While common MRI characteristics for schwannomas exist, diagnosis by imaging alone remains challenging. Detailed analysis of symptoms reported by the patient is very important in the differential diagnosis between meningioma and schwannoma in cases where MRI images are not sufficient for determining the tumor type. The pain, its classification of the character, and the timing seem to be an important predictive symptom in the differential diagnosis of spinal schwannoma. The most common extramedullary intradural spinal tumors are schwannomas 29%) followed by meningiomas (25%) . It is d9% follow1-weighted images, hyperintense on fluid-sensitive sequences, and often diffusely enhancing on contrast-enhanced images [1-weighted images and slightly hyperintense or hypointense on T2-weighted MRI. Upon contrast application, they enhance vividly  and frequently display a “dural tail” sign. About 5% of meningiomas may present in a dumbbell shape [The primary diagnostic modality for intradural tumors is magnetic resonance imaging (MRI) without and with contrast enhancement. However, differentiation between meningioma and schwannoma on the basis of MR image may be difficult without additional data from detailed anamnesis of the patient and symptom analysis. The typical magnetic resonance (MR) appearance of schwannoma is iso-to-hyperintense on Td images . Spinal ll shape .The aim of this paper is to present a diagnostically challenging case of intradural spinal tumor and to provide some useful guidelines for differential diagnosis between spinal schwannoma and meningioma related to preoperative pain characteristics. Pain is considered as a classic symptom of spinal tumors; however, there has been little discussion regarding the clinical significance of pain in differential diagnosis and its relevance in preoperative planning.6/μL; WBC 7,5 103/μL; PLT 263 103/μL; HGB 14 g/dL; HCT 41,1; MCV 91,3%; ALAT 15,0 U/L; ASPAT 26,0 U/L; creatinine 0,76 mg/dL; glucose 87,0; bilirubin 0,8 mg/dL; anti-HCV negative; HbsAg negative). The patient negated any comorbidities and ailments. sagittal and axial T1 and T2 and gadolinium-enhanced magnetic resonance images (MRI) of the thoracic spine were performed. MRI revealed an oval focal intradural extramedullary lesion significantly compressing the spinal cord (ap 9.4 × si 25 mm), located posterolateral at the Th1-Th2 level. The tumor was isointense on T1-weighted image and demonstrated heterogeneously raised hyperintense T2 signal. Upon contrast application, the T1-weighted sequence demonstrated strong, nearly homogeneous mass enhancement (Figures A 46-year-old woman presented to the Neurosurgery Department of University Medical Center in July 2018 with an impaired sense of pain and temperature in the anterior torso below the sternum. The patient complained of the numbness of both legs progressing from about nine months and the segmental pain in the back radiating to the right arm, induced by pressure and appearing during sports activity—horse riding and running. The patient has been suffering from micturition disorders for several weeks. Physical examination showed the abolition of abdominal reflexes, symmetric cloning of tendon reflexes, and impaired sensation in both legs, with no motor deficits. Laboratory blood tests were requested: they were all normal (RBC 4,5 10 Figures . The patRadical tumor resection was confirmed on postoperative MRI scans . No tumo1 and T2, and enhancement pattern [1 iso-to-hypointensity, T2 hyperintensity, or fluid signal intensity [2-weighted images and isointensive signal on T1-weighted images might indicate meningioma or schwannoma [MRI differences which are important in differentiation between intraspinal schwannoma and meningioma are tumor location and shape, mean size, dural contact characteristic signal intensity on Tntensity . In the hwannoma . Meningihwannoma . The moshwannoma . In the hwannoma . Pain aphwannoma .This case confirms that total tumor resection is associated with better functional outcomes after resection of tumors less than 5 cm in maximum dimension. The role of tumor size has been the object of extensive investigation in the literature, and this factor has been found to be a good prognostic indicator . Histopa


Appendiceal torsion is a rare phenomenon with only a few reported cases and never in a patient with Ehlers-Danlos syndrome (EDS). We present the first case of appendiceal torsion leading to acute appendicitis in a patient with EDS.A 36-year-old male with history of musculoskeletal EDS presented with one week of abdominal pain localizing to the right lower quadrant. He was evaluated in the emergency department with a complete set of labs and CT abdomen/pelvis. The CT scan showed acute appendicitis, but did not mention any appendiceal torsion. He was taken to the operating room for a standard laparoscopic appendectomy. Intraoperatively, there was inflammation at the tip of the appendix with a 270-degree torsion of the mid-appendix and mesoappendix. After untwisting, the appendix was safely removed from the base of the cecum. Patient recovered well postoperatively and no masses or tumors were identified on final pathology.Primary appendiceal torsion occurs without an identifiable cause and secondary torsion occurs due to pathology such as carcinoid tumor or other masses. Patients with EDS may be more prone to either torsion as they have hyperelastic skin, joints and ligaments. EDS patients require special workup prior to any operation including cardiopulmonary evaluation and may have unique postoperative complications.The ligamentous hypermobility of EDS may have predisposed our patient to appendiceal torsion and acute appendicitis. This is a rare phenomenon and may be underdiagnosed in EDS patients. Practitioners should be aware of this manifestation of EDS. The first case of appendiceal torsion was reported over 100 years ago in 1918 . The patAlthough not as rare as appendiceal torsion, Ehlers-Danlos syndrome (EDS) is an infrequent disease affecting roughly 1 in 5000 people . EDS is We present the first case of appendiceal torsion in Ehlers-Danlos syndrome. Although acute appendicitis has been reported in EDS , we coul2Patient is a 36-year-old Caucasian male with past medical history of EDS who presented to the emergency department (ED) of an urban, academic center with diffuse abdominal pain and cramping for nearly one week. Pain was initially epigastric, but then migrated to his right lower quadrant. He endorsed nausea and loose stools but no vomiting, fevers or dysuria. He had never had this type of pain before. Past medical history was significant for EDS which manifested with hypermobility and hyperelasticity of joints and skin with no other known manifestations. To our knowledge, it is unclear how he was diagnosed with EDS, either through genetic testing, clinical symptoms or tissue diagnosis. Regardless, he was diagnosed with EDS prior to arrival and had previously received treatment. Along with EDS, he had a history of gastroesophageal reflux, attention deficit hyperactivity disorder and depression. He denied any past surgical history or any significant family history including EDS. Physical exam revealed hypermobility of joints, no significant cardiopulmonary findings, soft, nondistended abdomen with tenderness to palpation in the right lower quadrant, consistent with acute appendicitis.On arrival, vitals were within normal limits and a full set of labs and an abdomen/pelvis CT scan with intravenous and oral contrast were obtained. The CT scan showed a dilated appendix (up to 1.4 cm) with mucosal thickening, adjacent fat stranding and edema. There was no mention of appendiceal torsion, masses or lymphadenopathy. There was no fecalith identified. No other non-invasive methods such as abdominal ultrasound were used for diagnosis. Laboratory studies revealed WBC of 7.7, HGB of 15.3, PLT of 298. He was diagnosed with acute appendicitis. He was given IV cefoxitin and made NPO for surgery.He was taken to the operating room for a standard laparoscopic appendectomy. Patient was placed supine and underwent general anesthesia. Foley catheter was placed preoperatively. Open technique at the umbilicus was utilized to gain pneumoperitoneum with a 12 mm port. Next, two 5 mm ports were placed in the left lower quadrant and above the pubic symphysis. To increase our visualization of the appendix, we placed the patient in steep Trendelenburg and rotated right side up. It was at this point the appendix came into view. The distal appendix was swollen with erythema and inflamed mesoappendix . In the Postoperatively he was discharged the following day after tolerating general diet. Two weeks later, he returned to the clinic with no issues. On the physical exam, the trocar sites were well healed. Pathology on the specimen returned simply with “Acute Appendicitis.” There was no mention of any appendiceal tumors.3Appendiceal torsion is rare and clinically indistinguishable from acute appendicitis. As with our patient, preoperative radiological imaging is generally unrevealing, and this condition is often diagnosed during the operation. While there have been no reported cases of appendiceal torsion in EDS patients, there have been reported cases of stomach and testicular torsion ,9. SimilIn our patient, primary torsion of the appendix may have been the initial event leading to ischemia and ultimately appendicitis. Alternatively, tip appendicitis may have led to inflammation, edema and a subsequent lead point for appendiceal torsion. Traditionally, secondary appendiceal torsion is attributed to a mass  causing twisting of the mesentery, not necessarily inflammation. We cannot definitively say what caused the torsion, although we would hedge toward a primary torsion leading to acute appendicitis. Either way, the patient was appropriately managed and underwent a safe laparoscopic appendectomy.Surgeries in patients with EDS are associated with significant complications, including poor wound healing, dehiscence and intraoperative bleeding . Poor woPreoperative recommendations for the management of classic EDS patients include cardiology assessment with echocardiogram to assess for aortic root dilation and mitral valve prolapse. Blood type and crossmatch testing should be performed prior to surgery in case of uncontrolled bleeding. In addition, the anesthesiology team must be informed of EDS diagnosis due to reported cases of cervical spine and mandibular instability, and skin trauma during intubation . During 4To our knowledge, this is the first case report in the literature of an appendiceal torsion in a patient with Ehlers-Danlos syndrome. This case serves as evidence of another manifestation of EDS. The ligamentous hypermobility of EDS may have predisposed our patient to appendiceal torsion and acute appendicitis. This is a rare phenomenon and may be underdiagnosed in the EDS patients.The authors have no conflicts of interest.There was no source of funding for the research.The Institutional Review Board is not required for publication of a case report at our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Study Concept and Design: Dustin Baldwin, Bernardo Duarte.Data Collection: Dustin Baldwin. Bernardo Duarte.Writing of Paper: Soobin Kim, Dustin Baldwin, Bernardo Duarte.Bernardo Duarte.Not commissioned, externally peer reviewed.


Inflammatory myofibroblastic tumors (IMTs) are particularly rare tumors that have been described in various anatomic locations, of which the urinary bladder is the most common. These benign tumors are amendable to conservative therapy but are notoriously difficult to diagnose given their mimicry of malignant sarcomas and sarcomatoid carcinomas, making an accurate diagnosis paramount to spare a patient radical and unnecessary treatment. We hereby present the case of a 37-year-old female patient who was diagnosed with an IMT of the urinary bladder during workup for painless gross hematuria. Patient was successfully managed with a laparoscopic partial cystectomy and is free of recurrence 5 years after surgery. IMTs are rare benign tumors that share the same clinical presentation as malignant bladder tumors. Deep biopsy and experienced pathologist are crucial in establishing diagnosis and avoiding patient radical treatment. This case is a classical demonstration of a remarkably rare tumor that was adequately managed with conservative therapy, achieving excellent clinical outcomes. Inflammatory myofibroblastic tumors (IMTs) are particularly rare tumors that have been described in various anatomic locations such as the lungs, pancreas, bladder, and prostate –5. FirstA 37-year-old female, nonsmoker, presented to our institution for painless gross hematuria. She had no previous history of abdominopelvic surgery, urinary or gynecologic instrumentation, nor any history of recurrent or chronic urinary infections. Physical examination and serum biochemical investigations were unremarkable. Urine analysis and microscopy revealed numerous morphologically normal red blood cells with the presence of inflammatory cells. Significant wall thickening of the right lateral wall of the urinary bladder centered around a 2 × 2 cm exophytic mass was seen on computed tomography (CT) scan, as seen in Histologic analysis of the resection fragments revealed evidence of ulcerations in the urothelium with submucosal proliferation of fusiform spindle cells with mild cytonuclear atypia and minimal mitotic activity in a richly vascularized and edematous myxoid stroma. Certain foci of necrosis were noted. A dense inflammatory infiltrate composed of lymphocytes, polynuclear neutrophils, and polynuclear eosinophils was present in the tumoral tissue . ImmunohGiven the histologic features and the immunohistochemical profile, diagnosis of a pseudosarcomatous myofibroblastic tumor of the urinary bladder was made. The patient successfully underwent a laparoscopic partial cystectomy to resect the remaining tumor mass . HistoloNonepithelial tumors of the urinary bladder make up 2% to 5% of primary neoplasms of the bladder . InflammPathologically, IMTs are described as gray-white or tan-yellow firm well-circumscribed lesions with sizes ranging from 1 to 20 cm and a variable degree of focal necrosis, hemorrhage or cystic changes, or calcification . A crossThe immunohistochemical profile of IMTs often overlaps with other malignancies, which makes the diagnosis of an IMT more difficult. In general, IMTs stain positive for vimentin, desmin, smooth muscle actin, muscle-specific actin, and keratin . ALK posClinically, IMTs are slow-growing benign tumors that are amendable to conservative treatment , 3. GeneIn conclusion, inflammatory myofibroblastic tumors are remarkably rare nonepithelial benign neoplasms of unknown pathogenesis that presents similarly to malignant diseases. These tumors present a diagnostic challenge due to the overlap of histologic and immunohistochemical features seen in malignant neoplasms such as leiomyosarcoma, embryonal rhabdomyosarcoma, carcinoid sarcoma, and other malignant soft tissue neoplasms. Certain histologic and immunohistochemical findings are somewhat specific to IMTs which aids in differentiating them. A deep transurethral resection biopsy and an experienced pathologist are paramount in establishing the diagnosis and avoiding the patient radical treatments. The standard of care is surgical resection with negative margins with chemotherapy and radiotherapy reserved for unresectable or incompletely resected tumors. These tumors generally do not recur or metastasize; however, cases of recurrence or metastasis have been reported. Our case is a classical demonstration of an IMT discovered in a 37-year-old female managed with a laparoscopic partial cystectomy and remains recurrence free after 5 years.


Non-occlusive mesenteric ischaemia (NOMI) is a condition in which intestinal ischaemia arises due to spasms of peripheral blood vessels; however, there is no obstruction of the main arteries. Risk factors include hypertension, diabetes, and increasing age, but the traumatic injury triggering NOMI onset is rarely reported. We report a case of NOMI caused by a pelvic fracture due to a fall injury.A 77-year-old man was transported to the hospital due to a fall injury. CT revealed a pelvic fracture and a haematoma in the pelvic extraperitoneal space. The next day, the patient developed shock, and CT revealed an increase in haematoma size. Both internal iliac arteries were embolized by transcatheter arterial embolization (TAE). The next day’s CT revealed intestinal necrosis of the ascending colon, and emergency surgery was planned. During surgery, necrosis was identified in the serosa of the ascending, transverse, and sigmoid colon. We performed subtotal excision from the ascending colon to the sigmoid colon. On postoperative day 10, melena was observed, and CT revealed partial thickening of the small intestine and a decrease in the contrast effect. Considering the post-total colectomy and general condition, we proceeded with conservative treatment. Over time, the patient developed liver and renal dysfunction and died 16 days after surgery.We experienced a case of NOMI caused by bleeding from a pelvic fracture. It is important to keep in mind the risk of developing NOMI in traumatic bleeding to avoid missing this diagnosis. Non-occlusive mesenteric ischaemia (NOMI) is a condition in which intestinal ischaemia arises due to spasms of peripheral blood vessels; however, there is no obstruction of the main arteries. Risk factors include hypertension, diabetes, and increasing age, but traumatic injury triggering its onset has rarely been reported. Pelvic fractures generally cause extensive blood loss, even in trauma, and vital signs are likely to become unstable. Herein, we report a case of NOMI caused by a pelvic fracture due to a fall injury.A 77-year-old man fell from a height of approximately 3 m into the gutter and struck his pelvis. He was found immobile and was rushed to our hospital.Medical history: none.Physical findings: Consciousness was clear, blood pressure was 100/70 mmHg, heart rate was 127/min, SpO2 was 97%, and no injury was noted on either the head or abdomen.As shown in Table CT findings on day 1 revealed a right pelvic fracture and a haematoma in the pelvic extraperitoneal space (Fig. CT findings on day 3 revealed thickening of the ascending colon wall, intramural emphysema, and a slight amount of air in the mesenteric vein. In addition, a small amount of ascites was observed near the ascending colon. There was no problem with the contrast effect of the small intestine, and the sigmoid colon was dilated, but there were no obvious necrotic findings. Fig. .Fig. 2CTBlood work on day 3 revealed elevated levels of cytopathic enzymes: AST 2363 IU/l, ALT 2233 IU/l, LDH 3181 IU/l, and CPK 4122 IU/l. Based these findings, we rendered a diagnosis of necrosis of the ascending colon and performed emergency surgery.Intraoperatively, necrosis was observed in the serosa of the ascending, transverse, and sigmoid colon. Subtotal resection was performed from the ileocecal region to the sigmoid colon. After confirming that there is no necrosis in the mucosa of cut end of small intestine, ileostomy was constructed. Although a slight ischaemic change such as edema and mild redness was observed in the serosa of the entire small intestine, we decided to preserve the entire intestine.Excised specimen findings showed scattered necrosis in the ascending, transverse, and sigmoid colon Fig. .Fig. 3ExPathological findings indicated necrosis throughout all layers of the intestinal wall in the ascending, transverse, and sigmoid colon.Postoperatively, the patient began drinking water 2 days after surgery. However, 6 days after surgery, CT revealed a dilated small intestine, which we diagnosed as paralytic ileus. Subsequently, the paralytic ileus did not improve, and melena was observed 10 days after surgery. CT performed 10 days after surgery revealed extensive small bowel dilation and niveau. In addition, wall thickening and a decrease in contrast effect were observed in partial small intestines Fig. .Fig. 4CTWe diagnosed haemorrhage due to necrosis of the residual small intestine. However, due to the postoperative total colectomy and deterioration of general condition, it was decided that intestinal resection was impossible, and treatment with blood transfusion and haemostatic agents was planned. At that time, the colour of stoma did not change greatly and there were no necrosis sites.The patient's condition gradually worsened even after treatment, and over time, he developed liver and renal dysfunction and died 16 days after surgery.NOMI is a disorder that causes irreversible ischaemia in the intestine, resulting in intestinal necrosis, despite the absence of organic obstruction in the mesenteric artery trunk. This phenomenon was first reported by Heer  and inclNOMI has no specific symptoms. Some of the many non-specific symptoms include abdominal pain, vomiting, abdominal distension, and melena, but these symptoms are often mild during onset. In particular, it is difficult to identify these symptoms in cases of sedation, analgesia, and consciousness disorder. In these cases, diagnosis is likely to be delayed. Similarly, in our case, it was difficult to diagnose intestinal ischaemia based on clinical symptoms, because analgesics are used for pelvic fractures, and systemic contusions are caused by trauma. Blood work showed an increase in deviant enzymes, but the diagnosis was made even more difficult after TAE was performed for active bleeding. In our case, follow-up CT was performed to identify active bleeding, but it is important to consider CT examination as necessary, keeping in mind that NOMI is caused by bleeding from trauma.When NOMI is considered as a diagnosis, one of the treatments is injection of a vasodilator into the responsible blood vessel using angiography , but thiWe treated a case of NOMI caused by bleeding from a pelvic fracture. It is important to bear in mind the risk of developing NOMI in traumatic bleeding so as not to miss this diagnosis.


Intraoral approach for the removal of impacted third molars represents a common surgical procedure for the specialized clinician. However, in some cases such as ectopic third molars, extraoral surgical removal seems to be inevitable. We present a step by step case of a 56 year old woman with an ectopic third molar of the lower jaw along with a cystic lesion, which were surgically removed by a submandibular approach. Postoperative clinical course was uneventful and there were no signs of facial nerve paresis. In such cases, appropriate preoperative planning must be made based on careful study of radiographic imaging and clinical examination. The more conservative technique that would minimize adjacent anatomic structures risk should be the surgical technique of choice. Key words:Ectopic third molar, mandible, cyst, extraoral approach. A tooth is considered as “ectopic” when it is located in an unusual site, distant from its natural anatomical position . Even thEctopic third molars are more commonly found in the following anatomical areas: maxillary sinus, palate, mandibular condyle, coronoid process, mandibular ramus, angle and lower border of the mandible, the orbit, nasal cavity and surrounding soft tissues -6.The etiology of the ectopic third molars has not yet been clarified. A variety of reasons could explain this displacement: Eruption, which is a natural process of tooth migration from an intraosseous to a functional site, whenever is aborted, could result in an ectopic impaction . Trauma Usually ectopic third molars are randomly found in panoramic radiographs during routine clinical examinations, as they remain asymptomatic for years ,7. In soCurrent paper presents an interesting case of an ectopic impacted third molar in the lower border of the right mandible, associated with a cystic lesion, which was removed using an extraoral surgical approach. Main aspects such as diagnosis, pathology and treatment are extensively discussed for a comprehensive presentation of this subject.A fifty-six-year old female referred to our clinic, reporting pain in the right side of her face and difficulties in mouth opening. She also reported that she was aware of a protrusion concerning the lower border of the right mandibular area for more than 10 years. Patient’s medical history did not include any concomitant diseases. Preliminary extraoral clinical examination showed a large painful inflammatory swelling located in the lower border of the right mandible. Panoramic x-ray revealed a deep impaction of an ectopic third molar in that area in combination with a radiolucent lesion. The cone beam computed tomography (CBCT) demonstrated that the impaction was mainly affecting the lingual plate of the lower border of the mandible (Fig. Due to clinical signs implying inflammation, the decision to remove the tooth along with the cystic lesion was taken. After initial prescription of antibiotic treatment for the reminiscence of inflammatory symptoms, the patient underwent surgery.Extraoral approach under general anesthesia was the surgical technique of choice. After careful preparation of the surgical site Fig. B, a submThe postoperative course was uneventful and clinical examination revealed no signs of paresis or paralysis of the marginal mandibular branch of the facial nerve Fig. B. PatholVery few cases of ectopic mandibular third molars have been reported in literature so far ,9. HowevThe etiology of ectopic tooth impaction has yet to be clarified. Several theories have been proposed such as alterations during odontogenesis and trauma to a developing tooth germ, pathologic and iatrogenic conditions or even crowding -6. More Concerning location sites of ectopic mandibular third molars, recent literature reviews reported that in most cases they were found in the condylar region, followed by the ramus, the coronoid process, the sigmoid notch and the angulus in terms of frequency ,9. A higMost usually, radiographic examination may accidentally reveal an ectopic impacted third molar when no other symptoms have been reported so far . PanoramThe choice of surgical approach is based on the preference and the experience of the surgeon and the position of the ectopic tooth. In general, classical intraoral and extraoral approaches are the main two surgical techniques of choice ,2,9. EndIntraoral removal of ectopic impacted third molars can be performed through the sublingual fossa or through the vestibule, depending on tooth displacement, however sagittal split osteotomy can also be performed if necessary . The intExtraoral surgical removal is ineviTable in some cases, especially when ectopic third molars are deeply impacted/projected. However, this technique is not commonly used due to the rarity of such impactions and due to the extent of technical difficulties and associated complications, such as nerve and vascular injuries, joint damage and skin scaring -14. ExtrThe preauricular, the submandibular and retromandibular surgical approaches constitute the three different routes for extraoral access to ectopic third molars -13. LastIt is always important to consider the complications that might occur from the existence and removal of ectopic mandibular third molars. Complications like jaw fracture, with or without nerve injury, might occur when excessive osteotomy is attempted and when there is limited visibility ,14. In cIn conclusion, ectopic impacted mandibular third molars represent a rare clinical entity and usually remain undiscovered unless they cause symptoms or accidentally found in a radiographic examination. In many cases they are associated with a dentigerous cyst. They can remain untreated but in cases where clinical signs of inflammation are apparent, surgical removal must be considered. Surgical approach must be carefully planned, choosing the more conservative and less traumatic technique based on tooth location. Postoperative follow-up with radiographic examination at regular intervals is mandatory.


Metastatic lesions from head and neck tumours to the small bowel are extremely rare, and metastasis from tongue squamous cell carcinoma in particular has been reported only twice in the English literature.A 76 year-old lady diagnosed with a loco-regionally advanced tongue squamous cell carcinoma but deferred surgical resection. Seven months later after her diagnosis, she presented with generalized abdominal pain, due to image-proven viscous perforation, thus taken for emergent exploratory laparotomy, where the perforation was found at the distal ileum, which was resected, and a primary side to side anastomosis was done. The histopathological examination of the resected segment revealed squamous cell carcinoma originating from the tongue. The patient was deteriorating clinically and vitally during her stay, and passed away on day 16 post operation due to multi-organ dysfunction syndrome.Metastatic lesions from tongue carcinoma found in the vicinity of the small bowel represent a terminal stage with a dismal prognosis, and when these lesions present clinically with a complicated course, the survival rate is decreased significantly. Metas2Our patient is a 76 year-old lady, who has been diagnosed with a loco-regionally advanced, stage IVb (T3N2cM0) squamous cell carcinoma of the tongue in September 2018. Surgical resection was offered to her early in the course of her disease, but she refused it. She was on a regular follow up with our medical and radiation oncology facilities, and since she was deemed unfit for systemic therapy, she was managed with radical loco-regional radiation therapy, 70 Gy/35 fractions, and she finished her course in December 2018, with a partial response, with an eventual development of pulmonary metastasis that was detected on follow up imaging in January 2019.12/L, haemoglobin 12 g/dl, lactate 3 mmol/L, PH 7.33, pCO2 43 mmHg, and bicarbonate 21.1 mmol/L. Her ECG showed sinus tachycardia, and acute abdominal series revealed the presence of free air under the diaphragm. Computed Tomography scan was obtained, and revealed moderate pneumo-peritoneum, that appeared to be likely from a perforated proximal transverse colon, with a moderate amount of peri-hepatic and pelvic free fluid (On the 22nd of March 2019, the patient presented to the emergency department with altered mental status, progressively increasing generalized abdominal pain over a period of 3 days associated with subjective fever. She also had worsening of her chronic constipation, however, this wasn’t associated with nausea, vomiting, or abdominal distention. On examination, she looked dehydrated, confused and in severe pain. Her initial vital signs were: blood pressure 109/56 mmHg, heart rate 110 beats per minute, oxygen saturation of 99% on 4 L nasal cannula, and she was afebrile at that time. Her abdomen looked slightly distended, with guarding and tenderness on palpation. Her initial laboratory findings were: white cell count 12 × 10ee fluid . Computeee fluid , anda pree fluid A–D. The During her stay, she was steeply deteriorating, with increasing doses of inotropic medications. On day 16 post operatively, she developed bilateral pulmonary infiltrates with thick tracheal secretions, and need of higher ventilator settings, and her drain output was increasing; picture that was worrisome of ventilator associated pneumonia and anastomotic leak. On day 16 post operatively, she arrested, the cause of death was attributed to multi-organ failure disorder.3Small bowel tumours are among the rare gastrointestinal tract malignancies with an incidence of 1 per 100,000 populations . MetastaIncidence of distant metastasis from head and neck tumours ranges from 7 to 23%, most commonly to the lung, liver and bones, and less frequently to the skin and brain ,7. A verThe mechanism of metastasis to the small bowel is due to spread of micro-metastatic lesions through the blood-stream, however, spread through the lymphatic system has not been proven ,5. BasedOnce distant metastasis is diagnosed with head and neck tumour, the prognosis is dismal, and the survival is less than 2 years in >90% of the patients and the median time from diagnosis till demise is +/− 4 months ,7. And iSecondary malignancies of the small bowel are rarely symptomatic, but when they are, the symptoms are dependent on the site involved. Those symptoms can either be vague and non-specific, which might not raise the suspicion of metastasis since it’s extremely rare, or they could be complicated. Complicated ileal lesions are often obstructive, whereas, perforation is mostly noted in the jejunum . PerforaThere are no consensuses on the appropriate management of patients with small bowel metastasis from head and neck tumours, but in general the intents of any treatment modality is palliative . Major s4In conclusion, secondary small bowel malignancies from the head and neck tumours are extremely rare, especially those arising from tongue cancer. Due to their rarity, vague abdominal complaints are often overlooked until the disease takes a more complicated course such as obstruction or perforation. The presence of those metastatic lesions carries a very poor prognosis, and being coupled with bowel perforation, survival can be limited to only a few weeks.No funding was required.Case reports do not require ethical approval as per King Fahad specialist hospital protocol.A written, informed consent was obtained from the patient’s next of kin for publication of this case and the accompanying images as per KFSHD and IJSCR guidelines. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request".Concept built: Mohammed AlDuhlieb and Hisham AlMaiman.Data collection: Hadeel AlOmran and Mohammed AlDuhlieb.Manuscript writing: Hadeel AlOmran.Manuscript review: Mohammed AlDuhlieb.Pathology diagnosis: Deena Boqari.Pathology picture preparation and description writing: Layla AlBayyat.Surgeon and main responsible physician: Tariq Madkhali.Not applicable.Hadeel AlOmran.Not commissioned, externally peer-reviewed.We declare no conflict of interest.


Fibroids are the most common pelvic tumors in women; serious complications are rare but can be life-threatening.We present a case report of a 38-year-old Persian woman with acute abdominal pain and a history of uterine fibroids. The patient refused to undergo a laparoscopic myomectomy. Her ultrasound examination revealed free fluid in the abdominal cavity, and her vital signs were indicative of vasogenic shock. A diagnostic laparoscopy was performed to identify and control the source of bleeding: 400 ml of blood and blood clots were removed. Active bleeding was seen from a vein overlying a subserosal myoma. A laparotomic myomectomy was performed, and the patient was discharged 3 days after surgery with no complications.Surgeons should consider the possibility of this complication in women with acute abdominal pain and a history of uterine leiomyoma. Fibroids are the most common pelvic tumors in women ; the lar3/μL, and 333 × 109/L, respectively. The results of the patient’s echocardiogram (echo) and electrocardiogram, Doppler ultrasound of lower limb arteries, troponin enzyme level, and creatine kinase-MB were normal. The report of an ultrasound examination that had already been done revealed an intramural subserosal leiomyoma measuring 9.5 × 6.5 cm with cystic degeneration in the fundus of the uterus. Both ovaries were normal, and there was free fluid in the abdominal cavity up to Morison’s pouch. Furthermore, a massive fluid collection with internal echoes had been seen in the pelvic cavity, suggestive of a clot. Our differential diagnosis included a ruptured ectopic pregnancy, a hemorrhagic ovarian cyst, and a ruptured ovarian cyst. The patient was admitted to the gynecology ward at 2:00 p.m.A 38-year-old Persian woman who was a virgin was referred to our emergency ward with right-sided abdominal pain at 11:00 a.m. Her pain had started in the right upper quadrant of the abdomen; its onset was sudden, and it persisted for 2 hours with one fainting episode. The patient’s last menstrual period had been 7 days before admission, and she reported no trauma or previous surgery. Her pulse rate was 110 beats/minute; her systolic blood pressure was 80 mmHg and diastolic blood pressure was undetectable; and her body temperature was 37.5 °C. Her abdominal examination revealed tenderness in the right lower and upper abdomen. She had an obvious tender mass extending to the umbilicus. She had a history of uterine leiomyoma. Laboratory tests and ultrasound were requested. Her hemoglobin, hematocrit, white blood cell count, and platelet count were 11.1 mg/dl, 35%, 13.9 × 10The result of her pregnancy test was negative. At 3:00 p.m., the patient was transferred to the operating room. A diagnostic laparoscopy was performed with the patient under general anesthesia in order to identify and control the source of bleeding. Further reasons for performing the laparoscopy were the patient’s unstable hemodynamic condition and the ultrasound report of a hemoperitoneum.A 10-mm trocar was inserted into the umbilicus, and two 5-mm trocars were placed in the right and left lower quadrants. The hemoperitoneum, consisting of 200 ml of fresh blood and 200 ml of clotted blood, was removed. Laparoscopy revealed a large subserosal leiomyoma (10 × 15 cm) located in the fundus of the uterus. The patient’s abdomen and pelvis were examined, and a large subserosal leiomyoma (10 × 15 cm) was found in the fundus of the uterus, with a congested and dilated venous plexus. On the basis of FIGO  classification of uterine fibroids, the fibroid was a pedunculated subserosal fibroid (type 7). A bleeding vessel was seen on the posterior surface of the leiomyoma (Fig. The uterine leiomyoma is a benign neoplasm. A variety of approaches are used to treat a uterine leiomyoma, such as observation; medical treatment; surgical myomectomy; and, in rare cases, hysterectomy . IntrapeA specific preoperative diagnosis can rarely be established in these cases. In one study, the correct diagnosis was made preoperatively in a mere 7.8% of cases . ComputeDespite its rarity, a bleeding leiomyomatous vessel should be included in the differential diagnosis of a hemoperitoneum of ambiguous origin. Rapid diagnosis and management are essential in this potentially life-threatening condition. Surgeons should consider the possibility of this complication in women with acute abdominal pain and a history of uterine leiomyoma in order to prevent severe morbidity or even mortality. When a patient undergoes conservative management of large asymptomatic subserosal fibromas, she should be informed of this rare complication.


Acetabular roof lesions (ARLs) in children are uncommon and may involve a variety of diseases. The acetabular roof is the main weight-bearing area of the hip joint, and lesions affecting the acetabular roof lead to fluid accumulation in the hip joint, causing hip pain and claudication. Methods for diagnosing and treating ARLs and the prognosis after treatment are rarely reported. We present our experience in a group of children and teenagers with ARLs to retrospectively explore the clinical and imaging features and histopathological diagnosis and report the treatment methods and follow-up observations.Patients with ARLs admitted to the Children’s Hospital of Chongqing Medical University from April 2011 to September 2018 were selected retrospectively. We collected the basic information of patients , main symptoms and signs, results of various laboratory tests, treatment methods, and intraoperative observations through the hospital medical record system. We collected X-ray, computed tomography (CT), magnetic resonance imaging (MRI) and pathological examination data through the Picture Archiving and Communications System. Follow-up data were collected through an outpatient medical record system, telephone, and chat software (such as WeChat). We used descriptive methods to analyze the lesion structure and destruction mode based on the imaging findings and histopathological diagnosis.There were 14 ARL patients, including 6 with eosinophilic granuloma (EG), 5 with chronic osteomyelitis, 2 with bone cyst, and 1 with tuberculosis. One patient underwent percutaneous needle biopsy, 2 underwent open biopsy, and 11 underwent curettage; among them, 5 patients also underwent bone grafting. These lesions had no characteristic imaging findings, and the diagnosis was mainly based on histopathological examination. Most patients showed complete symptom resolution and good hip function at the 1-year follow-up.ARLs are not common in children. The types of lesions are diverse and mostly benign, with EG being most common. Malignant tumors may also occur, such as Ewing’s sarcoma, non-Hodgkin’s lymphoma, metastases and neuroblastoma. CT and MRI can be helpful in diagnosing certain cases, but incisional biopsy is required in most cases. Acetabular roof lesions (ARLs) are rare in children and adults. ARLs mainly involve area II based on the Enneking and Dunham classification , and somARLs have rarely been reported in the literature, with only a few case reports of iliac lesions and few reports of cases involving acetabular roof destruction. One article reported 3 cases of eosinophilic granuloma (EG) of the pelvis in children . Two of Patients were eligible for inclusion if they had a lesion on the acetabular roof between 2011 and 2018. This research was approved by the Ethics Review Board of the Children’s Hospital of Chongqing Medical University. All patients or their relatives provided written informed consent to be included in this study. The inclusion criteria were as follows: (1) age less than 18 years; (2) X-ray images showing lesion involvement of the acetabular roof; (3) exact pathological diagnosis; (4) complete case and imaging data; and (5) more than 1 year of follow-up. The exclusion criteria were as follows: (1) children with acetabular roof fractures caused by trauma; (2) no pathological diagnosis or incomplete information; and (3) recurrence after various prior hip operations. We collected the clinical and imaging data, treatment methods, and follow-up results of the patients.The main clinical features recorded were age, sex, symptoms , and physical signs . We obtained the results of some laboratory examinations performed on admission, including routine blood parameters, the procalcitonin (PCT) and high-sensitive C-reactive protein (CRP) levels, and the erythrocyte sedimentation rate (ESR). Imaging studies of the lesion included X-ray examination in all patients, conventional and 3D computed tomography (CT) in 12 patients, and magnetic resonance imaging (MRI) in 8 patients. The size of the lesion was mainly evaluated on X-ray examination. According to the proportion of the orthotopic lesion in the acetabular roof, they were divided into small (< 1/3), medium (1/3–2/3), large (> 2/3), and extra large . Additionally, the status of the margin (with or without sclerotic margination), boundary (clear or unclear), cortical destruction , periosteal reaction, joint space (widened or narrowed), femoral head size (changed or osteoporotic), and hip joint (dislocated) was considered. Further examination by MRI can allow the evaluation of surrounding soft tissue edema, joint cavity effusion and effects of the lesion on the joint cavity, and CT can be used to evaluate cortical continuity in a more detailed manner.If the child could not be diagnosed based on clinical, laboratory, and imaging examinations, a needle biopsy or incisional biopsy was performed. Indications for incisional biopsy included the following: (1) no signs of malignancy on preoperative examination; (2) cystic lesions, due to the low success rate of needle biopsy with such lesions; (3) lesions with a maximum diameter > 3 cm ; (4) the need for bone grafting during surgery; and (5) insufficient tissue provided by needle biopsy for a definitive diagnosis . If the Postoperative assessments were performed at 1, 3, 6 months and 1 year and then annually thereafter. Postoperative follow-up was performed by an independent orthopedic surgeon, who recorded the clinical and imaging data of each patient during follow-up. The imaging assessment included X-ray examination of the lesion; if this clinical assessment was insufficient, CT or MRI was performed. The d’Aubigné-Postel scoring system was used for the clinical assessment of hip function  accordinThe study ultimately involved a retrospective review of 14 ARL patients, including 2 females and 12 males, with an average follow-up of 2.1 years (1–8 years). The mean age was 6.3 ± 4.7 years . The modified Harris Hip Score (MHHS) of children on admission is shown in Table A summary of the imaging findings for the 14 patients is shown in Table In all 14 children, the diagnosis was confirmed by pathology; there were 6 cases of EG, 5 cases of CO, 2 cases of BC, and 1 case of TB. The 5 patients with EG underwent lesion curettage and bone grafting, and the other EG patient with multiple lesions underwent open biopsy followed by chemotherapy for 6 months (prednisolone and vindesine). Three patients with CO underwent lesion curettage, 2 of whom with hip dislocation underwent hip reduction; 2 patients with CO only underwent biopsy, incisional biopsy in 1 case and needle biopsy in the other case. Two children with BC underwent lesion curettage and allogeneic bone grafting. One patient with TB underwent lesion curettage and isoniazid implantation followed by anti-TB treatment. Except for the two patients who underwent open and needle biopsy, other patients underwent frozen biopsy during surgery.At the 1-year follow-up, 13 patients showed complete resolution of pain and claudication, and none of them showed symptom recurrence, with an MHHS of more than 90 points and a d’Aubigné-Postel score of 17 points. Only one CO patient with pathological subluxation still had mild claudication at the last follow-up, with an MHHS of 85 points and a d’Aubigné-Postel score of 15 points. On X-ray examination, 1 patient with CO and 2 patients with BC still showed partial lesions at the last follow-up. The other 11 patients showed complete lesion healing and reconstruction.We selected 4 cases of lesions of different pathological types as representatives to describe their diagnosis and treatment and demonstrate in more detail the clinical and imaging manifestations, treatment methods and prognosis of children with various pathological ARLs.A 4.8-year-old boy presented with pain and activity limitation in the right hip lasting for 10 days. On physical examination, he was found to have hip tenderness and limited hip movement with an MHHS score of 75. His WBC count was 10.1*10^9/L. Radiography showed destruction of the right iliac bone, with a low-density shadow, a blurred boundary and a small periosteal reaction. CT showed cortical destruction. MRI showed equal strong T1 and abnormal T2 signals with cortical damage, surrounding soft tissue thickening and swelling, with long T1 and T2 signals  and restricted right hip movement. X-ray examination and CT revealed a destructive lesion in the right acetabular roof with hip subluxation. MRI showed patchy, slightly long T1 signals and slightly long T2 signals in the right ischial and iliac bone, as well as long T2 signals in the right hip joint space , 1 case of ES, 1 case of chondroblastoma (CB), and 1 case of Bartonella osteomyelitis (BO) Table . CombineAlthough ARLs mainly consist of EG and CO lesions, various other types of lesions can occur, and even desmoid tumors have been reported in adults . The levThe treatment of ARLs varies due to the diversity of the lesions. If OO can be diagnosed definitively, CT-guided radiofrequency ablation is preferred for minimally invasive treatment, but attention should be paid to protection of the articular cartilage . For BC ARLs in children are uncommon. In this series of 14 children, EG and nonspecific CO were the most common forms of ARL. These lesions had no characteristic imaging findings. Although all of our cases had a benign etiology, one must always suspect and exclude malignancy. The diagnosis is mainly based on histopathological examination. Surgical treatment can be effective, with good clinical outcomes at 12 months.


Pyometrocolpos is accumulation of infected fluid in the uterus and vagina. It is rare in children, mostly seen after menarche as a result of obstructive congenital genital malformation that impairs free drainage of the uterine secretions. In a child, it may present as an acute illness that necessitates urgent and appropriate management and treatment of the underlying cause, which can be a challenge in a resource-limited setting.Escherichia coli sensitive to ceftriaxone and gentamicin was isolated.We report a case of pyometrocolpos in an 8-month-old African infant who presented with fever, vomiting, decreased urine output, and abdominal distension of 12 days’ duration. An abdominal examination revealed a subumbilical midline incision scar and a midline lower abdominal mass. She appeared to have presented at the emergency department with similar complaints 2 months earlier and had been diagnosed with pyometra, which was managed by emergency laparotomy for pus drainage, and she was kept on antibiotics. Recovery was established after 10 days of admission, and the patient was discharged to home. Her symptoms reappeared 2 months after the first presentation. Her blood work showed significant leukocytosis with neutrophilia, and abdominal ultrasound depicted bilateral hydronephrosis with hydroureters and a fluid-filled uterus. Examination under anesthesia in the operating theater revealed normal-looking female genitalia with a cribriform hymen, beneath which lied a transverse vaginal septum. Foul-smelling pus was aspirated through the septum, and septectomy was performed to allow 350 ml of pus to drain. A pus sample was sent for culture and sensitivity, and Escherichia coli seems to be the most probable offending organism, but pus culture is crucial for antibiotic stewardship in proper management of the infection. Definitive treatment should focus on correcting the obstructive anatomical congenital deformity that caused the obstruction in order to avoid recurrence.Pyometrocolpos is rare in childhood but should be suspected in a girl presenting with a midline lower abdominal mass accompanied with urinary obstructive symptoms associated with fever and gastrointestinal symptoms.  Pyometrocolpos is defined as an infection of fluid within the uterus and vagina, which is usually a consequence of genital urinary malformations that impair free uterine drainage. It rarely manifests in children, leading to delays in its diagnosis and treatment. We describe what we believe is the first reported case of pyometrocolpos in a child in northern Tanzania and the second case in all of Tanzania. Pyometrocolpos was first reported in Zanzibar in 1948. Because of its rarity coupled with limited diagnostic capabilities in a resource-limited setting such as Tanzania, pyometrocolpos in an infant poses a great challenge in both diagnosis and management, as reflected by a recurrence of the condition as seen in this case. We describe the clinical presentation, diagnostic modalities, and management challenges and outcome of pyometrocolpos in an infant.We present a case of an 8-month-old African infant readmitted at our facility 2 months after laparotomy. She presented with abdominal distension of gradual onset for 12 days, accompanied with difficulty in passing urine and stool and low-grade fever. Two months earlier, she had presented with similar symptoms, at which time a diagnosis of obstructive uropathy due to pyometra had been made. This was then managed by an emergency laparotomy and drainage of 400 ml of pus from the uterus and postoperative treatment with antibiotics. In her current admission, she had nonprojectile vomiting that was nonbilious, nonbloody, and of food content.9 cells/L with a predominance of neutrophils at 15.83 × 109cells/L (59.3%) and a hemoglobin count of 14.5 g/dl.Clinical assessment revealed she was febrile (38 °C) with anthropometric measurements indicating moderate acute malnutrition. Abdominal examination revealed a healed subumbilical median incision scar with a mobile, regularly shaped, smooth margin suprapubic mass extending up to the level of the umbilicus. The girl’s complete blood count showed leukocytosis of 26.69 × 10An urgent abdominal pelvic ultrasound revealed a fluid-filled mass in the shape of the uterus with an echogenic area representing thicker fluid in the uterine cavity. The urinary bladder was displaced to the left, and the ureter and renal calyces were dilated, suggesting bilateral obstructive nephropathy secondary to a grossly distended uterine cavity with pyometra Fig. .Fig. 1MEscherichia coli sensitive to ceftriaxone and gentamicin.The infant was reviewed by a gynecologist, who ordered an estrogen assay and renal function tests, the results of which all appeared to be within normal ranges for age. In order to perform a proper assessment of the underlying malformations, clinical examination was continued with the patient under general anesthesia in the operating theater. In the operating theater with the patient under general anesthesia and in lithotomy position, vaginal examination revealed a cribriform hymen beneath which a midvaginal transverse septum could be seen. A 5-ml syringe was carefully inserted at the middle of the septum, and a dense yellowish fluid was aspirated. Hymenectomy had to be performed to allow septectomy, and about 350 ml of pus were drained Fig. . A pus sUterine lavage was performed, and a size 16 three-way catheter was introduced through the excised septum site for continuous drainage and to maintain patency along the excised margins for 10 days while the infant was in the ward.After 10 days, the drain (catheter) was removed, and the patient was observed for additional days before discharge. Six weeks after septectomy, she was seen for a follow-up appointment at the outpatient gynecology clinic. Abdominal pelvic ultrasound was performed, which revealed a normal empty uterus.Physical examination revealed that the septum patency was maintained, and the patient’s nutritional status had improved significantly. She was then discharged from the gynecology clinic.Pyometrocolpos refers to accumulation of infected fluid in the vagina and uterus. Developmental anomalies of the müllerian duct, in particular disorders of vertical (transverse) fusion resulting from abnormal canalization of the vaginal plate or failure of the uterovaginal primordium and the sinovaginal bulbs to fuse, can result transverse vaginal septum (TVS), an imperforate hymen, and in extreme cases a vaginal atresia . These cOur patient’s case is among the few occurring in childhood, with this particular infant undergoing surgery twice as a result of obstructive uropathy secondary to a recurrent pyometrocolpos due to a midvaginal transverse septum that was not corrected at the initial presentation. Similar to most reported cases, the clinical presentation in our patient’s case involved abdominal distension accompanied by both urinary and bowel obstructive symptoms together with gastrointestinal disturbances such as vomiting and irritability .The presence of a suprapubic mass identified as a distended uterus filled with fluid and obstructive uropathy was made through clinical examination and confirmed by ultrasound, similarly to other cases. However, unlike some other cases in which computed tomography and magnetic resonance imaging were further ordered to confirm the diagnosis and evaluate underlying anatomical anomalies, in our patient’s case, financial constraints and the urgency for intervention resulted in immediate surgery without further imaging studies as is noted in an almost similar case in Ethiopia . In resoEscherichia coli. Of 12 cases reported, only 33% yielded bacterial growth: 3 cases (75%) identified E. coli as the causative organism, and Pseudomonas was detected in 1 case [E. coli was identified, which was sensitive to ceftriaxone and gentamicin.Proper management apart from the surgical intervention requires identification of the organism that caused the infection that resulted in pus formation. The bacterium that has been most associated with pyometrocolpos as obtained from either pus or blood sample cultures is n 1 case . In our Little is known about the cause of pyometra and pyometrocolpos in infants due to the rarity of the condition. Some authors hypothesize that hypoestrogenized endometrium in infants is thinner and less resistant to infection than a thicker estrogenized endometrium. A hypoestrogenized endometrium combined with an obstruction to uterine drainage may lead to hydrometra or hydrometrocolpos and consequently pyometra or pyometrocolpos, respectively . The infTreatment of pyometrocolpos should entail identification of the underlying obstructive cause that predisposes patients to accumulation of fluid in the uterus and vagina; in our patient, the midvaginal transverse septum was identified. The failure to remove this mechanical obstruction during the first encounter led to persistent blockage, which resulted in reemergence of the condition 2 months later. Similar observation was noted in a case that involved a 10-month-old infant in whom the first surgery was performed to drain the uterus and in turn temporarily relieved the patient of the obstructive symptoms; however, a second surgical intervention was needed to insert a drain for continuous drainage of the uterine cavity .TVS can occur at nearly all levels in the vagina , with 46% superior, 40% middle, and 14% inferior . Unlike The diagnosis of pyometrocolpos, even though it is a rare condition in childhood, should be suspected in a girl presenting with urinary obstructive symptoms with a midline abdominal mass associated with fever and gastrointestinal complaints. Diagnosis in low-resource settings often relies solely on clinical presentation, physical examination, and ultrasound imaging. Management should include ruling out and correcting the congenital genital abnormality, which is crucial in ensuring that the surgical intervention is focused and curative and prevents recurrence.The care provided was timely with full explanation of the diagnosis and prognosis and with a follow-up plan explained. Mother’s statement: “It is was a relief for my family to learn of my child’s condition and final diagnosis and treatment. We are thankful for the treatment and management.”


The most common underlying diagnosis of intracranial tumor pathology is metastatic disease, followed by primary brain tumors. Chondrosarcomatous metastatic disease of the brain is a rare subtype of this disease process.The patient presented with right-sided weakness. Her history was significant for femur chondrosarcoma which was resected and treated. Laboratory analysis revealed persistent hypercalcemia and hyperglycemia. MRI of the brain was completed, which revealed a left parietal-occipital lesion with smaller lesions in the left frontal and right parietal lobe.Multidisciplinary tumor board recommended surgery for lesion resection and pathology. Surgical pathologic diagnosis after lesion resection was metastatic chondrosarcoma. The patient’s preoperative arm and leg weakness improved after surgery.Our paper delineates this unique case of intracranial spread of femur chondrosarcoma. Malignant tumors arising from the skeletal system are rare, representing only about 0.5% of all new cancers. Approximately 2100 new cases of malignant bone cancers (sarcomas) occur in the United States each year. The most common type of bone cancer is osteosarcoma. About one-fourth of malignant bone cancers are chondrosarcomas.The most common cause of neoplastic intracranial mass lesions is metastatic disease, followed by primary brain tumors. Recent studies have shown that brain metastases make up about 49% of intracranial neoplasms while gliomas make up 26%, followed by meningiomas, pituitary adenomas, and schwannomas. The most common metastatic tumors to the central nervous system are lung, breast, prostate, and renal carcinomas. Chondrosarcomatous metastatic disease to the brain is exceedingly rare -3. IsolaThe patient is a 51-year-old female who came to the emergency department with complaints of right-sided weakness after a recent trip to Mexico. Physical exam revealed 4/5 motor strength in the right arm and leg. An MRI of the brain with and without contrast was obtained, which revealed ring-enhancing lesion in the left parietal-occipital lobe  by malignant cells, which induces renal calcium absorption, accounts for 80% of cases. Excess osteolytic activity with bone resorption accounts for 30% of cases, and is usually seen in extensive skeletal tumor burden. Increased production of 1,25-dihydroxyvitamin D, which enhances intestinal calcium absorption as well as osteolytic bone resorption, accounts for 1% of cases of malignancy-related hypercalcemia .Hyperglycemia in cancer patients can be attributed to a few proposed mechanisms aside from a known diagnosis of diabetes mellitus. Steroids, which are used in a number of malignancy-related settings such as for cerebral edema from brain metastasis or in several chemotherapy regimens, are a common cause of drug-induced hyperglycemia. In the hospital setting, more than 50% of patients receiving high-dose steroids experience at least one episode of hyperglycemia . AnotherChondrosarcomatous brain tumors are rare with few primary cases reported in the literature. We report a case of a metastatic intracranial metastasis from an extracranial source, which has not been previously reported. Our case demonstration should help to clarify adjuvant treatment options. Treatment plans should take into account histopathological characteristics of the tumor along with patient functional status, endocrine status, and ability to tolerate adjuvant treatment side-effects. Future studies should address neurocognitive outcomes in addition to recurrence and survival rates with pathological correlation when comparing different treatment algorithms.


A 53-year-old woman presented with a rapidly growing pelvic mass suspected to be endometrial cancer due to endometrial biopsy showing grade 1 endometrioid adenocarcinoma. Due to severe aortic valve stenosis, she underwent a transcatheter aortic valve replacement (TAVR) for surgical optimization for a planned total abdominal hysterectomy, bilateral salpingo-oophorectomy, and tumor debulking. She was discharged on dual antiplatelet therapy with plans for future surgery, but was readmitted with abdominal distension, constipation, and urinary retention. The pelvic mass seen on prior imaging studies had increased in size. Unanticipated asystole cardiac arrest occurred two days after readmission, which on autopsy was found to be secondary to abdominal compartment syndrome from a rapidly enlarging ovarian small cell carcinoma pulmonary type. Compartment syndrome occurs in a confined space, when increased pressure leads to organ dysfunction as the result of ischemia. Many surgeons are familiar with compartment syndrome in the extremities following trauma, but it can also occur in the abdomen . The WorWhile most cases of primary IAH result from peritonitis, pancreatitis, and inflammatory or oncologic diseases, other causes include aortic aneurysm, abdominal and retroperitoneal tumors, mechanical bowel obstruction, abdominal trauma, and ascites . SecondaIn this case report, we discuss the unusual presentation of ACS secondary to an extremely rare gynecological malignancy, which led to our patient’s eventual demise. Early recognition and management can be crucial to reducing morbidity and mortality in cases of ACS.2 and a blood pressure at 162/72 mmHg while tachycardic at 102 beats per minute. A 4/6 aortic systolic murmur was auscultated, and her abdomen was distended with mild tenderness to palpation, particularly in the lower quadrants. She was found to have a stage 3 acute kidney injury with a creatinine of 5.7 mg/dL (baseline 1.4 mg/dL), calcium of 9.3 mg/dL, lactic acid of 1.2 mmol/L, hemoglobin of 7.8 g/dL, and leukocytosis with a white blood cell count of 65,000/mm3. A CT scan of her abdomen and pelvis showed a 15.5-cm pelvic mass with areas of high attenuation noted within and extending into the adjacent ascites. A review of previous imaging (CT urogram from nine months prior) showed no previous evidence of these findings. A CT of her chest was unremarkable. A 53-year-old woman presented to the emergency department with a 12-month history of menometrorrhagia and a one-week history of worsening nausea and vomiting. Her past medical history included a moderate developmental delay, severe valvular aortic stenosis, insulin-dependent diabetes mellitus, hypertension, morbid obesity, and hypothyroidism. She had no smoking history. On physical examination, the patient was 216 lbs with a BMI of 51.9 lbs/in2 six months prior on an echocardiogram and precluded her from receiving a dilation and curettage for her menometrorrhagia. Cardiac intervention with a transcatheter aortic valve replacement (TAVR) was planned but had not yet been accomplished.Her aortic valve area was measured to be 0.49 cmThe patient was admitted, and a paracentesis removing 3 L was performed. The serum ascites albumin gradient was <1.1 g/dL with a protein level of 3.5 g/dL and an albumin of 1.90 g/dL, and ascites cytology showed no malignant cells. A CT scan of her abdomen and pelvis and a transvaginal ultrasound showed a heterogeneous mass in the pelvis, superior and to the right of the uterus measuring 17.3 x 15.9 x 11.3 cm; these radiological findings were thought to be “likely consistent with a large focus of hemorrhage/hematoma” or an undetermined malignancy. The uterus had a 10-mm endometrial stripe, the right ovary measured 5.0 x 6.8 x 3.4 cm and the left ovary measured 3.3 x 1.8 x 2.4 cm.The patient was cognitively impaired due to developmental delay that prevented her from being able to make informed medical decisions. Due to a complicated social situation, it took nearly a week to establish her sister as her legal designated power of attorney (DPOA) that unfortunately delayed her treatment. A gynecology oncology consultant recommended an endometrial biopsy and resection of her pelvic mass by a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and tumor debulking. Anesthesiology and cardiology consultants recommended cardiac optimization for this surgery, which included a TAVR procedure.The CA-125 (cancer-antigen 125) was found to be significantly elevated at 1,357 U/mL. An endometrial tissue biopsy was performed for which a pathology review determined it to be an endometrioid adenocarcinoma, Federation of Gynecology and Obstetrics (FIGO) grade 1. A bilateral uterine artery embolization was performed to mitigate her menometrorrhagia, during which a consultant interventional radiologist noted her uterus to be hypervascular with equal blood supply from bilateral uterine arteries along with “an enlarged right ovarian artery arising from the right uterine artery supplying the enhancing portions of the previously seen large pelvic mass.” This enlarged ovarian artery was also embolized. This was the first radiographic evidence that her pelvic mass may have been of ovarian origin.Cardiology and cardiothoracic surgery performed a TAVR after a delay of several days due to scheduling issues. The patient was initiated on dual antiplatelet therapy with aspirin and clopidogrel with plans for one month of uninterrupted therapy, after which her surgery would be performed. A multidisciplinary meeting was arranged with consultants from radiology, gynecology oncology, medical oncology, and pathology for future treatment planning. It was concluded that (1) her pelvic mass most closely resembled a bulky uterine or ovarian malignancy with possible mesenteric implants, and no further biopsies were recommended due to the patient’s need for continual dual antiplatelet therapy; and (2) recommended preoperative treatment was megestrol acetate, as grade 1 endometrial adenocarcinoma is typically a hormonally responsive tumor, and the patient and her sister had chosen not to pursue any neoadjuvant chemotherapy. Recommendations for adjuvant chemotherapy or additional treatment would be based on final surgical pathology.A leukocytosis is persistent throughout her admission, which was suspected to be secondary to tumor production of granulocyte colony stimulating factor (G-CSF); this has been documented in the medical literature to be associated with ovarian cancers. Her acute kidney injury resolved and her creatinine decreased to 1.18 mg/dL. Two paracenteses performed during her admission removed a total of 4 L. After a three-week hospital admission, she was discharged to a skilled nursing facility on her previous diuretic therapy, aspirin and clopidogrel for her aortic valve replacement, and megestrol acetate for her endometrial cancer with a close gynecology oncology follow-up for surgical planning.3 and her creatinine was 1.26 mg/dL with a hemoglobin of 8.6 g/dL; there were no other significant lab findings. There was no evidence of any active infection and her lactic acid was 1.9 mmol/L. A foley catheter was placed, and 150 mL of urine was removed. An abdominal ultrasound showed only minimal abdominal ascites (an insufficient amount for a paracentesis) with an inaccessible ascites pocket in the pelvis along with a pelvic mass that appeared larger than during previous admission, confirmed by a CT scan  prophylaxis. During the autopsy, when incising the abdomen, approximately 2 L of blood-tinged fluid was ejected under high pressure. The patient’s diaphragm was found to be displaced upwards by abdominal contents and a large pelvic mass, around which there was a focal discoloration of the bowel and mesentery suggestive of ischemia  Figure .With OSCCPT being a rare malignancy, at the time of this report there is no established immunohistochemical profile and the diagnosis of OSCCPT was made based on the combination of histological pattern, clinical presentation, and supportive immunohistochemical staining. It was determined that a rapidly growing OSCCPT tumor and its associated ascites had resulted in ACS causing this patient’s untimely demise.We herein present a case of lethal ACS secondary to OSCCPT, a gynecological malignancy of which only a few cases have been reported in the literature . ThroughIAH and ACS are related entities with the former being a sustained IAP > 12 mmHg, and the latter being a sustained IAP > 20 mmHg with new organ dysfunction/failure . The patRapidly expanding intra-abdominal malignancies are an uncommon cause of ACS, and there are only a few cases of such in medical literature. In children, these malignancies have included neuroblastomas, nephroblastomas, and immature teratomas ,9. In adOvarian malignancies can have several unique characteristics as were demonstrated in this case: they can be associated with significant leukocytosis and can produce massive amounts of ascites. A review by Viau and colleagues suggests that, though uncommon, the presence of a gynecologic malignancy with a leukocytosis in the absence of infection should prompt suspicion for a phenomenon known as paraneoplastic leukemoid reaction, which is suspected to be secondary to autonomous secretion of G-CSF hematopoietic growth factor and IL-6 . EvidencWe present a case of a patient with endometrial adenocarcinoma and a rapidly growing OSCCPT with malignant ascites and a paraneoplastic leukemoid reaction whose surgery was delayed in order to establish a DPOA and complete post-TAVR dual antiplatelet therapy. She was readmitted to the hospital at which time there was no clinical suspicion for ACS in the absence of abdominal pain, lactic acidosis, or any significant organ dysfunction. It was only when her post-mortem autopsy was performed that the cause of her death was established to be ACS causing her cardiac arrest to the dismay of her medical team. The patient’s outcome was affected by unfortunate delays in therapy due to the delay from her TAVR procedure being performed, the need to establish a legal DPOA, the uncertainty of diagnosis of her pelvic mass on imaging studies, and the need for 30 days of uninterrupted dual antiplatelet therapy following her TAVR before performing surgery. A high clinical index of suspicion is necessary to diagnose ACS, and this should be considered in a distended abdomen with a rapidly expanding intra-abdominal tumor.


Echinococcus granulosus. Humans are accidentally contaminated by ingesting the parasite´s eggs mainly released through the faeces from infected dogs. Hydatidosis affects the bone in 0.5 to 2% of cases, with 44% of these cases involving in the spine. Vertebral hydatidosis is rare and it represents the most frequent and most dangerous form of bone involvement. This manifestation is extremely delicate, difficult to correctly identify and manage. The authors report two cases of vertebral hydatidosis revealed by medullar compression and increasing lumbar-radicular pain and functional impotence of lower limbs. Imaging showed multicystic bony lesions in lumbar spine. The extension into the spinal canal and to the perivertebral soft tissue were involved in both cases. We present those two cases to highlight the role of radiological exploration for diagnosis especially with magnetic resonance imaging (MRI) and the importance of monitoring this dangerous pathology.Hydatidosis is a zoonosis caused by  Echinococcus granulosus tapeworm [Hydatid disease is a parasitic infection caused by the larval or adult form of the tapeworm . This istapeworm . The difFirst case presentation: a 28-year-old female, of rural origin, complained of weakness and numbness of the lower limb for 25 days. There was no history of trauma, fever, vomiting, altered sensorium or loss of consciousness. The interrogation revealed the presence of sphincter disorders. On examination, the patient was afebrile, conscious and alert. There was no cranial nerve deficit. Neurological examination revealed osteo-tendinous reflexes abolished with flacid tone and bilateral sensory deficit. Biological examinations revealed neither inflammatory syndrome nor eosinophilia. MRI of the spine showed multiple cysts at L3 level with extension into the spinal canal at L2 and L4 levels compressing the cauda equina and to the peri-vertebral soft tissue, presenting low signal on SE T1 weighted images (WI) and high signal on SE T2 WI without any enhancement after gadolinium injection (njection . The othSecond case presentation: a 34-year-old female of rural origin, with occasional contact of dogs, had three years history of lumbar-radicular pain caused by spine hydatid cystic lesions at L3 level and was treated with medical treatment and surgery: corpectomy on L3, disc decompression and stabilization with screws. The parasitological examination of the lesions has documented the presence of Echinococcus granulosus. Three years later, she complained increasing lumbar-radicular pain and functional impotence of lower limbs. On examination, the patient was afebrile, conscious and alert. There was no cranial nerve deficit. The patient had difficulty standing, the Lasegue´s sign was positive on the right and Mingazzini test is positive on either side, especially on the right and she has right foot dorsal flexion deficit. She was hospitalized and a lumbosacral MRI was performed. The exam had documented expansible heterogenous mass with multiple cysts at L3 level with extension into the spinal canal at L4 and L5 level compressing the cauda equina and to the soft tissue. The lesions presented low signal on SE T1 WI and high signal on SE T2 WI (SE T2 WI  without The bone involvement of hydatid disease is rare accounting for 0.5-2% of cases . ClinicaThe CT helps also to evaluate the soft tissues involvement, the presence of the collections. The MRI is currently considered the technique of choice, it is non-invasive and provides a better contrast resolution and multiplanar slices . The MRIThe vertebral hydatidosis is dangerous by its insidious evolution and its late discovery. It is considered a very aggressive lesion because of the extension of the lesions and its constant recurrence. The literature recurrence ranges from 30% to 100% [


We report a case of a 21-year-old healthy woman with a history of a painful growing mass in the palm of the right hand, with a trigger finger phenomenon. The mass was surgically entirely excised, and the histological findings of the tumor were those of a fibroma of the tendon sheath (FTS) starting from the flexor tendons. Although the initial outcome was good, the patient experienced the same symptoms at the same location 4.5 years later. The MRI demonstrated a 50 × 10 × 5 mm mass of low intensity on T1-weighted images and high intensity on T2-weighted images and gadolinium enhancement. A second complete excision of the tumor was performed by the same senior surgeon, and the histology confirmed the recurrence of the FTS. We also reviewed the scientific literature about FTS in the hand. Most recent studies show a low rate or no recurrence at all. We hypothesize that a lot of recurrences are missed because of a short follow-up and that the recurrence rate may be higher than thought. Fibroma of the tendon sheath (FTS) is a rare and benign slow-growing soft tissue tumor that has a predilection for the palmar aspect of the wrist and the hand, mostly in male adults –4. It waIn this study, we want to present a case of recurrence of FTS, 4.5 years after surgery, and to show that recurrence rate is probably underestimated because of short-term follow-up periods in most studies.A 21-year-old, healthy, right-handed Caucasian woman, working as a nurse, presented with a history of limited 4th finger extension, pain in the right palm, and a trigger phenomenon in November 2012. She consulted her family doctor in December 2012 because of worsening symptoms, particularly the trigger phenomenon and the pain. She was referred to a hand surgeon. The physical examination demonstrated a sizzling noise while moving. A strong tenosynovitis was suspected, and the patient underwent an open trigger finger release and synovectomy in February 2013. A senior hand surgeon performed the surgery.Intraoperatively, a plurilobated, grossly firm, and white-colored tumor was identified in Zone 3 of the flexor tendons of the 4th finger. The mass was 10 × 7 × 4 mm, adherent to the deep flexor tendon and peduncled to the radial side of it. The tumor was carefully dissected from the flexor tendons and the neurovascular structures and excised in toto.The external surface of the mass was smooth and glistening without any visible abnormalities.The lesion was histologically well circumscribed and contained proliferating synovial cells in a collagenous background. There was no mitotic atypia. The histological diagnosis was FTS, and the analysis showed that the excision was complete.Immediately after the surgery, the 4th finger could reach complete passive motion. The pain level reduced gradually, and three months after the surgery, the patient could achieve full active range of motion of the 4th finger with no tenderness. She had the last medical control 2 months after the surgery and stopped the ergotherapy 3 months postoperatively.She returned to her job 3 weeks after the surgery and felt only a lack of force in the ring finger, with a complete recovery after 4 months. No further problems or symptoms until May 2017 were reported, when she started to present with identical symptoms, a new rising tumefaction in the scar area in the last 3 weeks. She complained again of a reduced finger function, and the physical examination showed an active extension of the 4th finger of metacarpophalangeal joint: 30°; proximal interphalangeal joint: 60°. The passive motion was not limited, and some pain in the palm of the right hand while moving was present.A magnetic resonance imaging (MRI) was performed and confirmed the diagnosis of a recurrent FTS, revealing a 50 × 10 × 5 mm mass of low intensity on T1-weighted images and high intensity compared with normal muscle on T2-weighted images and gadolinium enhancement Figures .A second surgery was performed in June 2017 by the same senior hand surgeon. The surgical approach was done through the scar of the 1st surgery, extended with a Brunner incision . The cicHistologically, the lesion was overlayable with the first lesion, containing fibroblastic spindle cells without cytonuclear atypia in a collagenous background, some hemosiderin deposits, and small intralesional vessels . No inflThe histological diagnosis was clearly a FTS, without necessity for immunohistochemistry.It showed a local recurrence, 4.5 years after the first complete surgical excision of the tumor.The healing time lasted longer than after the first surgery, and the patient complained of a loss of sensitivity in the palmar aspect of the third phalanx, with spontaneous resolution after 3 months. An ergotherapy treatment was started postoperatively during 2 months. The grip strength (Jamar test) was diminished in the right hand with 16 kgs versus 26 kgs in the left hand after the surgery. At the end of the ergotherapy treatment, the Jamar showed an almost completely recovered strength of 24 kgs.Two years after the second surgery, the patient has no more pain and her finger recovered complete active range of motion. She only complains of a subjective impression of diminished strength in the finger and estimates the force at about 70-80% compared to the left ring finger.FTS is a rare and benign slow-growing soft tissue tumor initially described by Buxton in 1923 . It may Millon et al. mainly focused on soft tissue hand tumors in a large study over a 15-year period. Three percent of the 208 lesions were histologically diagnosed as FTS . Like AlActually, the etiology of FTS remains unclear, and in most studies, the notion of previous trauma is absent. Only 3 patients out of 18 (17%) in the study of Hashimoto et al.  and 2 paWhile Al-Qattan reported the FTS in a series of 23 slow-growing and painless mass of the hand , 10, 12.Although MRI is usually used as the first step in the diagnosis, a definite diagnosis cannot be made on the basis of only the MRI characteristics. However, we think that MRI is not (yet) accurate enough to see if the mass is intratendinous or only in contact with the tendon. This has to be evaluated intraoperatively and should lead to a more aggressive resection in case of a tendon involvement of the tumor.Histologically, the FTS presentation is quite similar to common giant cell tumors of the tendon sheath but is distinguished by the lack of giant cells, synovial cells, and foamy histiocytes . It appeOur case shows a late recurrence of FTS with the reappearance of a trigger finger and pain, more than 4 years after the complete excision of the mass. Most of the recent studies would have missed this late recurrence. Like what Millon et al. and Al-Qattan reported , 9, a moIn our opinion, as Smith et al. suggested , Chung aFTS is a very rare cause of trigger finger, pain, or even CTS. The treatment consists of a surgical marginal excision. Although the recurrence rate could be diminished with improved and sometimes more aggressive surgical techniques, it is probably underestimated because of the short-term follow-up of recent studies. We suggest that the follow-up should last for at least 3 years. We also suggest that the future literature should be more attentive in recognizing factors associated with the recurrence.


Cryptogenic multifocal ulcer stenosing enteritis (CMUSE) is a rare disease characterized by multiple superficial ulcers, stenosis, and obstruction of the small intestine of unknown origin, and the course can recur.We encountered a 62-year-old male patient with intestinal obstruction. The patient was admitted to the hospital for surgical treatment due to intestinal obstruction, and was diagnosed with cryptogenic multifocal ulcer stenosis enteritis due to comprehensive surgery and postoperative pathological considerations.In the future, we will continue to follow up the patient. The present study aims to remind clinicians of this disease, and reduce the incidence of misdiagnosis. Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare idiopathic disease, At present, there are only over 60 cases of CMUSE reported in the world , this wa9 /L, hemoglobin: 91 g/L, serum albumin 22 g/L, and the remaining assay examination was normal. Previous history: good health, no history of abdominal surgery, and no history of medication. Since the obstruction was long and severe, emergency laparotomy was performed.A 62-year-old male patient was admitted to the hospital due to “abdominal pain and abdominal distension for one month, with aggravation for five days”. The patient presented with abdominal pain in the previous one month without obvious inducement, mainly around the umbilicus, paroxysmal, accompanied by abdominal distension, with a small amount of exhaust and defecation. The patient continued to eat without paying attention to this. Five days ago, these symptoms aggravated, and the patient stopped venting and defecating. The patient visited our hospital for treatment and underwent abdominal CT, which revealed small intestinal obstruction Fig. . PhysicaObservations during the operation: there was no adhesion in the abdominal cavity, there was no twist and compression of the intestine, no tumor was detected, and the obstruction was located in the small intestine at 70 cm away from the ileocecal area. The small intestine above the obstruction was highly dilated, and the diameter of the intestine was 8–10 cm. The appearance of the following small intestine was normal. The intestinal canal was longitudinally dissected at the obstruction, a small amount of food fiber was expelled from the intestinal canal at the obstruction site, and a “stenosis ring” was formed in the small intestinal cavity. Merely pores with a diameter of 0.3–0.4 cm were left, and no obvious abnormality was observed in the intestinal mucosa Fig. . The disPathological findings included: intestinal stenosis was obtained, shallow intestinal segmental ulcer formation, mucosal erosion and inflammatory granulation tissue formation, the mucosal muscle layer disappeared, submucosal fiber hyperplasia, and longitudinal extension to the mucosal layer, causing mucosal uplift and intestinal wall stenosis A large amount of neutrophil infiltration, and vasodilatation and congestion were observed in the serosa, but no obvious structural abnormalities were found in the muscle layer and serosa layer Fig. .Fig. 4PThe etiology and pathogenesis of CMUSE remains unknown. Some scholars speculate that autoimmune abnormalities, excessive formation of fibrous tissue, vasculitis, and mutations in the gene PLA2G4A encoding cytosolic phospholipase A2-a are correlated to its pathogenesis , 4.Yu Zhang et al.  summarizDifferential diagnosis could include: (1) Crohn’s disease (CD): CD is one of the most important differential diagnoses for CMUSE. The difference is that Crohn’s disease is transmural inflammation, and the typical lesions are longitudinal and fissured ulcers, which are prone to fistula formation and intestinal perforation. Giant cell granulomas are observed in its pathology . (2) NSAMain treatment methods includes: (1) Hormones: Glucocorticoids are presently the first line of treatment, but these are likely to cause hormone dependence, relapse, and steroid resistance . (2) EndCMUSE is a rare disease of unknown etiology. Multiple superficial ulcers and intestinal stenosis in the small intestine are its typical manifestations. Its diagnosis depends on the comprehensive judgment of clinical manifestations, imaging examinations, endoscopy and pathological examinations. The investigators will continue to follow the patient and monitor for its recurrence. The present study aims to remind clinicians of this disease. When encountering similar lesions, the possibility of this disease must be considered. This also provides a differential diagnosis for small bowel ulcers and stenotic diseases, reducing the occurrence of misdiagnosis.


Massive ascites as a presentation of endometriosis is a rare clinical entity that is most commonly seen in black nulliparous females. Herein, we describe a case of a 32-year-old multiparous Thai woman who presented with a two-year history of abdominal distension. Computerized tomography of the abdominopelvic region showed an infiltrative enhancing lesion involving the cul-de-sac and perirectal region with massive loculated ascites, suggesting carcinomatosis peritonei. Abdominal paracentesis was performed to yield fluid samples for evaluation, which revealed no malignant cells, and polymerase chain reaction (PCR) was negative for tuberculosis. The patient underwent exploratory laparotomy which revealed a large amount of serosanguinous ascites, thickened matted bowel loops, and necrotic debris covering the entire surface of the peritoneum and visceral organs. The surgical procedures included drainage of 6.5 liters of ascites, lysis adhesion, biopsy of the peritoneum, and right salpingo-oophorectomy. Histologic examination revealed benign endometrial glands with stroma at the peritoneum tissue and broad ligament. Other causes of ascites were excluded. The ascites responded to drainage and hormonal suppression. A final diagnosis of endometriosis was made based on these findings. Endometriosis should therefore be considered in differential diagnosis in women of childbearing age who present with ascites. Endometriosis is a benign, estrogen-dependent disease characterized by endometrial tissue outside the uterine cavity , 2. EndoThe occurrence of ascites secondary to endometriosis is rarely encountered. It appears to occur more often in black nulliparous females . TherefoA 32-year-old woman, G1P1001, presented with two years of increasing abdominal distension. She had also experienced poor appetite and weight loss. Her menstrual period was regular, and she had neither abnormal vaginal bleeding nor pelvic pain.Six years prior to this visit, she experienced chronic pelvic pain and had been treated with injectable progestin for clinical suspicion of pelvic endometriosis.One year prior to this visit, she had visited the provincial hospital due to abdominal distension. A computerized tomography (CT) scan of the abdominopelvic region revealed a large amount of ascites with peritoneal nodule and pleural effusion. Abdominal paracentesis and pleural tapping were performed, which indicated exudative fluid, but no malignant cells were noted. She was then referred to another hospital for further work-up. Another CT scan of the abdominopelvic region was performed, which revealed circumferential wall thickening at the mid to upper rectum suggesting rectal cancer with a large amount of ascites and right pleural effusion. Colonoscopy and tissue biopsy at the rectum showed only acute colitis with no dysplasia or malignancy detected. However, she did not return to follow up after this operation.2. Her abdomen was markedly distended due to a large amount of ascites (Upon presentation at our hospital, the patient appeared chronically ill and emaciated with a body mass index of 14.9 kg/m ascites . There w ascites . A chestWe performed abdominal paracentesis, which yielded a clear yellowish fluid. Cytologic examination suggested inflammation without malignant cells. The ascites sample was also sent for tuberculosis PCR and acid-fast bacilli staining, both of which were negative. Exploratory laparotomy was scheduled for tissue diagnosis. Upon laparotomy, we noted a large amount of serosanguinous ascites, thickened matted bowel loops, and necrotic debris covering the entire peritoneal surface . The rigHistologic examination of peritoneum tissue showed benign endometrial glands with stroma deposited within a thick fibrous tissue and chronic inflammation background . ImmunohThe patient's postoperative course was uneventful. GnRH analog was prescribed for six months postoperatively. The patient has subsequently been on a daily regimen of oral progestin. At fifteen months following the operation, the patient had no symptoms and the results of a physical examination were unremarkable.Although endometriosis has been implicated as a precursor for certain types of epithelial ovarian cancer , 8, the The term ascites describes the pathologic accumulation of fluid within the peritoneal cavity . CirrhosOwing to the rarity of massive ascites associated with endometriosis, the diagnosis of this clinical entity is made after the exclusion of other more common causes. The presentation of ascites, weight loss, and peritoneal lesions mimic advanced gynecologic malignancy and peritoneal tuberculosis. Consequentially, most of the cases reported, including that in this report, underwent abdominal paracentesis to obtain an ascites fluid sample for cytological examination in order to exclude malignant cells and tuberculosis infection. The appearance of ascites fluid secondary to endometriosis could be bloody, dark brown, or serosanguineous , 12, 13.The definitive diagnosis of endometriosis with ascites is made upon the operative assessment and histological examination of a biopsied tissue. Extensive adhesions have often been encountered upon operation. Extrapelvic endometriosis has usually involved surrounding structures including the omentum, bowel, or pelvic organs . IntraopThe pathogenesis of endometriosis-associated massive ascites remains unknown, so there is yet no specific treatment for this rare clinical entity , 19, 20.Due to the fact that almost all patients with endometriosis-associated massive ascites have been of reproductive age and nulliparous, conservative surgery and postoperative medication has been the most common treatment protocol. Medications for suppressing ovarian function include GnRH agonist, progestogenic agents, and combined hormonal contraception. Although our patient was multiparous, radical surgery could not be carried out due to extensive adhesion. Hence, ascites drainage, lysis adhesion, biopsy of the peritoneum, and right salpingo-oophorectomy were performed. Postoperative GnRH agonist was prescribed for six months followed by long-term administration of a progestogenic agent. During the treatment, there was no evidence of ascites reaccumulation.Herein, we describe a case of endometriosis diagnosed in a reproductive-aged Asian woman who presented with massive ascites. Evidence to support the diagnosis of endometriosis-associated massive ascites includes the two-year history of ascites accumulation, exclusion of other possible causes, and response to hormonal suppression. The clinical course of our case was similar to those previously reported in patients of other ethnicities. This suggests that, despite its extreme rarity, clinicians should include endometriosis in the differential diagnoses of Asian women presenting with massive ascites.