Ovarian mucinous cystic tumours with mural nodules are rare tumours of the ovary that are often missed out during diagnosis. They are classified under the ovarian mucinous surface epithelial-stromal tumours. These mural nodules can be sarcoma-like (benign), anaplastic carcinoma, sarcomas, or mixed malignant (carcinosarcoma). However, very few cases of anaplastic malignant mural nodules have been reported. Here, we present a case of a borderline ovarian mucinous cystadenoma with anaplastic mural nodule that has sarcomatoid differentiation, in a 39-year-old woman who presented with a 1-year history of progressive abdominal swelling and pain. There were intraoperative findings of huge right ovarian cystic tumour with omental and umbilical deposits. Differential diagnosis of possible germ cell tumours, vascular tumours, melanoma, sarcoma and sarcoma-like nodules were ruled out with routine histology (Haematoxylin & Eosin), histochemical (reticulin) and immunohistochemical stains  and the final diagnosis of a mural nodule of anaplastic carcinoma with sarcomatoid differentiation in a borderline ovarian mucinous cystadenoma established. Unfortunately, due to the aggressive nature of the tumour and disease progression, the patient passed on a few months after the surgery. This rare tumour, especially the ones with anaplastic carcinoma or mixed tumours, usually has an aggressive clinical course with most patients presenting late when the disease is advanced with poor clinical outcomes as is seen with the index patient. A high index of suspicion of this tumour with early detection and a multidisciplinary approach to its management is advised. Mucinous cystic tumours of the ovary with mural nodules are well-described tumours that are rare and often missed out during diagnosis , 2. Theyet al [Nodules of anaplastic carcinoma almost always occur in the background of borderline or malignant mucinous ovarian tumours . These net al  prior toA 39-year-old woman, para 2 (3 Alive), who presented to the gynecological emergency unit of the Lagos University Teaching Hospital, Lagos, Nigeria, with a 1-year history of progressive abdominal swelling, a 2-week history of worsening abdominal pain, and a 5-day history of low-grade fever. She had an earlier abdominopelvic ultrasound scan done in a private health facility that revealed a right ovarian cyst. An earlier ultrasound-guided percutaneous drainage of the ovarian cyst, performed at a peripheral hospital, yielded an amber-colored fluid that was sent for cytologic analysis. The cytology report was negative for malignant cells.T = 37.6°C) and anicteric. Her abdomen was distended. There was abdominal guarding and tenderness with an epigastric bulge noted.On physical examination, she was found to be mildly pale, febrile , Alpha-fetoprotein (AFP), and quantitative beta-human chorionic gonadotropin (HCG)) were normal. Pre-operative chest X-ray was normal.Preoperative complete blood count revealed a haemoglobin concentration of 7.6 g/dl, white blood cell count of 14.29 × 10Preoperative abdominopelvic computed tomography (CT) scan revealed a huge heterogeneous, majorly cystic, septated and multiloculated mass in the right adnexum measuring 15.6 × 16.8 × 25.5 cm in anteroposterior, transverse and coronal sections. There was also mild fluid collection noted in the pelvis. The uterus and other intraabdominal structures were normal.A presumptive diagnosis of right ovarian tumour (CT diagnosis), most likely malignant with possible intra-abdominal sepsis was made.She was immediately commenced on broad-spectrum intravenous antibiotics (Ceftriaxone and Metronidazole) and later extensively counseled on the above presumptive diagnosis and management options including the possibility of a staging laparotomy for suspected ovarian malignancy to which she agreed. A written informed consent for the surgery was then obtained after the counseling.She was then scheduled for an emergency exploratory laparotomy in view of the acute abdomen, huge right ovarian tumour as well as clinical and haematologic evidence of ongoing sepsis. She later had the emergency exploratory laparotomy with Total Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy with Omentectomy (TAH & BSO). The important surgical findings include haemorrhagic ascitic fluid ( ~ 1.5 L), a huge punctured right cystic ovary measuring 20 × 16 × 15 cm, an omental nodule, a subcutaneous periumbilical nodule, and moderate adhesions between the bowels, omentum, right ovary and the anterior abdominal wall. The excised TAH & BSO with omentectomy samples and an excised periumbilical subcutaneous nodule were sent for histopathologic evaluation.However, about 6 days post-op , the patient became anemic and febrile. Imaging studies done on the patient suggested an intrabdominal abscess collection for which she subsequently had another emergency abdominopelvic re-exploration for the evacuation of the abdominal abscess. At this second emergency surgery, she had about 3 L of haemoperitoneum with numerous ragged haemorrhagic amorphous tumour seedlings extensively infiltrating the majority of the abdominal cavity and encasing the small bowel loops and friable mesentery. There were dense adhesions between the bowel loops, and a dilated small bowel. She was then admitted to the intensive care unit for post-operative care in view of her poor clinical state post-surgery. The patient did not receive any chemotherapy. Unfortunately, the patient passed on a few months after the second emergency surgery due to the progression of the disease.The specimen received from the first emergency surgery (laparotomy with TAH & BSO and omentectomy) included the uterus with its adnexae, an omental tissue and a soft tissue labeled ‘ periumbilical subcutaneous mass’. There was a huge right ovarian mass that weighed 3 kg and measured 26 × 20 × 15 cm. The surface of the ovarian mass was smooth with areas of fibrinohemorrhagic exudates. The cut section of the ovarian mass revealed a mutiloculated cystic cavity containing about 3 L of mucoid fluid. Within the lumen of the cyst were multiple areas of yellowish mucoid soft-to-firm solid excrescences. Each of these excrescences measured about 0.2 × 0.2 × 0.2 cm. Their cut surfaces were yellowish and mucoid.The serosal surface of the uterus and its adnexae were haemorrhagic. The uterine adnexae were matted to the uterus. However, there was no obvious mass seen within the uterus, uterine adnexae and cervix grossly.There was a haemorrhagic, dark-greyish solid mass with an infiltrative border, measuring 8 × 6 × 4 cm, within the submitted omental tissue.The specimen tagged ‘subcutaneous mass’  was a pendunculated fibrofatty haemorrhagic tissue that measured 4 × 3 × 3 cm. Its cut section revealed a well-circumscribed, soft, haemorrhagic mass that measured 2.5 x 2.0 x 1.0cm. The gross pictures of all the received tissue biopsies are as shown in Microscopically, the major parts of the wall of the right ovarian cyst were lined by a single layer of columnar mucin-secreting, intestinal-type epithelium. However, there were focal areas of the wall that were lined by two to three-layered stratified atypical cells, some having goblet cells. There were adjacent areas of a cystically degenerated tumour nodule in which atypical spindled- to-rhabdoid-to-epithelioid pleomorphic large-sized tumour cells were irregularly distributed in a relatively abundant and very loose highly vascularised/haemorrhagic stroma, with a mild mixed inflammatory cell infiltrates. The large-sized tumour cells were markedly atypical with abundant eosinophilic cytoplasm and mildly hyperchromatic nuclei that often have large prominent nucleoli. There were numerous mitoses including atypical forms. Occasional osteoclast-like multinucleated tumour cells are seen. The cells were irregularly distributed individually and in small clusters without definite secondary structures, no glandular differentiation, and no evidence of cytoplasmic keratinisation. Some of these atypical cells were distributed in a peritheliomatous pattern. Many plump atypical spindle cells that appear to be fibroblastic, albeit non-monotonous, were also noted. There were no areas of haematogenous or lymphovascular invasion. There were no teratomatous germ cell tumour cells seen. Sections of the omental and subcutaneous masses showed deposits of similar malignant tumour cells. Photomicrographs of the mural nodule, ovarian cystic tumour and omental deposits are as shown in On immunohistochemistry, there were a fairly uniform expression of CD30 and vimentin and variable weak-to-strong expression of broad-spectrum cytokeratins (AE1/3). The tumour cells were completely negative with EMA, HCG, CD31, CD34, S100 protein and AFP. The surrounding stroma cells stain positively with reticulin histochemical stain. The photomicrographs of the cytokeratin AE1/3, CD30, vimentin immunostains and reticulin stains are as shown in The histologic features are those of a rare but well-defined phenomenon of a mural nodule of anaplastic carcinoma with sarcomatoid differentiation in a borderline mucinous cystic ovarian tumour.Ovarian tumours with mural nodules are well-described but very rare entities. Prat and Scully , 5, wereMany histologic types of mural nodules have been described in different reports –11. Thiset al [The aetiopathogenesis of these mural nodules is uncertain. Mural nodules have also been associated with other mucinous non-ovarian cystic neoplasm, including that of pancreas and gall bladder –16. A coet al  employedet al [et al [et al [A study by Yamazaki et al  showed al [et al  put forwl [et al  also repet al [It is important to differentiate mural nodules of anaplastic carcinoma and true sarcoma from prognostically favourable sarcoma-like nodules. Chan et al  employedet al , 22.The result of the immunohistochemistry and histologic morphology of tumour cells of the index case ruled out differentials of yolk sac tumour (AFP−), sarcoma-like mural nodule (pankeratin AE1/3+), sarcoma , choriocarcinoma (HCG−), angiosarcoma , and melanoma (S100 protein−). The likelihood of embryonal carcinoma was rule out due to the non-conforming histologic picture , even though the tumour cells stained positive for CD30 and broad spectrum cytokeratin AE1/3. It is not unusual to have anaplastic mural nodules stain positively with vimentin and reticulin . This onInternational Federation of Gynecology and Obstetrics (FIGO) Stage T1a  is considered a favourable outcome in patients that have ovarian mucinous neoplasm with malignant mural nodules . HoweverTo summarise, a rare case of an anaplastic carcinoma mural nodule with sarcomatoid differentiation in a borderline mucinous ovarian tumour is described in this report. Histopathologic morphology with ancillary techniques including special stains and immunohistochemistry were used to establish the diagnosis.Ovarian tumours with mural nodules are rare and are often missed during diagnosis , 2. Few An informed consent for the publication of this article in a journal, including the anonymous dissemination of the patient’s clinical information for educational/medical research purpose, was obtained from the diseased patient’s next-of-kin.The authors of this article have no funding or conflict of interest to disclose.


Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space.We present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued.Although a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening. Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. In most cases, headache following epidural puncture is due to post-dural puncture headache (PDPH) characterized by cerebrospinal fluid leakage from the dural puncture resulting in low intracranial pressure . Patient19-year-old primigravida Hispanic female with no past medical history or family history presented to the antenatal unit at 40 weeks and one day for elective induction of labor. She had an uncomplicated pregnancy, had regular antenatal follow-up visits, and was not taking any medications. On presentation, she reported no complaints. Vital signs were all within normal limits and the physical exam was significant for a gravid uterus with a size corresponding to her gestational age. Labor was induced with misoprostol followed by oxytocin infusion.For the management of labor pain when she had reached about 3 cm of cervical dilatation, epidural analgesia was requested. Epidural puncture was performed in the L4-L5 intervertebral space with the patient in the sitting position. The patient was monitored during the procedure with non-invasive blood pressure monitoring, pulse oximetry and cardiac monitoring. The procedure was noted to be technically difficult with a noted tachycardia during the procedure, which resolved spontaneously. After successful placement, she was commenced on analgesia with Fentanyl as needed. 8 h following epidural catheter placement, she complained of severe frontal headache and neck pain. Headache and neck pain were described as 10/10 in severity, pounding in nature, non-radiating and worsened with positioning and movement of the head and neck. She denied any visual disturbances, photophobia, nausea or limb weakness. Vitals had remained within normal limits and a neurological examination at that time was unremarkable. At that time, differential diagnosis for her new onset headache and neck pain post-difficult epidural puncture included subarachnoid puncture with acute loss of cerebrospinal fluid (CSF), post-dural puncture headache and pneumocephalus. Though she was experiencing headaches and neck pain, the epidural analgesia was noted to be effective for the management of labor pain and was continued. She was observed closely and reviewed frequently, during which time she had reported improvement in the severity of the headache.Due to failure to progress in the first stage of pregnancy, she was taken to the Cesarean section without complications. She still complained of a persistent headache following the Cesarean section but reported that the headache had improved.On postoperative day (POD) 1, a computed tomography (CT) of the head and neck was done on the advice of the anesthetic team, as the patient was still complaining of persistent positional headaches, which had been waxing and waning in intensity. CT head was significant for a small to moderate amount of pneumocephalus predominantly within the frontal horn of the lateral ventricles and, to a lesser extent, the suprasellar cistern and perimesencephalic cisterns without significant mass effect, midline shift or hydrocephalus Figs. . There wOn POD 2 she reported feeling much better with improvement of the headache. She was ambulating without difficulty and without any worsening of headache and neck pain. She was subsequently discharged on POD 3 with recommendations to return for worsening headache or neck pain, vision changes, limb weakness, heavy vaginal bleeding, fever, or foul-smelling vaginal discharge.She initially reported good relief of headaches with analgesia. However, two days following discharge, she presented with frontal headaches that gradually worsened to 10/10 severity despite analgesia with acetaminophen and oxycodone. She described the pain as radiating to her neck and bilateral arms with numbness and paresthesias to the arms bilaterally. On this presentation, she was hemodynamically stable and afebrile with normal oxygen saturations on room air. Her physical exam was significant for a well-opposed Cesarean scar without bleeding or discharge and revealed no focal motor or sensory, neurological deficits. Repeat CT head imaging at that time showed decreased small intraventricular and left perimesencephalic cistern pneumocephalus without any hydrocephalus, bleed or infarct and repeat CT neck showed decreased small dorsal cervical/upper thoracic spine epidural air when compared to the previous scan Figs.  and 5. APneumocepahlus—otherwise sometimes referred to as pneumatocele or intracranial aerocele—is defined as the presence of air in the intracranial space. Over the years, it has typically been found to occur following trauma, cranial surgeries, and infections . PneumocSeveral mechanisms have been proposed over the years regarding the pathophysiology for the development of pneumocephalus secondary to accidental dural puncture. One of the more recognized theories is the “ball-valve” theory first described by Dandy in 1926. This theory proposed that air may enter the cranium through a dural membrane defect caused by an accidental dural puncture, which acts as a one-way valve—the dural defect allows air to enter the dural space, but subsequently closes, preventing any outflow of air. It is thought that the prevention of air outflow is caused by an increase in intracranial pressure (ICP) that forces the brain parenchyma to block the entry site . AnotherPneumocephalus can be classified based on the timing of either acute pneumocephalus—occurring within less than 72 h of dural puncture or delayed pneumocephalus which occurs more than 72 h following dural puncture . The sevHeadache is the most common presenting symptom of pneumocephalus. It is often localized to the frontal or occipital regions and postural in nature, worsening in the upright position similar in presentation to PDPH, a more common cause of headache following epidural or spinal punctures. Similarly, both PDPH and pneumocephalus may be associated with nausea, vomiting, neck pain or stiffness, changes in vision, and cranial nerve deficit. Therefore, the timeline of the events and a high level of clinical suspicion are needed to make the diagnosis . Unlike Our patient presented with sudden onset severe bifrontal headache and neck, worsening by movement, eight hours following difficult epidural analgesia for pain management during labor. Given the difficulty of the procedure, an accidental dural puncture was considered, with PDPH initially considered the primary differential diagnosis. Given the persistent nature of the headache, a CT of the head was done after an emergent Cesarean section, which revealed air within the intracranial space and in the cervical spinal canal without any evidence of mass effect or herniation—simple pneumocephalus.A non-contrast head CT is the most common test for diagnosing pneumocephalus due to its high sensitivity and specificity, even for identifying minimal air. It can be helpful in differentiating the more benign simple pneumocephalus from tension pneumocephalus , 5.Following diagnosis, the treatment of pneumocephalus often depends on the severity. In most cases, simple pneumocephalus resolves without intervention as the intracranial air may be absorbed over the following two to three weeks. Conservative management of simple pneumocephalus with simple analgesia is the delivery of oxygen at a concentration of 40–100% in the supine or recumbent position to increase the intracranial air absorption rate . On the Our patient’s simple pneumocephalus was managed conservatively with simple analgesia, though she did experience a recurrence of her headache following initial improvement and discharge. However, at the time she represented, CT imaging showed significant improvement of the intracranial air suggesting that her pneumocephalus was resolving. Therefore, conservative management continued.In conclusion, pneumocephalus remains an extremely rare complication of spinal or epidural-related procedures worldwide. Careful attention must be exhibited not only during the procedure in question itself but also during the time thereafter in which symptoms of complication present. While most cases can be managed conservatively, all cases ought to be worked up thoroughly in the event a tension pneumocephalus is in play and emergent neurosurgical intervention becomes warranted. Further research and data pooling is needed to characterize how frequently this pathology occurs, how different patients present, and if new interventional techniques can be developed—so that patient care can continue to become as efficient and safe as possible.


Solitary fibrous tumors (SFT) is a rare mesenchymal tumor originating from a CD34-positive dendritic mesenchymal cell, most of which is benign, the most common sites is pleura and mediastinum, and rarely in the bladder. The clinical manifestations are mainly related to the tumor volume. When the tumor volume is large, it will compress the surrounding tissues or organs and cause corresponding symptoms. Laparoscopic Incision biopsy is effective means for diagnosing SFT.A 70-year-old female patient was admitted to the hospital with a bladder neoplasm detected by computed tomography scan after experiencing intestinal obstruction 3 days following esophageal cancer surgery. She denied any history of tumor disease.No abnormality was found in the physical examination and laboratory testing after admission. Ultrasound imaging showed a large solid mass with low echogenicity in the bladder. Urological computed tomography with 3D reconstruction revealed a large cystic-solid mass located on the right wall of the bladder, measuring approximately 6.8 cm × 7.1 cm × 6.5 cm, with uneven density and mild inhomogeneous enhancement after contrast administration. Cystoscopy revealed a large mucosal bulge on the right wall of the bladder and laparoscopic exploration revealed a smooth-surfaced round mass, approximately 7 cm in size.Incision biopsy was performed to make a clear diagnosis, and appropriate tissue specimens were obtained for pathological testing.The patient was diagnosed as SFT according to pathology. The patient was followed up for 6 months after surgery, and no recurrence was observed.SFT occurring in the bladder are extremely rare, and the site is scarcely reported in the relevant literature; thus, it is easy to misdiagnose and laparoscopic incision biopsy may be a good choice. While SFT are most commonly found in the pleura and mediastinum, rare cases have been reported in the bladder.–4 The diagnosis of SFT of the bladder involves a combination of clinical symptoms, imaging, and histopathological examination. The diagnosis was confirmed via immunohistochemical examination.Solitary fibrous tumors (SFT) are a rare type of tumor in the gastrointestinal stromal tumor family, first described as a distinct disease by Klemperer and Coleman.A 70-year-old female patient was admitted to the hospital with a bladder neoplasm detected by computed tomography (CT) scan after experiencing intestinal obstruction 3 days after esophageal cancer surgery. The patient did not display any urinary symptoms such as frequency, urgency, or pain. A physical examination showed no obvious positive signs. Ultrasound imaging revealed a large solid mass with low echogenicity in the bladder and a small blood flow signal on color Doppler ultrasound. Urological CT with 3D reconstruction revealed a large cystic-solid mass located on the right wall of the bladder, measuring approximately 6.8 cm × 7.1 cm × 6.5 cm, with uneven density and mild inhomogeneous enhancement after contrast administration. The diagnosis was consistent with that of a large nerve sheath tumor Fig. A and B. –7 Although SFT can occur in various locations in the body, primary bladder SFT is rare, and patients may present with urinary symptoms and pelvic compression or be asymptomatic. In this case, the diagnosis was incidental during the evaluation of other diseases, and the patient did not have significant urinary symptoms.SFT were initially thought to arise from the mesothelial or submesothelial mesenchymal cells in the pleura. However, subsequent studies using immunohistochemical techniques and electron microscopy have shown that SFT originates from dendritic mesenchymal cells that are CD34-positive and capable of differentiating into fibroblasts, myofibroblasts, and vascular epithelial cells. In this case, CT showed a homogeneous cystic solid mass with no significant enhancement of the solid component in the arterial phase, slight enhancement in the venous phase, and gradual enhancement in the delayed phase. These findings were not consistent with the literature and may be related to the presence of more mucinous-like changes in tumors with fewer tumor cells. The SFTs usually appear as solitary lesions with clear borders on MRI with low signal intensity on T1 WI and mixed signal intensity on T2 WI. Some researchers believe that the low signal intensity area on T1 WI is due to the collagen-rich fibrous matrix and sparse cellular structure in the lesion, while the area with iso-intensity is composed of the cell-rich area. The contrast scan shows that the SFT has obvious inhomogeneous, sustained, and delayed enhancement. The sustained enhancement area corresponds to histologically cell-rich and vascular-rich areas, and the delayed enhancement area corresponds to areas with sparse collagen tissue or cellular structure.,11 However, MRI was not performed in this patient prior to surgery and was not included in the clinical data.Ultrasound of the SFT in the bladder typically shows an echogenic mass with low or heterogeneous echogenicity with well-defined borders. On CT scan, a large solid soft tissue mass with mixed density was observed. On contrast CT scan, nodular or map-like heterogeneous enhancement in the arterial phase, with cystic, hemorrhagic, or necrotic areas can be seen. The enhancement of the mass gradually increase in the venous and delayed phases and the density of the lesion became more homogeneous with a “fast-in, slow-out” pattern. but not for Desmin, CK, or S-100. In this case, the pathological presentation was consistent with typical SFT.The gross specimen of bladder SFT is usually a well-defined, solitary solid mass with a round, oval, or slightly irregular shape. The tumor section was grayish to tan in color, with visible hemorrhages and cystic changes. The microscopic morphology of SFT is characterized by the presence of a mucus-like interstitial matrix with alternating sparse and abundant cellular areas, coarse collagen fibers, and a branching hemangioepithelioma-like vascular pattern. The cells were spindle-shaped or round, with no significant atypia. Mitotic are generally, mitotic cells do not exceed 3 nuclei per 10 high-power fields. Immunohistochemical analysis revealed positivity for CD34 and Bcl-2, which are the most specific and accurate markers,,14 ③ Neurofibroma or nerve sheath tumor of the bladder: appears as a round mass with smooth margins in the bladder. The nature is either cystically or cystically solid. On CT, it appears equal or slightly hypodensity with progressive enhancement and gradual expansion. Scattered dotted or pinpoint enhancing vessels can be observed inside the lesion. It can be difficult to differentiate from mild SFT, but it is different from the typical bladder SFT. ④ Metastases may present as polyp-like or nodular lesions and, can be easily differentiated from bladder SFT based on medical history and clinical symptoms. Additionally, a specific fusion gene, NAB2-STAT6, has been found in both benign and malignant SFTs, which can be used to differentiate them from most spindle cell soft tissue tumors.,17SFT of the bladder must be differentiated from several other lesions, including: ① Bladder cancer, a common type of malignancy among middle-aged and elderly men. It is typically located in the bladder triangle and appears as a soft tissue mass with a cauliflower-like growth pattern or limited cavity thickening. Bladder cancer is prone to cystic necrosis and shows significant inhomogeneous enhancement on CT scans with or without lymph node metastasis. It can be easily differentiated from SFT of the bladder. ② Paraganglioma of the bladder, a tumor with a rich blood supply, which appears on imaging as a solid mass in the bladder wall that protrudes into the lumen with a clear border and wide base. It is common for paragangliomas to have cystic and necrotic changes, and the enhancement of the lesion is obvious, with characteristic abnormal capsule enhancement. This type of tumor is often associated with paroxysmal hypertension, particularly a transient increase in blood pressure after urination. making the prognosis difficult to predict. The size of the tumor may not determine the prognosis, but rather the severity of the patient’s symptoms. The simple histological pattern may not be sufficient to determine its prognosis. Long-term follow-up is necessary for these patients. SFT may not respond well to radiation or chemotherapy, but targeted therapy, such as imatinib, has shown promising results in some studies.The primary treatment for bladder SFT is complete surgical resection, with consideration for repeat resection in cases of local recurrence. The most important factor affecting prognosis is whether the tumor has been completely removed. Most SFT cases have a good prognosis with no recurrence or metastasis after surgery. However, a few histologically benign SFTs may become malignant upon recurrence,In conclusion, the diagnosis of bladder SFT relies on clinical symptoms, imaging features, and pathological examinations. The confirmation of the diagnosis is typically achieved through immunohistochemical testing, using CD34 and Bcl-2 as the most specific and sensitive immunomarkers. Bladder SFTs are generally biologically benign, and complete surgical resection is the primary treatment option. However, a small proportion of patients may exhibit local recurrence or malignant transformation, emphasizing the importance of long-term follow-up after surgery.We would like to thank all the staff and nurses for their kind cooperation. We would also like to thank the patient.Supervision: Tian Yu Li, Bo Zhang, Ji Zhang.Writing – original draft: Tianyu Li.Writing – review & editing: Tianyu Li, Bo Zhang, Ji Zhang.


The clinical appearance of this lesion is red-bluish in color, presenting a similar tissue to the one observed in the liver, usually measuring less than 2 cm. The treatment of the PGCG is the surgical excision. The recurrence of this lesion is rarely described in the literature. The present case highlights the importance of considering the traumatic extractions as one of the main uncommon etiologic factors, leading to the development of peripheral giant cell granuloma. It precisely describes the diagnosis, the treatment of a peripheral giant cell granuloma located in maxillary canine-premolar region, occurred consecutively after ancient traumatic extractions of the 13 and 14 since 1 year. This paper also reports a maxillary location of giant cell granuloma, while the literature reports more commonly the mandibular location. This lesion was excised surgically, and healed uneventually, and in which the follow-up didn´t show any sign of recurrence.Peripheral giant cell granuloma (PGCG) is described as an elevated lesion that is located mostly on the gingival mucosa and alveolar crest, consecutive to irritative factors and trauma. It predominantly occurs more in the mandible than the maxilla, and it is usually seen in the 4 Peripheral giant cell granuloma is a non-malignant lesion that develops as a consequence of chronic tissue injury. It has been described as an exophytic lesion characterized by non-malignant nodular swellings that develop as a consequence of chronic tissue injury and an exuberant tissue response originating from periodontal ligament cells -4. LocalPeripheral giant cell granuloma is often characterized by a painless, smooth surface lesion that can range from a few millimeters to several centimeters. It's typically brown, red, or even purple in hue and may have a sessile or pedunculate implantation base, with a soft to a firm consistency. Microscopically the lesion features an abundance of multinucleated giant cells. This is how it differentiates from other exophytic oral differential diagnoses . The disPatient information: a female patient aged 60, reported to the Oral Surgery and Oral Medicine Department, of the Dental Teaching Hospital affiliated to the International Faculty of Dental Medicine of Rabat, complaining of discomfort consecutive to an extraoral inflammation in the superior right maxillary, dating back 1 year. The patient´s medical antecedents showed nothing in particular. The patient was apparently healthy.Clinical findings and timeline of the current episode: the patient reported that the exophytic lesion was basically a small lesion and slowly increased in size over 1 year. According to the patient, the lesion occurred right after having undergone traumatic extractions of residuals 13 and 14. It was accompanied by intermittent pain. There were no other locations of the same type of lesion in any part of the body.Diagnostic assessment: the intra-oral examination revealed the presence of a swelling on the left maxillary canine premolars. The lesion measured about 1.5 x 1.5 cm. The exterior of the lesion was lobulated close to 12, 13, and 14. The lesion was firm in consistency and presented a blue-reddish color, with a firm pedicle. The covering mucosa was intact  were seen in the maxilla and 12 (75%) were observed in the mandible [et al. reported a case of PGCG two months after the orthodontic extraction of a deciduous molar. This study suggested that the presence of growth factors in the healing socket may have contributed to the PGCG development and ultimately, its progression into a lesion. Our current clinical case is in concordance with the Mighell et al. study where our patient underwent traumatic extractions 1 year before the lesion appeared, which has led to the occurrence of the lesion [In this current case report, a patient was 60 years old and had a lesion seen in the maxillary canine premolar region. It has been reported that PGCG is about 1.5 times more likely to occur in the mandible than in the maxilla [a and 12 5% were oe lesion . Considee lesion .et al. recurrence rates ranged between 11-50% in their multiple case series [For PGCGs, surgical excision of the mass and preventative measures to eliminate any potential predisposing factors are the recommended treatment. This can include the extraction of any associated teeth in cases of periodontal ligament involvement . Fortunae series . In our Early detection of peripheral giant cell granuloma on the basis of clinical, radiographic, and histopathological examination enables conservative management with minimal risk to the adjacent hard tissues consisting of complete excision of the lesion in order to minimize further recurrences. It is important that clinicians should be aware that traumatic extractions can be one of the main etiologic factors leading to the occurrence of peripheral giant cell granuloma.


Hourglass bladder is a definition used to describe a particular configuration of the urinary bladder, divided into two compartments, upper and lower, communicating through a narrowed segment resembling an hourglass. It may be due to various conditions, such as bladder diverticula, bladder neck obstruction, neurogenic bladder, or other abnormalities. Congenital hourglass bladder is an extremely rare anomaly. To the best of our knowledge, only 24 cases have been reported. We present the case of a 2-year-old male, probably the youngest patient with congenital hourglass bladder ever recorded. We aim to increase knowledge about the incidence of this likely underdiagnosed condition and its management and stress the importance of long-term follow-up. True hourglass bladder is a congenital malformation, most common in males, caused by a partial transverse septum that divides the cavity into an upper and a lower compartment ,2. The cA 2-year-old male was born at 40 weeks of gestation by normal pregnancy and delivery to non-consanguineous parents. His birth weight was 3,270 grams, without complications during the perinatal period. Prenatal ultrasound, performed at 32 weeks of gestation, revealed a 13 mm left renal calyceal-pelvic dilation, reduced to 10 mm by the 35th gestational week. When the patient was two weeks old, an abdominal ultrasound detected mild ectasia of the renal calyces and a minor dilatation of the extrarenal pelvis. Subsequently, micturating cystourethrography (MCU) showed fourth-grade, left vesicoureteral reflux with an unclear focal dilation, initially interpreted as either enlargement of the terminal ureter or a diverticulum. Antibiotic prophylaxis was started. His physical examination was unremarkable. He had no difficulty with micturition and never experienced UTIs. Renal function testing revealed normal serum urea, creatinine, and electrolyte levels. The cytology of the urine specimen was normal. Technetium-99m mercaptoacetyltriglycine (99mTc-MAG3) dynamic renal scintigraphy further confirmed normal kidney function, with an 83.3 ml/min tubular excretion rate, ruling out any obstructive forms (Figure At the age of two years, urinary ultrasonography Figure  and MCU Hourglass bladder may occur in patients with mixed neurogenic urinary incontinence or, more commonly, in children following seromuscular colocystoplasty and patients undergoing bladder auto-augmentation to treat neuropathic bladder secondary to myelomeningocele -5. In 20The reported patient’s first MCU was unclear; dilation of the terminal ureter and bladder diverticulum were possible diagnoses. Adherence to a strict clinical and radiological follow-up, with periodic ultrasounds and repeated MCUs, allowed us to detect his rare congenital deformity and assess the evolution of the clinical scenario from a very young age.This case underscores the importance of a multidisciplinary approach involving different imaging modalities. Long-term follow-up for such cases is necessary. It should include urinalysis, abdominal ultrasonography, and a daily voiding diary to detect urinary tract infections early and micturition complications affecting the voiding or post-voiding phase. MCU and urodynamic testing may be repeated if the ultrasound reveals structural anomalies in the urinary tract.


Epiretinal membranes (ERMs) typically remain stable or progressively worsen. Here, we report two rare cases of spontaneous ERM regression and one case of ERM separation. This is a case series of three patients. The patients’ clinical data were collected and ERMs were evaluated with serial optical coherence tomographies (OCTs).Cases one and two were female patients presenting with floaters. Mild-to-moderate idiopathic ERM was diagnosed which spontaneously regressed over the following years without intervention and evidence of separation. Patients’ vision was slightly decreased or remained stable, respectively. Case three was a female patient presenting with blurry vision. A mild ERM was diagnosed with vitreomacular traction (VMT) and a tiny macular hole. Over the following three months, ERM separation along with VMT release was evidenced on OCT. The macular hole healed simultaneously. Her vision improved from 20/70 to 20/30.The possibility of spontaneous regression of idiopathic ERMs should be a factor to consider in management. Further research must be done to determine the mechanism of this phenomenon. An epiretinal membrane (ERM) is composed of two layers overlying the internal limiting membrane. The outermost layer consists of non-cellular extracellular matrix proteins, and the innermost layer contains myofibroblastic pre-retinal cells that reach the retinal surface via defects in the internal limiting membrane or from the vitreous cavity . The preTreatment generally consists of vitrectomy with membrane peeling if symptomatic. In rare instances, spontaneous separation of ERM has been observed -13. EvenCase one: spontaneous regression of idiopathic epiretinal membraneA 66-year-old female with a past medical history of migraines, hyperlipidemia, coronary artery disease, cervical cancer, chicken pox, measles, mumps, and a two-year history of PVD in both eyes (OU) presented with floaters OU for one week and pain in the right eye. She reported blurry vision in the mornings, without flashes. There was no history of ophthalmic surgeries. Visual acuity (VA) was 20/20 in the right eye (OD), and 20/20 in the left eye (OS). Intraocular pressure (IOP) was within normal limits. Slit lamp examination was unremarkable except for 1+ nuclear sclerosis OU. Fundus examination was indicative of PVD OU, mild ERM OD over macula, and blunted macular reflex OS. No optical coherence tomography (OCT) was performed at this visit.At the sixth-month follow-up visit, the patient reported stable floaters. VA was 20/20 OD and 20/25 OS. Fundus examination was indicative of lattice degeneration OU. OCT was indicative of moderate ERM OD without edema Figure . At the Case two: spontaneous regression of idiopathic epiretinal membraneA 62-year-old female with no known past medical history presented with constant floaters OS for the past two years. The patient had no complaints of flashes, pain, and blurred vision. There was no history of ophthalmic surgeries. VA with pinholes was 20/25 OD and 20/25 OS. IOP was within normal limits. The slit lamp examination was indicative of trace nuclear sclerosis OU. Fundus examination was indicative of PVD OS, and mild ERM OS. OCT was indicative of mild ERM OS Figure . At the Case three: spontaneous separation of idiopathic epiretinal membraneA 66-year-old female with a past medical history of osteoporosis, iron deficiency anemia, gastroesophageal reflux disease, and rheumatoid arthritis on hydroxychloroquine presented with blurry vision OS. She had no complaints of eye pain, floaters, and flashes. She has had no prior ophthalmic surgeries. VA with pinholes was 20/30 OD and 20/70 OS. IOP was within normal limits. The slit lamp examination was indicative of 1+ nuclear sclerosis. Fundus examination was indicative of mild ERM overlying macula OS. OCT was indicative of vitreomacular traction (VMT), mild ERM, and tiny macular hole OS Figure . At the Idiopathic ERMs typically remain stable or progressively worsen, and it is quite unusual for resolution to occur naturally without intervention. Spontaneous idiopathic ERM separation, as described in case 3, is rare clinically but has been reported in the literature several times . The folSpontaneous idiopathic ERM regression, as described in cases one and two, is even more unusual with only a few reports. The regression observed in cases one and two appears to be a dissolution rather than a peeling as there is no OCT evidence of the ERM separating as a whole, rather the ERM appears to thin and disappear gradually. Typically, this type of regression may occur with the resolution of inflammation in ERMs that is secondary to an acute inflammatory process such as trauma, infection, or uveitis . Our casThe current literature on spontaneous regression of ERM without signs of separation includes five cases -17. ThreWe have presented one case of separation of idiopathic ERM and two cases of regression of idiopathic ERM. The case of separation had OCT evidence of separation and was thought to be due to PVD and VMT release. The mechanism behind the cases of regression is unknown as this is a rarely reported event. ERMs secondary to an inflammatory process may regress as the underlying inflammatory process resolves, but this mechanism could not occur in the cases we present here as these ERMs are idiopathic. Elucidation of the mechanism of ERM regression may help identify the cause of the disease and prompt future therapies to induce such an event. The possibility of ERM regression occurring spontaneously, especially in patients with pre-existing PVDs, should be a factor to consider in management.


Adrenal mixed corticomedullary tumors (MCMTs) are composed of an admixture of cortical and medullary cells. Owing to the presence of two distinct components of different embryonic lineage, these tumors are extremely rare. Less than 30 tumors of this type have been reported to date. MCMTs have varied presentation including hypertension, Cushing syndrome or even as adrenal incidentalomas. Also noted is a slightly higher female preponderance. We report a case of a 26-year-old female who was evaluated for uncontrolled hypertension. A renal ultrasound followed by MRI abdomen revealed a 9.3 × 8.1 × 7.0 cm partially cystic, partially solid enhancing mass in the region of/replacing the left adrenal gland. Hormonal work-up was significant for elevated catecholamines concerning pheochromocytoma. She underwent laparoscopic left adrenalectomy, with adequate pre-operative adrenergic blockade. Histology and immunochemical testing were consistent with a mixed corticomedullary tumor. She was monitored annually for recurrence of the tumor. We also performed a comprehensive review of literature of the cases published so far to the best of our knowledge. The adrenal cortex is derived from the dorsal mesentery, which is mesodermal in origin, and the medulla from cells that have migrated from the neural crest, which are ectodermal in origin . Most adWe describe a distinctive case of a young woman who presented with uncontrolled hypertension and had markedly elevated urinary and plasma metanephrines. Imaging revealed a large left adrenal mass, which, following resection, revealed a mixed corticomedullary tumor on histopathological analysis.A 27-year-old asymptomatic woman was incidentally found to have a blood pressure of 163/114 mm Hg during a regular office visit. Repeat measurements confirmed a persistently high blood pressure at 183/129 mm Hg, which triggered treatment initially with lisinopril followed by the addition of hydrochlorothiazide by her primary care physician. Her past medical history was significant for an uneventful pregnancy four years prior to presentation. Her family history was negative for endocrine tumors or syndromes. On examination, vitals including temperature, heart rate, and respiratory rate were normal except for the elevated blood pressure; physical examination revealed no abdominal masses. Laboratory data showed leukocytosis  and a normal basic metabolic panel. A renal artery ultrasound, ordered as an initial work up for secondary hypertension, showed a mass adjacent to the spleen and left kidney with an echogenic, homogeneous texture and a hypoechoic, cystic interior. The entire mass measured 9.7 cm × 7.5 cm × 7.5 cm, with the cystic portion measuring 6.2 cm × 5.8 cm × 5.5 cm. Within 2 weeks of initial presentation, the patient developed episodic dizziness, flushing, palpitations and left flank pain. Her blood pressure continued to be uncontrolled and labetalol was added. An MRI of the abdomen and pelvis revealed a 9.3 × 8.1 × 7.0 cm partially cystic, partially solid enhancing mass with T2 hyperintensity in the region of/replacing the left adrenal gland . EndocriTaking her clinical presentation and laboratory findings into consideration, a provisional diagnosis of pheochromocytoma was made, and she was initially treated with phenoxybenzamine for adequate alpha adrenergic blockade and metoprolol was later added two days prior to surgery. A left adrenalectomy was performed laparoscopically. Histopathological examination demonstrated predominantly large epithelioid or polygonal cells with amphophilic cytoplasm and mildly atypical vesicular nuclei, focally arranged in nests, suggestive of pheochromocytes. Admixed with this were nests and cords of more uniformly rounded epithelial cells with granular eosinophilic cytoplasm and smaller, more uniform vesicular nuclei indicative of cortical adenoma cells . While tAs the two components of the adrenal gland have different embryological origins, it is not surprising that mixed corticomedullary tumors are rare. A total of twenty eight patients with adrenal mixed corticomedullary tumors have been described ,22,23,24The pathogenesis of mixed corticomedullary tumors is poorly understood. Several hypotheses have been proposed. One of these known as the ‘collision theory,’ proposed a separate embryological origin of the two components of the tumor, with the cortical cells arising from the mesoderm and the pheochromocytes from the neural crest and then fusing to form the tumor ,16. AnotThis case illustrates a rare case of mixed corticomedullary tumor of the adrenal gland that are composed of an admixture of cortical and medullary cells.Owing to the presence of two distinct components of different embryonic lineage, these tumors are extremely rare. Less than 30 tumors of this type have been reported to date.Patients may present with Cushing’s syndrome, hypertension or non-specific symptoms like weight loss.A high degree of suspicion is required to avoid a hypertensive crisis during surgery. For this reason, clinicians should be aware of this entity.


Fonsecaea spp. and Cladophialophora spp.,,Chromoblastomycosis (CBM) is an uncommon implantation mycosis caused by pigmented fungi, most commonly A 52-year-old man with diabetes presented with a lesion on the tip of his right index finger. The lesion was present for 8 years. It grew to the current size several years ago but had since remained unchanged. He denied previous trauma or associated systemic symptoms. However, the lesion was somewhat tender, prompting a referral to dermatology. The patient lived in the Northeastern United States for decades after immigrating from the Dominican Republic (DR) at the age of 13 years. He traveled back to the DR biannually, visiting beaches and lakes. He also reported a distant history of frequent gardening work with his father in the DR.On physical examination, the ventral surface of his right index finger had a 5 mm, well-demarcated, firm, smooth, nonscaly, nonerythematous, slightly tender, pale-to-skin-colored, dome-shaped papule .Fig 1NonThe differential diagnosis included a callus, glomangioma or glomus, mucoid cyst, and acral digital fibrokeratoma. A 4-mm punch biopsy was performed, revealing a nodular dermal aggregate of epithelioid histocytes and multinucleated giant cells forming epithelioid granulomas containing brown-staining thick-walled structures characteristic of sclerotic bodies and septate fungal hyphae, consistent with CBM . Given t,,The presentation of CBM can be diagnostically challenging, as illustrated by the subtle lesion described in this report. Classically, CBM presents acutely, most often on the lower extremities, as an erythematous macule that gradually develops into a pink papule over time.Fonsecaea spp., given the humid, tropical climate of the DR and the overwhelming majority of CBM cases caused by Fonsecaea spp. (90%).A missed diagnosis can lead to many CBM complications such as bacterial infections, lymphedema, ankylosis, and carcinogenesis.Here, the patient’s small, localized lesion was cleared during biopsy. If not cleared by biopsy, excision is recommended for small, well-demarcated primary lesions.In summary, the present case depicts a seldom-reported subtle manifestation of CBM that could have been easily overlooked. In contrast to the prominent, pigmented, and verrucous lesions on the lower extremities more often described in the literature, this patient’s biopsy-proven CBM on the finger was a relatively asymptomatic (only mildly tender), solitary, nonpigmented, and smooth papule, resembling a callus. To avoid delays in patient care that may lead to progression and further morbidity, clinicians should be suspicious of seemingly innocuous early presentations of CBM in patients who frequently visit or are originally from endemic areas with an unexplained, persistent acral papule.None disclosed.


Carcinoma of the gallbladder is the most common biliary tract cancer. The majority of gallbladder cancers are adenocarcinomas, whereas clear-cell carcinoma of the gallbladder (CCG) is a rarely recorded variant. Usually, diagnosis is established incidentally after cholecystectomy, performed for another reason. Clinically, the different histological types of carcinomas are impossible to be recognized preoperatively, since they present with a wide and common range of symptoms. We present a male patient who underwent an emergency cholecystectomy due to suspected perforation. After an uneventful postoperative period, the histopathological report led to the diagnosis of CCG, but the surgical margins were infiltrated by the tumor. The patient decided not to proceed with any additional treatment and passed away 8 months after the operation. In conclusion, it is of great necessity to record such unusual cases and enriches global knowledge with information clinically and educationally noteworthy. Gallbladder cancer (GBC) is the most common cancer of the biliary tract . Its incAn 82 years old man presented to the emergency department of our hospital due to acute abdominal pain. He reported that since the previous week, he was experiencing the symptom mentioned above to a mild degree. During the six previous hours, it gradually worsened and shifted to the right upper quadrant. No other associated symptoms were noticed. On clinical examination, the patient's blood pressure was 144/59 mmHg, his pulse rate was 88 beats per minute, his respiration rate was 19 breaths per minute, and his temperature was 36°C. There was rebound tenderness and involuntary guarding on palpation of the right upper quadrant of the abdomen, with Murphy's sign positive all indicative signs of peritonitis. His anamnesis revealed only arterial hypertension, treated with an angiotensin-converting enzyme inhibitor. He had known cholelithiasis for the last 7 years, but because he remained asymptomatic, he never scheduled a surgical evaluation. These initial findings were evidence of acute abdomen; hence the appropriate investigation was initiated.9/L (3.91–8.77 × 109/L), hemoglobin 11 g/dL (11.9–15.4 g/dL), platelets 419 × 109×/L (150–450 × 109/L), international normalized ratio 1.05 (0.85–1.15), creatinine 0.87 mg/dL (0.67–1.17 mg/dL), total bilirubin 0.96 mg/dL (0.3–1.20 mg/dL), alkaline phosphatase 182 U/L (30–120 U/L), gamma-glutamyl aminotransferase 137 U/L (9–55 U/L), alanine aminotransferase 27 U/L (3–41 U/L), aspartate aminotransferase 40 U/L (3–38 U/L), amylase 65 U/L (28–100 U/L), and C-reactive protein 428.6 mg/L (0–5 mg/L). The differential diagnosis was broad and included any hepatobiliary pathology, perforated viscus, or intrabdominal infection. Therefore, an abdominal multidetector computed tomography (MDCT) was immediately requested. The imaging results suggested perforation of the gallbladder. The images obtained revealed contrast enhancement of the gallbladder's wall, with irregular thickening, ranging from maximum width of 8 mm at the fundus, to ill-defined foci. Multiple intrahepatic and pericholecystic collections were evident, as well as increased contrast enhancement of the liver parenchyma adjacent to the gallbladder. The common bile duct's diameter was 1.25 cm with intraluminal gas  was isolated from the bile sample collected during the operation, which was sensitive to the antimicrobial treatment he was receiving. On POD 7, he was discharged, receiving painkillers and low molecular weight heparin for venous thromboembolism prophylaxis. The patient would have been evaluated at the outpatient department, after performing blood tests, to decide if an investigation for possible choledocholithiasis was required.The severity of the cholecystitis was classified as Grade II . Hence, On gross examination, the gallbladder was opened, measuring 8 cm in length and 3 cm in diameter at the fundus. A small piece of liver parenchyma was attached to the gallbladder. No lymph nodes were retrieved. A diffuse and irregular mural thickening was observed, reaching a maximum width of 1 cm at the fundus. A tan-white colored mucosa was covering the inner surface. The serosa showed necrotic areas with multiple vascular emboli. On microscopic examination of the hematoxylin and eosin (H&E) stained sections, cuboidal and polygonal cells with clear cytoplasm and hyperchromatic nuclei were evident. They consisted of more than 50% of all the tumor cells in the sections examined. The clear cells were arranged in nests and acini. Areas of conventional adenocarcinoma, as well as areas of pyloric and intestinal metaplasia and dysplasia, were also identified . The tumOn receiving the histopathological report, the patient underwent a thoracic and abdominal MDCT 6 weeks after the operation. A metastatic lesion on liver segment IVa was detected, which was absent on the admission's CT . No visiOf all subtypes of biliary tract cancer, gallbladder malignancy is the most common , 8. Its Adenocarcinoma is the most common histological type of GBC , whereasSalmonella sp., Helicobacter pylori, or Clonorchis sp. [Cholelithiasis is strongly associated with gallbladder carcinoma. Randi et al. calculated a relative risk of 4.9, derived from published cohort studies , whereaschis sp. , 13, 16.chis sp. . Among tRegarding the present case, the patient was incidentally diagnosed with cholelithiasis 7 years before this acute complication. It was not possible to determine whether the initial abdominal ultrasound mentioned any gallbladder polyp and it was not the examination of choice to reveal any anatomic variation of the pancreato-biliary duct junction. Finally, the patient could not recall any relevant family history.Metaplasia of the epithelium lining of the gallbladder is probably the phenomenon that initiates the development of malignancy , 34. ThiThe most common histological characteristics of CCGs were initially described in the case series of Bittinger et al.  and VardThese histological characteristics of CCG are similar to lesions from various other sites, such as renal, endometrial, ovarian, liver, and lung clear cell carcinomas , 20. HowIn conclusion, CCG is an exceptionally rare type of infrequent condition of GBC. The accumulation of knowledge concerning this malignancy can thus primarily be obtained from case reports. An accurate pathological analysis of the specimen is primordial for the identification of different histologic types of GBC, such as CCG. The proper investigation and the final interpretation of all the laboratory and imaging results, can prevent misdiagnosis and offer the patient the appropriate treatment and the analogous prognosis, which in the case of GBC remains unfortunately very poor.


Craniopharyngioma (CP) represent 1.2-4.6% of all intracranial tumors in children and carry a significant morbidity due to their lesional intimacy with structures involved in neurological, visual, and endocrinological functions. Variable treatment modalities being available, including surgery, radiation therapy, alternative surgeries, and intracystic therapies or combinations of them, their common goal is to reduce immediate and long-term morbidity while preserving these functions. Multiple attempts have been made to re-evaluate surgical and irradiation strategies in order to optimize their complication and morbidity profile. However, despite significant advances in “function sparing” approaches, such as limited surgery and improved technologies of radiation therapies, achieving interdisciplinary consensus on the optimal treatment algorithm remains a challenge. Furthermore, there remains a significant span of improvement given the number of specialties involved as well as the complex and chronic nature of CP disease. This perspective article aims to summarize recent changes and knowledge gains in the field of pediatric CP, outlining updated treatment recommendations, a concept of integrative interdisciplinary care and the implication of novel potential diagnostic tools. A comprehensive update on the multimodal treatment of pediatric CP is presented, focusing on “function-preserving” therapies and their implications. Craniopharyngioma (CP) are the most common non-neuroepithelial intracerebral neoplasm in children, accounting for 1.2-4.6% of all pediatric intracranial tumors , 4, and via MRI should be completed. Its importance is reflected in answering the following questions:The diagnosis of CP in children often gets delayed for various reasons , 32. MosDo morphology and imaging characteristics  of the tumor potentially correspond to the diagnosis of CP?Does the tumor have a cystic component and if so, how prominent is it?What are the tumor’s features with respect to location, invasiveness, and extent of neurohypophyseal and hypothalamic damage (grading)rd ventricular type, while taking the tumor origin into account , followed by the analogous postoperative grading algorithm for hypothalamic damage. The authors demonstrated that its degree significantly correlated with patient outcome. Furthermore, they revealed that a thorough evaluation of the preoperative MR images was a helpful tool for stratifying patients and guiding the surgical strategy: GTR versus STR . Another account . The aboFurther investigations in suspected CP patients, should include tests to generate baseline exams in all potentially involved specialties, such as ophthalmology, endocrinology, pediatrics, and neuropsychology. Additional diagnostic analysis may comprise histopathological and molecular genetic analysis once a biopsy or resection was performed and allowed to obtain tumor tissue. A schematic overview of involved disciplines and diagnostic pathways is given in The benign nature of CP implied that complete resection was always considered as the ultimate cure and therefore the initial mainstay therapy in the 1990s. However, over the last decades an increasing number of studies have alternated this principle into a more variable and individual approach due to the awareness that GTR leads to unacceptable hypothalamic injury and that surgical invasiveness correlates with subsequent endocrinological dysfunction , 40. CurRadiotherapy is mainly administered in CP residuals after STR or in tumor recurrences . Types ovia an intracystic catheter attached to an accessible Ommaya reservoir  in these patients. The most frequent symptoms resulting from neuroendocrine dysfunction are obesity and eating disorders, followed by various co-effects, such as physical fatigue, social distancing and impacted psychosocial development . Obesityvia radical tumor resection, followed by attempted medical compensation of hypothalamic dysfunction. However, the therapeutic goals for pediatric CP have changed and now rather focus on upfront function preservation. Accordingly, there has been a paradigm shift in management strategies of pediatric CP with growing worldwide advocacy for structure and function preserving techniques, for instance less aggressive surgical approaches (via Ommaya reservoir insertion (ORI)  , 63. ORItoxicity , 52, 64.toxicity , 66, instoxicity , 52. Pretoxicity , 67–69. toxicity , 70, 71.toxicity . Latter toxicity . Also, itoxicity . These rvia regular interdisciplinary information exchange , and neurological dysfunctions , 15. TheHence, the authors advocate for a multidisciplinary approach of CP patients involving all related experts. Although achieving treatment consensus within a multidisciplinary setting remains challenging, it offers a comprehensive and wide perspective on the individual patient’s needs. Another advantage of multimodal care is reciprocal knowledge exchanges about advances and new technologies in the field as available per each specialty. In this context better understanding of CP molecular biology recently resulted in development of targeted neoadjuvant treatments (BRAF/MEK inhibitors) for a subset of CP patients harboring the papillary subtype with a BRAFV600E mutations . Two stuThis narrative highlights the complexity of the natural history of pediatric CP, its requirement for multidisciplinary management and the importance of “function sparing” therapies. Treatment algorithms experienced several changes over the last decades and will be subject to constant optimization. Implementation of experienced interdisciplinary networks generating individual therapeutic strategies is mandatory to avoid or minimize long-term consequences for the patient. Alternative treatments, including intracystic ORI combined with other therapies or even molecular genetic approaches may evolve further and offer more robust opportunities for function preservation in CP patients.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.L-NL performed the literature review and drafting of the manuscript. AP helped drafting the figures and reviewed the manuscript. UB and EK guided the manuscript design, supervised the quality of literature included and critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.


Abdominal trauma can be one of the causes of chylous ascites in pediatric cases, along with tuberculosis and malignancy. However, a definitive diagnosis is more reasonable to be done by excluding other causes.Chylous ascites (CA) is a rare type of ascites. Though it has high mortality and morbidity rates, which usually happen due to the rupture of lymph vessels into the peritoneal cavity. Congenital abnormalities, including lymphatic hypoplasia or dysplasia, are the most causes in pediatrics. CA following trauma in children is very rare, and to the best of our knowledge, there are very few reports in this regard. Here, we report a 7‐year‐old girl who was referred to our center with CA after a car accident. Abdominal trauma can be one of the causes of chylous ascites in pediatric cases, along with tuberculosis and malignancy. However, a definitive diagnosis is more reasonable to be done by excluding other causes. Turbid milky ascites is the primary key for diagnosis.2A 7‐year‐old girl presented to the physician with bright red blood after defecating for 26 days beforehand. Her colonoscopy revealed erythematous mucosa and a few erosions on her rectum. In addition, biopsies from that site revealed nodular lymphoid hyperplasia and apoptotic colonopathy. She received some stool softeners and a topical agent. About 10 days later, the patient was involved in a car accident. Therefore, a computed tomography (CT) scan of the abdomen was performed due to abdominal trauma and revealed a massive amount of fluid in the abdominal cavity. The patient was discharged from the hospital after 3 days.About 14 days later, the patient presented to the pediatric department with increasing abdominal distention.2. On abdominal examination, she has moderate distension. Other parts of the physical examinations were normal. His blood test showed hemoglobin of 13.7 g per deciliter, white blood cells of 5000 cells/mm3, 55.1% neutrophils, and 37.4% lymphocytes. In addition, biochemical analyses were performed, which showed triglycerides 59 mg/dL, cholesterol 125 mg/dL, albumin 4.6 gr/L, amylase 110 u/L, lipase 25 u/L, LDH 479 u/L. The renal function test and urine analysis were all normal. The rest of the laboratory data are summarized in Table On physical exam, the patient's blood pressure was 100/75 mmHg, respiratory rate 22, pulses rate 110 beats per minute, weight was 18 kg, and height was 111 cm, so her body mass index (BMI) was 14/6 kg/mAn abdominal ultrasound examination revealed moderate free fluid in the abdomen, so abdominal fluid was tapped under ultrasound guidance, and its laboratory parameters are presented in Table Cytology from the fluid showed some isolated and loose clusters of mesothelial cells, a few histiocytes with numerous lymphoblasts, and immature lymphocytes in favor of lymphoproliferative lesion, and the authorized pathologist recommended bone marrow aspiration. An aspiration of her bone marrow was done after suspicion of malignancy was raised. The marrow showed mild hypocellularity. According to flow cytometry, 2–3% of myeloid cells were immature.Several factors can cause a CA. In our case, the three primary differential diagnoses were tuberculosis, malignancy, and trauma, so we launched different tests to determine our diagnosis and treat our patient. A tuberculosis smear, culture, and adenosine deaminase test (ADA) were performed to exclude tuberculosis. To establish the diagnosis of lymphoproliferative disorder from the fluid, bone marrow aspiration and flow cytometry were performed, which were not indicative of malignancy. As a result, the malignancy cause of CA was excluded, and the patient was treated with a diagnosis of traumatic CA and received medium‐chain triglyceride (MCT) oil and octreotide. After all, in the follow‐up 2 weeks later, abdominal ultrasonography reported mild free fluid. Ultimately, with the treatment continued for a month, there was no trace of free fluid in the abdominal cavity.3As we know, CA is a rare type of ascites.For CA diagnosis, like the other diseases, history and physical exam should be taken carefully.Traumatic and atraumatic are two important etiology groups.One of the vital causes of CA is malignancy. Different solid malignancies, including lymphoma, neuroendocrine tumors, and sarcoma, can lead to CA, but among them, lymphoma has the highest prevalence, about one‐third of the cases.Treatment of CA includes three parts: conservative, interventional, and surgical treatment.Choosing a treatment method is to depend on the etiology of CA. Total parenteral nutrition (TPN), MCT diet, and octreotide can be used in conservative treatment. The surgical approach should be made in refractory CA.4We still recommend that tuberculosis and malignancy are among the more important causes of CA. However, in rare cases like ours, trauma can be included in the differential diagnoses, and relevant work‐ups can be performed.Anahita Jafari: Conceptualization; writing – original draft; writing – review and editing. Hamid Reihani: Conceptualization; writing – original draft; writing – review and editing. fereshteh karbasian: Conceptualization; project administration; supervision; writing – original draft; writing – review and editing. Behnaz Darban: Conceptualization; writing – original draft; writing – review and editing. Seyed Mohsen Dehghani: Supervision; writing – original draft; writing – review and editing.None.The authors declare that they have no competing interests.Our study has been reviewed and approved by the Medical Ethics Committee of Shiraz University of Medical Sciences.Written informed consent was obtained from the patient's parents to publish this Case report. A copy of the written consent is available for review and can be requested at any time by the journal's editor.


Tracheal leiomyoma is an extremely rare benign tumor. It mostly presents in the third decade of life and mostly affects men. Herein, we describe a patient with tracheal leiomyoma which was treated as asthma for 2 years before definite diagnosis.A 41-year-old female with a history of asthma was referred due to dyspnea and refractory cough. On bronchoscopic examination, a tumoral lesion was found in the distal trachea with near total obstruction and histopathologic examination of the bronchoscopic biopsy was inconclusive. The tumor was surgically resected. On the follow-up bronchoscopic examination, the trachea was normal and symptoms were relieved. Histopathologic results were compatible with Leiomyoma.Airway leiomyoma is commonly misdiagnosed as asthma or bronchitis long before a definitive diagnosis. Fiberoptic bronchoscopy is the modality of choice for direct visualization of intraluminal lesions and tissue sampling. Surgical resection is the gold standard approach. The best surgical approach is not clearly determined to date and both endoscopic procedures and surgical resection have been utilized for treatment in case reports.Usually there is a long interval between onset of clinical symptoms and a definite diagnosis. In the case of refractory signs and symptoms to medical treatment, alternative diagnosis should always be considered. •Tracheal leiomyoma is an extremely rare benign tumor.•A 41-year-old female with a history of asthma was referred due to dyspnea and refractory cough.•On bronchoscopic examination, a tumoral lesion was found in the distal trachea with near total obstruction.•Surgical resection is the gold standard approach. The thoracic surgeon had evaluated the patient and found a tumoral lesion close to the carina in fiber optic bronchoscopy. Histopathologic evaluation of the tissue biopsy was inconclusive. Her medical history included asthma diagnosed 2 years earlier based on spirometry: FEV1/FVC: 64, FEV1: (1.78) 65 %, FVC: (2.78) 83 %. She was receiving Budesonide/Formoterol 320–9 μg MDI 2 puffs twice daily for controlling asthma. Despite good adherence to treatment, there was no significant improvement in symptoms and her condition has progressively gotten worse during the past 2 months. She was not a smoker and denied secondhand smoking. Her allergic history and family history was also unremarkable. Her initial vital signs were BP 115/80 Hg, pulse rate 90 bpm, respiratory rate 22 pm, temperature 37.1. On admission in thoracic surgery ward, she had inspiratory and expiratory stridor in the physical examination. The patient had a chest computed tomography scan which was carried out in the first hospital, showing a tracheal mass close to the carina . Possibl3Primary leiomyoma of airway is a scarce disease and has been described only as case reports. Distal part of tracheobronchial tree is affected more than the proximal part and the lower third of the trachea is involved the most and it commonly originates from posterior membranous wall Leiomyoma doesn't have any pathognomonic radiologic findings. Tracheal masses are hardly ever visible on plain chest radiographs Fiberoptic bronchoscopy is the modality of choice for direct visualization of intraluminal lesions and tissue sampling. In the case of complete obstruction, airway patency distal to the stenosis cannot be assessed by bronchoscopy. Hence, 3-D reconstruction of high-resolution CT can help further investigations Medical treatment is ineffective and surgical resection is the gold standard approach. Prognosis is excellent with complete removal of the tumor. The best surgical approach is not clearly determined to date. Tracheal sleeve resection, carinal resection, endoscopic resection, Nd-YAG laser ablation, electrocoagulation, cryotherapy, have been employed in case reports. Endoscopic resection and ablation can result in complications such as tracheal perforation, positive surgical margin, and lost removed tumor 4Tracheal leiomyoma is a rare benign airway tumor. Due to its rarity, there is a long interval between onset of clinical symptoms and a definite diagnosis. In the case of refractory signs and symptoms to medical treatment, alternative diagnosis should always be considered, and further investigation should be attempted.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.Ethical approval was waived by the authors institution.N/A.Amini Hesam.Amini H: Conceptualization, Writing - Original draft, Investigation, Resources.Soltanmohammadi S: Methodology, Validation, Supervision, Writing - Review and editing.Rafieian Sh and Ershadi R: Writing - Original draft, Resources.N/A.


Abdominal cocoon syndrome is defined as idiopathic encapsulation of the bowel within a fibrocollagenous membrane and is considered as a rare cause of small bowel obstruction. A 15-year-old female presented complaining of right lower abdominal pain, distension and vomiting for 24 hours with previous similar attacks in the last four years. She had no another significant medical or surgical history. Computed tomography study revealed matted mildly distended bowel loops centrally with a suspicion of acute appendicitis. Next day, abdominal pain was the only clinical finding and acute appendicitis was the primary diagnosis. During surgery, most of the small bowel was found to be encapsulated within a cocoon-like fibrous membrane. The appendix was congested. Appendectomy, full resection of the membrane and dense adhesiolysis were performed. Herein, we will present the first reported case from Somalia and discuss the radiological findings affecting the management for such a rare disease. Abdominal cocoon syndrome (ACS) is a rare disease that is defined as idiopathic partial or total encapsulation of the bowel within a fibrocollagenous membrane and is considered as a rare cause of small bowel obstruction (SBO) .Peritoneal encapsulation (PE) is a congenital abnormality, in which part or all of the small intestine is covered with a thin peritoneal membrane and without intestinal adhesions and rarely characterises by intestinal obstruction , 3.Sclerosing encapsulated peritonitis (SEP) is an acquired disease including two types: iatrogenic SEP or ACS and secondary SEP. Secondary SEP can be found in patients with peritoneal dialysis, tuberculosis, ventriculoperitoneal shunt, povidone peritoneal lavage, etc. , 4.The histopathology study for the membrane of ACS is characterised by the presence of a fibrocollagenous membrane with an inflammatory process, which is considered the corner stone to differentiate SEP and PE .Herein, we will present the first reported case of ACS from Somalia and discuss the radiological findings affecting the management for such a rare disease.A 15-year-old female was admitted to the hospital complaining of right lower abdominal pain and vomiting for 24 hours. The pain started as severe in the periumbilical area and the right iliac fossa (RIF) and associated with vomiting, nausea and constipation. She had previous similar attacks in the last 4 years with average one attack per 3 months, which resolved within hours with anti-pain medication. She had no other significant medical or surgical history. The patient was referred to us from another hospital with a diagnosis of acute appendicitis. On examination, she was moderately ill looking, stable, afebrile and with regurgitation. Abdominal exam revealed mild distension centrally with tenderness on RIF and periumbilical area. Abdomen US revealed dilated cecum with reduced bowel movement and the appendix could not be visualised. Abdominal enhanced computed tomography (ECT) revealed matted small bowel in the center of the abdomen with mild proximal small bowel distension and minimal free fluid in the pelvis, mostly due to acute appendicitis. Laboratory investigations were within normal limits with mildly elevated CRP = 7.4 mg/L.Then, the patient was scheduled for exploratory laparotomy. Due to a financial issue, laparotomy was postponed to the next day. When the patient was examined again, she was improved with neither distended abdomen nor vomiting and passed flatus. The pain was localised on RIF with marked tenderness. Acute appendicitis was the primary diagnosis. After intubation, a movable mass in the center of the abdomen was palpated and midline incision was carried out. There was a mild amount of serous fluid in the pelvis and most of the small bowel was encapsulated within a thickened white, cocoon-like fibrous membrane, including the distal half of the jejunum, ileum and cecum. The appendix was not included within the membrane and was congested . A carefThe post-operative course was uneventful and she was discharge on post- operative day 4.The histopathology study revealed a fibrocollagenous membrane with foci of moderate active chronic inflammation, early appendicitis with mild periappendicitis.The symptoms of ACS are non-specific as recurrent abdominal distension, nausea, vomiting, abdominal pain and a palpable mass , 5. MostDue to the rarity of ACS and its non-specific symptoms, ACS is commonly misdiagnosed. Recently, ECT is the modality of choice to detect the diagnosis of ACS. Identifying a fibrous membrane surrounding the small intestine is considered the specific radiological finding .On a retrospective review of our patient’s ECT, we recognised a membrane encapsulating the small intestine centrally, which indicates the diagnosis of ACS  and 5.The specific ECT findings in patients having recurrent attacks of subacute SBO with unknown causes help in diagnosing and determining the proper management of ACS.However, it is acknowledged that we misdiagnosed ACS as acute appendicitis that provoked the surgery.. In mild attacks of SBO with the specific ECT findings, conservative management should be kept in mind.Surgery is the traditional therapy for ACS as most of the cases are discovered post-operativelyConservative management is still the treatment of choice for managing adhesive SBO with high success rates. In non-responding cases, surgical dense adhesiolysis might by followed with recurrent severe adhesions . This faConservative treatment consists of observation alone or insertion of a long nasointestinal decompression tube with medical treatment. Some reports have demonstrated successful trials by using steroids, colchicine, tamoxifen or azathioprine .The incidence rate of ischemia and perforation is rare in ACS. The thickened fibrotic membrane encapsulating the bowel with the dense adhesions prevent the vascular pedicle from twisting . TherefoOn comparison with conservative treatment, surgery has a high incidence of iatrogenic complications  when attempting lysis for the severe adhesions between bowel loops . In the Most of the patients with ACS have intermittent mild attacks of SBO and rarely develop peritonitis or strangulation. When ACS is diagnosed with ECT, the treatment for such a case is a balance between conservative and surgical treatment. We believe that surgical management can be preserved for the cases with peritonitis or when not responding to the conservative management.Notably, the limited number of reported cases was of patients who have sought a medical consultation and, maybe, there are more patients still not diagnosed because they have mild or no symptoms. This might be supporting the conservative management as the primary choice for mildly symptomatic ACS. More comprehensive studies are necessary to establish the proper management for ACS. Increasing the published reports will improve the awareness of the specific radiological findings and avoid the patient unnecessary surgery.


We discuss the unusual presentation and subsequent diagnosis of a patient with a glomus tympanicum tumor, also known as middle ear paraganglioma, which is a rare and benign tumor of the middle ear that usually presents with pulsatile tinnitus, cranial nerve pathology, hearing loss, and dizziness. The patient was a 35-year-old female with no past medical or surgical history who presented with a three-year history of mild left-ear hearing loss. The initial examination was negative for otalgia or otorrhea but was notable for a mass filling her left ear canal. The patient denied pulsatile tinnitus or dizziness. CT imaging was used to examine the soft tissue mass in the middle ear and ear canal and was consistent with a soft tissue heterogeneous mass with a subsequent biopsy confirming a diagnosis of paraganglioma. After the diagnosis, a laser surgical excision was scheduled to remove the tumor. Constant awareness is needed to examine the different presentations of middle ear paragangliomas so that appropriate treatment is promptly provided. Middle ear paragangliomas, also called glomus tympanicum tumors, are rare, benign, and slow-growing tumors that develop in the middle ear. These tumors are typically found in the area surrounding the cochlea and the vestibular system -3. TheseThe symptoms of middle ear paraganglioma typically include hearing loss, dizziness, cranial nerve impairment, and pulsatile tinnitus . Glomus A 35-year-old female presented to our clinic with a primary complaint of decreased hearing in the left ear over the past three years. She reported that the hearing in her left ear felt “muffled”. Due to her mild symptoms, she had initially presented to her family physician, who referred her to a general otolaryngologist. The general otolaryngologist had noted a mass filling the ear canal and referred her to an otologist. On evaluation, the patient was noted to have a smooth mass filling the ear canal and blocking any visibility of the tympanic membrane. An audiogram Figure  showed lFigures  The otoscopic view of the left ear mass is presented in Figure Due to the uncertain nature of the left middle ear mass, the patient was taken to surgery for a middle ear exploration and biopsy of the left middle ear mass. The biopsy was sent for pathological identification, and the pathology report subsequently revealed a left middle ear paraganglioma. Figure Based on the size and location of the paraganglioma, it was classified as a type 4 glomus tympanicum . A referMiddle ear paragangliomas, also called glomus tympanicum, are benign and highly vascular tumors that are rarely seen in clinical practice . The incIn rare cases, paraganglioma tumors can increase the production of adrenaline, resulting in rapid heartbeat, headaches, and sweating . In lighParagangliomas are benign, slow-growing tumors found throughout the body, including the middle ear. Although several different types exist, type 4 glomus tympanicum tumors are a rare type of paraganglioma found inside the middle ear. Most of the case reports in the literature focus on type 1 and type 2 middle ear paragangliomas. More research is needed to determine the incidence, examination, and treatment of type 4 paraganglioma tumors.


Pheochromocytoma (PCC) is a rare neuroendocrine catecholamine-secreting tumour of the adrenal gland. It originates from the chromaffin cells found within the adrenal medulla or the extra-adrenal paraganglia. We present a case report of a 24-year-old female who presented with hypertension, headache, palpitations, chest pain and blurry vision. On ultrasound evaluation, a right suprarenal mass was noted, which was further evaluated using contrast-enhanced computed tomography (CT). Based on our imaging findings, the patient was diagnosed with a case of right-sided pheochromocytoma. The patient was operated on, and our diagnosis was confirmed with histopathological examination. Pheochromocytoma (PCC) is a rare neuroendocrine catecholamine-secreting tumour of the adrenal gland. It grows from the chromaffin cells of the adrenal medulla or extra-adrenal paraganglia. PCC occurs in 0.1%-0.6% of hypertensive patients. The mean age of presentation varies, with a female-to-male ratio of 1.4:1 [Approximately 40% of PCC cases are hereditary in origin. The most common syndromes associated with familial PCC are familial multiple endocrine neoplasia MEN2A) or MEN2B, neurofibromatosis (NF1) and von Hippel-Lindau syndrome (VHL2) [A or MEN2The clinical presentation of PCC shows a wide spectrum of symptoms ranging from asymptomatic presentation to cardiac arrest. The diagnosis of PCC is dependent on the identification and characterisation of a suprarenal mass on imaging with clinical, biochemical and histopathological confirmation . The claPatient informationA 24-year-old female presented with chief complaints of headache, palpitation, chest pain and blurry vision for the past two months. The patient also developed hypertension and was prescribed medication by her general physician.Clinical findingsOn examination, vital parameters indicated blood pressure of 180/100 mmHg, heart rate of 104 bpm and respiratory rate of 24 breaths/minute. The patient was conscious and well-oriented. Haemoglobin, total leukocyte count, liver function test, kidney function test and D-dimer were normal.Assessment on imagingThe right kidney was small in size, measuring 70 × 30 mm. An iso-hyperechoic well-defined solid mass sized 60 × 40 × 47 mm (transverse (T) × anteroposterior (AP) × craniocaudal (CC)) in the right suprarenal region was present. No calcification was present within the mass. Multiple small anechoic areas were also present within the mass, suggestive of necrotic changes Figure .On colour Doppler, the mass showed moderate peripheral and central vascularity Figure .The rest of the abdominal organs were normal.A well-defined soft tissue attenuation (+12 to +15 HU) lesion of approximately 53 × 47 × 56 mm (T × AP × CC) was noted involving the right suprarenal gland. Multiple hypodense areas were noted within this lesion , which was surprisingly within normal limits. The patient was advised to take phenoxybenzamine  for 14 days prior to the excision of the lesion. Subsequently, the patient underwent a wide excision of the right adrenal lesion, along with a right adrenalectomy.HistopathologyOn the gross cut specimen, black haemorrhagic areas were noted. On microscopy, sheets and nests of tumour cells with scanty intervening stroma were noted. The tumour cells were large and polygonal with round to oval vesicular nuclei and clumped chromatin nucleoli, along with granular and eosinophilic cytoplasm. These findings confirm the histopathological diagnosis of pheochromocytoma Figure .Follow-up and outcome of interventionThe postoperative period proceeded without complications, and the patient made a satisfactory recovery. During the follow-up after two months, the patient’s blood pressure level was measured at 120/80 mmHg, which falls within the normal range. Additionally, other symptoms such as blurred vision, headache, palpitations and chest pain have also subsided.PCC develops from chromaffin cells and secretes the excess catecholamines. Extra-adrenal PCC, also known as paragangliomas, arises from the paraganglionic sympathetic and parasympathetic nervous system. It tends to occur at any region extending from the base of the skull to the urinary bladder along the sympathetic and parasympathetic paraganglia. The organ of Zuckerkandl is a common location of extra-adrenal paragangliomas .PCC appearance on ultrasound and computed tomography is variable, with solid to mixed solid-cystic appearance . TumoursOn post-contrast CT evaluation, it shows uniform or heterogenous enhancement and, mostly, enhancement of solid components. Washout of contrast usually overlaps with either benign lesions or malignant lesions; hence, they are difficult to differentiate on contrast evaluation alone. On magnetic resonance imaging (MRI) evaluation, it was hypointense on T1-weighted images (T1WI) and hyperintense on T2-weighted images (T2WI), which is the classical “light bulb appearance.” On post-contrast evaluation, it commonly enhances avidly. Metaiodobenzylguanidine (MIBG) scan is used in clinically suspected PCC for localisation and confirmation, as well as excluding metastasis. The sensitivity of MIBG is not high, but the specificity is 100%. Scintigraphy performed with somatostatin receptor analogues, such as octreotide, can be another alternative for the localisation of PCC. In clinical practice, 18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) is a widely used modality in diagnosing PCC, which shows increased uptake on PET. However, this is seen in cases of adrenal metastases as well .ManagementThe primary treatment for tumours remains surgical removal. Performing a needle biopsy in cases of clinically suspected pheochromocytomas is discouraged due to the potential risk of increased catecholamine hypersecretion. Preoperative management for pheochromocytoma involves alpha-blockers for 14 days prior to surgery to reduce complications. Beta-blockers can be used for tachycardia control, but only after alpha-blockers, and laparoscopic adrenalectomy is the preferred surgical approach .Pheochromocytoma is a rare catecholamine-producing tumour of the adrenal gland. In young hypertensives, PCC should be a suspected diagnosis. Numerous imaging modalities are used in evaluating pheochromocytoma, but ultrasound and CT are excellent modalities for early diagnosis, which also helps in optimum management.


Post-traumatic testicular torsion is a rare condition, accounting for approximately 4%-8% of all reported cases of testicular torsion in the literature. Prompt clinical suspicion and intervention are crucial; as testicular torsion is considered a medical and surgical emergency that may lead to testicular necrosis. Ultrasound imaging plays an important role in assessing the integrity of the traumatized scrotum and facilitating early detection of associated testicular torsion. In this case report, we present a neglected post-traumatic testicular torsion in a 13-year-old child that led to orchiectomy. Testicular torsion is by far the most prevalent urological emergency before the age of 25. Trauma is an underappreciated cause of this pathology ,2.It occurs notably when predisposing anatomical factors are present, such as “bell clapper deformities” A traumatized testicle is often swollen, making a meticulous examination difficult, and symptoms can easily be mistakenly attributed to the trauma than torsion.Clinical examination findings vary with the duration and degree of spermatic cord rotation. Ultrasound imaging plays a crucial role in assessing the integrity of the contents of the traumatized scrotum. This evaluation is essential for the early detection of traumatic testicular torsion and the identification of any associated complications An early diagnosis can ensure testicular salvage and help avoid unnecessary complications such as testicle necrosis.In this case report, we present a case of post-traumatic testicular torsion in a 13-year-old boy. We will discuss the diagnosis, treatment, and prognosis of this condition based on a comprehensive review of the existing literature.We report the case of a 13-year-old male child admitted to the pediatric emergency room 32 hours after testicular trauma following a bicycle accident. The patient initially received analgesic treatment in the first few hours following the trauma. However, due to the persistence of pain and an increase in scrotal swelling, the patient sought medical attention on the second day.Clinical examination revealed a large, painful, reddish bursa , very teAn ultrasound exploration was immediately requested by the surgeon to explore the scrotal content.The ultrasound study was performed on both B-mode and Doppler modes. The findings revealed an ascended left testicle that appeared heterogeneous and hypoechoic. Small hypoechoic zones were also observed within the testicle  , and redIf an inconclusive finding is detected by an imaging technique, the patient must be recommended for urgent surgical exploration Orchiectomy is the terminal option in the management of testicular torsion, a necrotic and irrecoverable testis  should bPost-traumatic testicular torsion is a well-documented but poorly appreciated entity. Physicians must always try to think and see beyond the obvious because the clinical presentation can sometimes be misleading. Thus, torsion pathology should always be considered in any post-traumatic acute scrotal pain.In cases where there is suspicion of traumatic testicular torsion, conducting a thorough examination of the scrotum is crucial. When uncertainty persists, Doppler ultrasound is widely regarded as the “gold standard” for ruling out torsion in patients with blunt testicular injury.Preserving the testicles is indeed the ultimate goal in cases of testicular torsion, and it relies on 2 key factors: the duration of symptoms and the promptness of treatment. Time is of the essence in testicular torsion, as the longer the duration of torsion, the higher the risk of testicular damage and necrosis.Not applicable.Written informed consent was obtained from the child's parents, and legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The data sets are generated on the data system of the CHU Hassan II of Fes, including the biological data and the interventional report.