tissue with a low fatty component.PVNS is a rare intra-articular lesion that affects the synovial membrane of joints and tendon sheaths. MRI tends to reveal a low signal intensity on T1-w and T2-w sequences with “blooming effect” , which iHoffa’s disease refers to impingement of infrapatellar fat, first described by Hoffa in 1904. Infrapatellar fat becomes hypertrophic due to previous trauma. In this case, MRI will show a mass of low signal intensity in T1-w and T2-w images, attributable to subacute or chronic fibrosis. On T2-w images, there may also be an increase in signal intensity in cases of inflammation or hemorrhage. Hoffa’s disease is occasionally accompanied by ossification. However, unlike intra-articular lipoma, it is rarely found in the suprapatellar bursa or intercondylar region .Histopathologically, intra-articular lipoma is consisted on mature adipocytes covered with a synovial membrane and may also contain a vascular fibrous septum. That is why it is a true neoplasm of uncertain etiology. The natural history of the disease has not been studied in depth, although it is known that it grows slowly and follows a silent clinical course until the symptons appearance due to a space-occupying lesion.The gold-standard treatment has not yet been established for intra-articular lipoma. Arthroscopic excision has been performed as well as open arthrotomy. There have been no recurrences of the lesion following arthroscopic excision in previous studies, which suggests this treatment is valid so long as it is practicable. Arthroscopy did not seem to be an option in our case given the large size of the patient’s lesion, so we deemed limited arthrotomy to be a much more realistic option.Clinical examination is essential in the diagnosis of the lesion. MRI is primordial for both differential diagnosis and preoperative planning. Excision can be performed by open arthrotomy or arthroscopy, depending on the size of the lesion.


The majority of ruptured intracranial aneurysms are combined with subarachnoid hemorrhage, but patients with only intracerebral hematoma without any subarachnoid hemorrhage are extremely rare.The patient was hospitalized due to sudden dizziness combined with slurred speech. The patient showed considerable decreased physical activity without any nuchal rigidity. Head CT showed hematoma in the left temporal lobe, and the shape of hematoma was extremely irregular. MRI indicated the absence of any vascular malformations. The patient was diagnosed with middle cerebral artery bifurcation aneurysm in the left by head CTA. Intracranial aneurysm clip and removal of hematoma in the left temporal lobe were performed under general anesthesia. The patient did not show any significant neurological dysfunction after the surgery and was followed up for 4 months after discharge with GOS score of 5 points.Intracranial hematoma with irregular morphology around the lateral fissure of the brain should be considered critical in order to avoid misdiagnosis and any possibility of missed diagnosis of vascular lesions, so as to ensure an exact therapeutic strategy with good prognosis for the patients. There are two manifestations of intracranial aneurysm rupture: ① The first is simple subarachnoid hemorrhage (SAH), accounting for 85%. ② The second is intraparenchymal/intracranial hematoma (IPH/ICH), accounting for 15%, which can be combined with subarachnoid hemorrhage or intraventricular hematoma (IVH). Some previous case reports have indicated few cases, which are manifested as IPH and IVH without any SAH [The male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms , erythrocytes broken into the subarachnoid space are intact with oxy-hemoglobin and without any damage. During this phase, a CT scan cannot easily detect the presence of hemorrhage, because of a lack in contrast due to the same density with the brain tissue. In addition, the CT shows a continuous decrease in the sensitivity of SAH, and any further CT examination later after onset of symptoms, most likely lead to missed diagnosis of aneurysmal SAH . In our If only a small amount of SAH is caused by aneurysm rupture, SAH would quickly fit into the subarachnoid space, thus SAH cannot be displayed by CT. In our study, preoperative head CT of this case showed the presence of hematoma in the temporal lobe, which was confirmed to be caused by aneurysm rupture happened during the surgery, thereby we concluded that undetectable SAH could not be correlated with the amount of hemorrhage.The direction of rupture of the aneurysm towards the upper side may determine whether the bleeding occurs in the parenchyma, the ventricle or the cistern. If aneurysm rupture points to intracranial fissure with lower tension or larger space, blood would not flow into the subarachnoid space with relatively high tension after hemorrhage. In this case, after removing some hematoma during the surgery, examination of the middle cerebral artery and its branches showed that aneurysm ascus rupture was located in the facies medialis of the temporal lobe, pointing to the direction of hematoma in the temporal lobe. Therefore, undetectable SAH in this case was considered to be caused by the formation of aneurysm asci and the rupture pointing towards the temporal lobe.Recurrence of hemorrhage may also be one among the various causes for aneurysm rupture without SAH . The posThis case reminded us that, hematoma performance of head CT should be carefully examined to determine whether the hematoma sites were located in the walking areas of intracranial great vessels. Furthermore, the presence of intracranial aneurysms should be thoroughly evaluated to reduce the chances of misdiagnosis and missed diagnosis in order to ensure a good prognosis of the patients.Nevertheless, due to the limitation of the number of cases in this study, conclusions derived from this single case study may only represent personal opinions of the author. Therefore, we suggest that clinical neurologists should carefully evaluate the necessity of various auxiliary examinations, so as to reduce unnecessary medical burden of the patients.


There is a wide differential diagnosis for intraabdominal tumors. Surgical resection and microscopic analysis of tissue structure can identify tumor origin in most cases. Most rapidly growing invasive tumors are neoplastic. Inflammatory pseudotumors are a subcategory of intraabdominal tumors that are non-neoplastic and can be rapidly growing. Urachal cysts originate from the dome of the bladder; however they are typically not invasive. There is limited literature on the appropriate management of these tumors.A 37-year-old female presenting with symptoms of abdominal pain was found to have a large intraabdominal mass invading multiple organs. Core biopsies demonstrated inflammation. The mass grew significantly over the course of a year and patient's abdominal pain worsened. The patient was taken to the operating room for resection. Final pathology revealed reactive fibrous tissue with acute and chronic inflammation invading bladder, urethra, abdominal wall, appendix, and ovary. Intraoperative frozen section demonstrated low grade spindle cells with concern for inflammatory pseudotumor but final pathology demonstrated inflammation.Although benign, these tumors cause significant morbidity due to their size and level of organ invasion. Management should involve surgical resection as well as potential post-operative chemotherapy or NSAIDs based off clinical picture. We demonstrate the importance of close follow up for residual disease or recurrence of patients with inflammatory pseudotumors of the abdomen.This case highlights difficulties in diagnosis of a tumor that has potential to cause significant morbidity. There is need for further research to discover the best management after surgical resection of these tumors. Differentiating among these different lesions is clinically important due to the wide range of prognosis and treatment. The rare group of tumors composed of fibroblastic or myofibroblastic cells represent reactive pseudoneoplastic tumors and may be benign or malignant . Case reUrachal remnants that are asymptomatic are observed and managed conservatively. Those that are symptomatic or become infected are traditionally excised surgically . It is i2A 37-year-old female presented to the emergency room at our institution with intractable abdominal pain and fever. She has a history of dysuria and hematuria for 10 months, which at the time prompted an MRI demonstrating an abdominal wall mass with extension into the bladder. Outside biopsy was reported as “inflammation”. She was initially treated with antibiotics. A cystoscopy was performed and a transurethral bladder biopsy showed acute and chronic cystitis and Von Brunn nests. Cytology report indicated presence of atypical urothelial cells and she was then referred to the urology service due to suspicion for malignant neoplasm. Follow up CT scan imaging demonstrated a heterogeneous ill-defined enhancing soft tissue density in the space of Retzius inseparable and compressing the anterior aspect of the urinary bladder measuring 11.3 × 4.5 × 12.8 cm with a peripherally enhancing loculated collection measuring 4.7 × 6.0 × 3.0 cm along with marked thickening of urinary bladder As the patient’s symptoms continued to progress, including persistent hematuria diagnosis was uncertain despite multiple percutaneous and transurethral biopsies, she was referred to Surgical Oncology team for multidisciplinary management. As there were still concerns for neoplastic malignant process vs desmoid vs pseudoinflammatory neoplasm, the multidisciplinary team recommendations were to offer operative management in coordination with the surgical oncology and urology teams with an intention to provide larger tissue for definitive diagnosis to guide extend of surgery, which would include complete bladder removal with construction in the form of ileal conduit, abdominal wall resection with abdominal wall reconstruction if malignancy were to be confirmed intraoperatively.2.1Intraoperative cystoscopy demonstrated an ulcerated infiltrative tumor into the dome of the bladder. Intraoperative frozen biopsies did not provide definite diagnosis and suggested spindle cell neoplasm, possible of urachal origin but malignancy could not be confirmed, thus the decision was to proceed with palliative resection including abdominal wall resection with en bloc resection of pelvis tumor, partial cystectomy and partial oophorectomy, as the mass was found to have invaded the abdominal wall below the umbilicus as well as the ipsilateral ovary and ureter. There was significant thickened white tissue within the muscles and extending to posterior rectus sheath. 2.2The final pathology showed an ill-defined pale-tan markedly fibrotic area measuring 8.5 × 5 × 5 cm extending from the mucosa. The mucosal and submucosal aspect of the bladder showed markedly necrotic aspects. The abdominal rectus muscles were grossly present in the specimen and were focally involved by the fibrotic area. The abdominal wall mass was predominantly reactive fibrous tissue with acute and chronic inflammation and fibrosis without evidence of malignant neoplasia. The mass contained low-grade spindle cell proliferation with abundant inflammation, granulation tissue, and chronic abscess. The mass had connections to the bladder suggesting urachal origin. The muscularis layer was noted to have attached granulation tissue. Left partial oophorectomy yielded unremarkable parenchyma with attached reactive fibrous tissue containing chronic inflammation and hemorrhage.The frozen section demonstrated an ill-defined pale-tan markedly fibrotic area measuring 8.5 × 5 × 5 cm extending from the bladder mucosa. The mucosal and submucosa of the bladder showed markedly necrotic aspects. The abdominal rectum muscles were grossly present and were focally involved by the fibrotic area .Fig. 3Mi2.3The patient’s final pathology was discussed in multidisciplinary tumor board and recommendations were to treat her with NSAIDS to attempt control residual disease if symptoms returns or progression occurs. A post-op MRI 10 months later showed resolving residual inflammation. She is recommended to remain on NSAIDs and close follow up and monitoring her with imaging.3Tumors of the abdominal cavity can be particularly difficult to diagnose and manage. In the case described here, the top differential diagnoses included urachal cyst and inflammatory pseudotumor, however this tumor was unique in its invasive properties and rapid growth. Little has been documented in the literature regarding similar tumors and their management.Tumors of similar pathology have been documented and include reactive nodular fibrous pseudotumors of the gastrointestinal tract, inflammatory myofibroblastic tumors, retroperitoneal fibrosis, sclerosing mesenteritis ,6, nodulInflammatory myofibroblastic tumors have been documented to be invasive in cases. These tumors have the highest incidence in children and adolescents. They are classified as benign; however, they have been documented to invade multiple organ systems and metastasize. Surgical resection, when feasible, is the recommended management. Unresectable tumors may be sensitive to chemotherapy and have been documented to spontaneously regress in some cases . Successshould be discernable within the mass as an area of glandular tissue [The urachus is a structure that normally involutes at 6 months gestation and becomes the umbilical ligament. Urachal remnants typically present in adulthood with infection with or without abscess formation, or rarely with formation of malignant tumors. Microscopically, these tumors appear similar to the tumor described in our case report – with inflammatory tissue and spindle cells in collagenous stroma. A urachal remnant r tissue .Immunohistochemical staining can play a diagnostic role in tumors of unknown origin, and is particularly useful when the final pathology is indicative of neoplasm. Reactive nodular fibrous pseudotumors of the gastrointestinal tract are commonly known to stain positive for CD117, which is also seen in many myofibroblastic proliferations and gastrointestinal stromal tumors. Other commonly positive stains in pseudotumors of the gastrointestinal tract include vimentin, muscle specific actin, smooth muscle actin, desmin, S-100 protein, CD34, ALK-1, and keratin [This case report highlights the importance of determining appropriate management of non-neoplastic, invasive, inflammatory abdominal tumors of unknown origin. Decisions to biopsy based on initial imaging, as well as decisions to operate based on pathology should be further evaluated.4Prognosis of urachal cyst versus malignant inflammatory pseudotumor varies greatly; thus, proper diagnosis is of critical importance. Initial management, treatment, and long term follow up for tumors composed of reactive fibrous tissue is not well documented in the literature. Our patient represents a difficult case in management both preoperatively and postoperatively due to vague clinical presentation and inconclusive biopsies suggesting an infiltrative neoplasm. Close follow up imaging and clinical monitoring are recommended to determine future progression of disease and response to therapy. In patients with recurrence of inflammation from urachal cyst or residual disease, there is a need for further management other than surgery. These patients benefit from multidisciplinary discussion and management.NA.Projects that do not meet the federal definition of research pursuant to 45 CFR 46 do not require IRB review. This tool was developed to assist the University of Miami community in determining when a project falls outside of the IRB’s purview.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.VA – literature search, case report design, gathering history, data interpretation.KK – literature search, gathering history, data interpretation, editing.AR – pathology report, images.SS – review and additions to manuscript.MM – literature search, case report design, gathering history, data interpretation.Not a clinical trial.Dr. Mecker Moller.Pseudotumor, invasive, intraabdominal, inflammatory, urachal cyst, invasion, invasive, invading multiple organs, extension, contiguous spread, contiguous extension.Not commissioned, externally peer-reviewed.N/A.


This case serves to raise awareness of trichobezoar as a diagnosis in young children who present with abdominal pain, a palpable mass, and signs of acute small bowel obstruction. This case serves to raise awareness of trichobezoar as a diagnosis in young children who present with abdominal pain, a palpable mass, and signs of acute small bowel obstruction. The pain had begun gradually in the central abdomen with eventual radiation across both the left and right sides. It had worsened over the next three days but was not exacerbated by movement or eating. Her bowels had opened normally on the day of hospital presentation, and there was no history of diarrhea, rectal bleeding, or urinary symptoms.Other than mild asthma for which she took a preventative inhaler, there was no relevant past medical or psychiatric history. Her immunization status was up‐to‐date. There was no relevant family history of medical or psychiatric conditions. The patient had achieved all normal developmental milestones for her age and was of normal to above‐average intelligence. She performed well at school and lived with her parents and four siblings, all of whom were healthy. Her family came from a middle‐class background with no suggestion of social disadvantage or neglect.On general inspection, the patient appeared pale and listless. Although she was febrile to 38.1°C, all other vital signs were normal for a child of her age . She appeared well nourished and weighed 24.1 kg, which put her between the 50th and 75th percentiles for her age.9/L (neutrophils 20.7 × 109/L) and C‐reactive protein of 4 mg/L. Hemoglobin was 169 g/L, and renal function was normal. Urinalysis was also normal. Transabdominal ultrasound revealed an echogenic mass in the right iliac fossa which contained a hyperechoic curvilinear structure at its superficial margin associated with posterior acoustic shadowing . A 10 mm longitudinal enterotomy was made on the antimesenteric border just proximal to the intraluminal mass Figure , 6. The Upon closer questioning of the patient's parents postoperatively, it was revealed that she had suffered from trichotillomania and trichophagia at the age of 4 years. It had always seemed to occur in response to physical fatigue, for example, at the end of a long day at preschool. This behavior had resulted in bald patches developing on her scalp which necessitated her parents shaving her head to prevent its continuation. After approximately 12 months, there was no objective ongoing evidence of this behavior and it was presumed to have ceased spontaneously. As a result, professional help had not been sought at the time. Both parents denied the existence of recent social stressors and had not observed any recent unusual behavior from their daughter. They seemed to be genuinely loving parents, and there was no indication of family dysfunction based on the observations of the treating surgeon.The patient has an uneventful recovery and was discharged on the 5th postoperative day. She is planned to follow‐up in 4 weeks with the treating surgical team for routine review. Referral was also made to the childhood and adolescent mental health service for ongoing counseling regarding the underlying behavioral issues which resulted in trichotillomania and trichophagia, as well as to ensure cessation of this unwanted behavior.3Trichotillomania (TTM) was first described in 1889 and affects 1 in 2000 people in the general population. It involves the pulling of hair to the point of alopecia and is most commonly performed on the scalp, although eyelashes, eyebrows, and the axilla are all potentially susceptible.When trichophagia is repeated and long‐standing, the accumulated strands of hair are retained in the gastric rugae because there is insufficient friction for them to be moved forward by peristalsis.The majority of trichobezoars present with abdominal pain and a palpable mass and as previously discussed they are usually confined to the stomach.Once a trichobezoar is diagnosed, the primary management involves its retrieval. Surgery is the usual modality of choice with laparotomy being the most commonly performed procedure and is associated with a 99% success rate.A critical aspect of management which cannot be overlooked is secondary prevention. Recurrent trichobezoar has been reported and usually occurs in patients who have not had adequate psychiatric evaluation or follow‐up.Given the rarity of TTM and trichophagia, it is estimated that only 1‐2 people per million will be affected by trichobezoar. To our knowledge, there are only six documented cases of children younger than our patient having a trichobezoar4Small bowel trichobezoar causing acute small bowel obstruction in a young child is an exceedingly rare condition that has only been described in the literature several times before. It should be suspected in young children who present with abdominal pain, a palpable mass, and signs of acute small bowel obstruction, especially when a history of trichotillomania is present. When this history is absent or not forthcoming, a very high index of suspicion is required to make the diagnosis clinically. Although its surgical treatment is relatively straightforward, the rarity and late presentation of this condition preclude the development of new techniques and approaches. As such, laparotomy remains the mainstay of treatment even in pediatric populations. Secondary prevention is also crucial and requires comprehensive psychiatric evaluation and follow‐up.The author declares no conflict of interest.AMFK: was the treating surgeon, performed the literature review, and composed the manuscript.


Cicatricial organizing pneumonia is an uncommon form of organizing pneumonia, which may manifest as persisting linear opacities on computerized tomography (CT) scan mimicking a fibrosing interstitial pneumonia. It may also manifest with pulmonary ossification, which is a metaplastic bone formation within the lung tissue. The latter presentation could be either nodular or dendriform, both secondary to underlying lung disease and rarely idiopathic. Dendriform pulmonary ossification (DPO) has rarely been described as a cause of spontaneous pneumothorax. We present a case of a 55-year-old male with history of recurrent pneumothoraces and worsening dyspnea on exertion. A CT of the chest revealed progressive bilateral sub-pleural and peribronchovascular reticular opacities associated with densely ossified branching and nodular opacities. Video-assisted thoracoscopic biopsy of the lung demonstrated cicatricial organizing pneumonia with areas of marked diffuse DPO. The case highlights that dendriform pulmonary ossification arising from cicatricial organizing pneumonia should be considered in the differential diagnosis of recurrent pneumonias among patients with lower lobe sub-pleural reticular opacities. The case highlights that dendriform pulmonary ossification rarely can cause spontaneous pneumothorax and can be associated with cicatricial organizing pneumonia and reticular opacities on imaging. Organizing pneumonia (OP) is characterized by the presence of organizing fibromyxoid proliferations within the lumens of respiratory bronchioles and alveolar ducts. Peripheral and /or peribronchiolar consolidations are the most frequent findings of OP on a computerized tomography (CT) scan. These opacities could be migratory in nature. OP is often steroid-responsive and reversible with total resolution of radiological opacities, but occasionally may recur , 2.Cicatricial OP (OPc) is a newly described entity in the pathology literature , 4 and dA 55 year-old, nonsmoker male presented with a recurrent large left pneumothorax requiring a chest tube placement. He had a same side pneumothorax three and six years earlier, also requiring a chest tube placement. The patient also reported dyspnea on exertion with stairs and inclines, which had progressed over last three years along with a dry cough.He had a remote exposure to quails while training hunting dogs. He was known to have hypertension and suffered with symptoms of gastroesophageal reflux disorder (GERD). His physical examination was unremarkable. A review of his pulmonary function revealed gradual decline in his FEV1, FVC and diffusion capacity over the past seven years .Review of serial chest CT imaging revealed progressive bilateral sub-pleural and peribronchovascular branching dense opacities suggestive of DPO . He undeOrganizing pneumonia is usually steroid-responsive and pathologically characterized by presence of loose fibromyxoid plugs within the lumens of the respiratory bronchioles and alveolar ducts , 2. CicaOn CT, conventional OP presents as patchy bilateral peribronchial and subpleural consolidations –19, whicPulmonary ossification is a metaplastic process where mature bone is present in the alveolar interstitium and/or alveolar spaces. Pulmonary ossification is classified into DPO and NPO. NPO is usually a localized process of lamellar bone and can occur in the setting of chronic congestion as seen in mitral valve stenosis. Unlike DPO, NPO usually does not contain bone marrow (fat or hematopoietic cells) . On CT, DPO manifests on CT as small  nodules, which are seen predominantly in the peripheral interstitium . These nodules form contiguous and branching pattern resembling tree branches. In most instances these nodules are of high attenuation, reflecting the underlying ossification. The detection of small high-attenuation foci is improved using thin slices and maximum-intensity-projection images. DPO has tendency to affect lower lobes and posterior aspect of upper lobes. Association with recurrent aspiration and DPO has been suggested . The preSpontaneous pneumothorax has been reported in several cases of DPO –14 incluThe case we present showed evidence of radiographic progression and worsening restrictive pattern on PFT over several years. The reported cases of cicatricial OP by Churg and his colleagues  have beeIn summary, we present a case of cicatricial OP with DPO presenting with recurrent pneumothoraces and slow progressive pulmonary physiologic restrictive impairment. Cicatricial OP should be considered in the differential diagnosis of peribronchial or subpleural reticular opacities with DPO. Radiologists and clinicians alike should be aware of this newly described entity as distinct from other classical fibrosing processes, its potential association with DPO, and the presumed association between subpleural DPO and spontaneous pneumothorax.


Emphysematous gastritis is the infection of gastric mucosa by gas producing microorganisms. It is a rare infection with less than 100 cases reported in the literature. The association of portal venous gas along with emphysematous gastritis is a rare entity. The concomitant portal venous gas worsens the outcome and warrant for surgical treatment. Our case has portal venous gas on CT scan along with suspicion of emphysematous gastritis and an esophageal ulcer on upper GI endoscopy. Medical treatment was given in our case of portal venous gas with the esophageal ulcer. Our case is unique because our patient responded to the conservative management. The patient presented with past history of polysubstance abuse and chronic kidney disease presented with symptoms of acute abdomen. CT scan revealed portal venous gas and suspicion of gastric emphysema. In addition, few foci of gas are seen along the vessels traversing between the stomach and liver. Endoscopy with gastric mucosa biopsy showed Candida albicans. Subsequently, antifungals were started. There was improvement in clinical condition of the patient. We, hereby, also summarize all the reported cases of emphysematous gastritis with treatment and outcome in each case. There has been change in trend from surgical to medical treatment. Emphysematous gastritis (EG) is a polymicrobial infection of gastric mucosa that is caused predominantly by gas producing bacteria. Though EG is a rare condition with a handful of cases reported, it is associated with a poor prognosis. In addition, the presence of portal venous gas in individuals with EG further worsens the outcome. Until recent years, surgery has been the main modality of treatment for emphysematous gastritis, especially in patients with associated portal venous gas. However, there has been a change in trend from the surgical management to a more conservative approach because of the postsurgical complications and insignificant difference in long-term prognosis between two approaches.Herein, we report a case of a middle aged male with past medical history of polysubstance abuse and chronic kidney disease who was suspected of emphysematous gastritis with associated portal venous gas. Our case report is unique because our patient responded adequately to the conservative treatment despite the associated portal venous gas.A 48-year-old man with past medical history of COPD on home oxygen, chronic anemia, remote history of polysubstance abuse and alcohol abuse, tobacco use, and chronic kidney disease, PUD gastritis, and GI bleeding, presented to our hospital with complaints of fever, sudden onset nausea, abdominal pain, and hematemesis for 3 days.On physical examination, his abdomen was distended and there was tenderness on palpation over the epigastrium, right and left upper quadrants but without any guarding and rebound tenderness. In addition, the bowel sounds were hypoactive. His vital signs were unremarkable apart from mild tachycardia.Acute onset of pain with upper GI bleeding was suggestive of borderline features of acute abdomen.9/L. His basic metabolic panel was significant for deranged kidney functions and electrolyte disturbances with elevated creatinine (1.97 mg/dl) and BUN (30 mg/dl), mild hypokalemia (3.2mEq/L), and hyperphosphatemia (8mg/dl). LFTs and lactate were within normal range. Furthermore, his CT scan revealed irregular thickened distal esophagus with markedly distended stomach (probably secondary to gastric outlet obstruction) as well as portal venous gas. There was suspicion of limited gastric emphysema as well. In addition, few foci of gas are seen along the vessels traversing between the stomach and liver  and nitrogen (N2). Clostridium, Streptococci, Staphylococcus, E. coli and Pseudomonas species, Candida and mucor constitute the group of organisms responsible for infection in EG [Emphysematous gastritis is a not so common entity with less than hundred cases reported till now on pubmed search. Emphysematous gastritis occurs when the gas producing microorganisms invade the wall of stomach and ferment glucose to produce gases like carbon dioxide (COon in EG . A recenon in EG . HoweverIngestion of corrosives, alcohol abuse, recent surgery, compromise of blood supply due to atherosclerosis and other comorbidities like end-stage renal disease, peptic ulcer disease, diabetes mellitus, malnutrition, NSAIDs, and steroid use are certain factors that increase the risk of infection in gastric mucosa. In addition, hydrogen peroxide , AIDS 55, coxsacDiagnosis of emphysematous gastritis can be made on the basis of clinical features and characteristic findings on imaging. Clinically, in addition to acute abdomen symptoms of pain, nausea, or vomiting, EG also presents with fever, neurologic changes, and hemodynamic instability , 11. NonDue to the rare occurrence of disease, there are no established guidelines for diagnosis and management of emphysematous gastritis. During the past decades, patients used to present in advanced stage of emphysematous gastritis with ischemic and necrotic changes of gastric mucosa, peritonitis, and hemodynamic instability . In suchGas within gastric wall could be of two origins. It could be intraluminal air dissecting the wall of stomach that occurs in case of gastric emphysema. Secondly, gas could be produced by fermentation process of bacteria or fungi like that in case of emphysematous gastritis . Gastric


Glomus tumors are rare tumors of the arteriovenous junction that play a role in temperature regulation. They are most commonly found in the subungual finger. We present the case of a 77-year-old female with a chief complaint of a painful mass in her ulnar wrist. The differential diagnosis at the time was broad. Following a detailed history and physical exam, the etiology was believed to be that of a peripheral nerve sheath tumor. The patient was taken to the operating room for resection and biopsy of the mass. Histological evaluation confirmed that the mass was a glomus tumor. Our patient’s symptoms had completely resolved and functional status had improved to baseline by the time of her two-week postoperative clinic visit. This case report demonstrates the many complexities in the diagnosis of a glomus tumor and the important role of surgical treatment in obtaining relief from extradigital glomus tumors. The glomus body is a contractile neuromyoarterial structure present in the reticular dermis at the arteriovenous junction whose main function is to control body temperature . Glomus A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.On physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.The location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to immunostaining of type IV collagen and smooth muscle actin Figures , 2.The three most frequent types of benign mesenchymal tumors in the hand are synovial ganglion cysts 52%), a giant cell tumor of the tendon sheath (11%), and epidermoid cysts 6%) . Though 2%, a gia% . ThougPhysical exam was significant for point tenderness, although this is extremely non-specific, especially given the location proximal to the wrist joint. A glomus tumor usually is a benign condition that responds favorably to a complete excision, leading to a cure with a low incidence of recurrence . Our patRadiographs were obtained to rule out an acute osseous etiology. In subungual glomus tumors, radiographs will occasionally demonstrate scalloping of the terminal phalanx at the site of the lesion . Our patWhile previous literature has described obtaining magnetic resonance imaging (MRI) as crucial in clinching a diagnosis of glomus tumor early , we elecThe diagnosis of a glomus tumor is confirmed when histology demonstrates cells with a positive expression for CD34 and smooth muscle actin . Three dThere is a broad differential for soft tissue masses found throughout the hand and upper extremity. This case is an example of a unique discovery from an unexpected etiology. Our scenario also demonstrates how we, as both clinicians and surgeons, have many tools at our disposal; by avoiding unnecessary studies, we can provide our patients with the efficient, diagnostic, and hopefully pain-relieving service that they desire.A diagnosis of an extradigital glomus tumor is difficult to obtain in the clinical setting. The above case illustrates many of the features that make the diagnosis of an extradigital glomus tumor challenging. It is important to have the suspicion of a glomus tumor in the clinician’s differential because expedited and relatively simple treatment can provide quick relief to a significant problem.