The presence of macroscopic fat on computed tomography (CT) imaging has been traditionally regarded as an indication that an adrenal lesion is likely to be a benign myelolipoma, for which further investigation is not usually required. Two cases are described where an adrenal lesion was eventually found to be malignant on histology , despite the presence of macroscopic fat on CT. In both cases there were other clinical and radiological indicators of potential malignant pathology. These cases add to increasing awareness in the literature that malignant adrenal tumors may rarely contain macroscopic fat, emphasizing a need for clinical vigilance. Adrenal lesions are a common radiological finding. Although the vast majority are benign , some reA 62-year-old woman, initially presenting with abnormal liver function tests, was found to have a well-circumscribed lobulated heterogeneous mass in the right adrenal gland on CT abdomen measuring 4.9 cm in maximal dimension. Three hypodense foci, measuring up to 10 mm, were identified within the mass and thought to represent macroscopic fat on the basis of being visible to the eye and of similar density to fat seen elsewhere. The mass was therefore initially reported as consistent with adrenal myelolipoma. Later retrospective review measured density for 2 of these foci as −60 and −90 Hounsfield units, consistent with fat, and calculated this fat as comprising < 2% of the mass . Representative images are presented in Results of functional testing included a significantly elevated 24-hour urine cortisol  and suppressed adrenocorticotropin hormone (ACTH) (< 0.2 pmol/L), consistent with adrenal-based Cushing syndrome. Plasma aldosterone was below the limit of quantification. 24-hour urine metanephrine, plasma testosterone, and plasma dehydroepiandrosterone sulfate (DHEA-S) were within the normal range.Past medical history included hypertension and type 2 diabetes mellitus (possibly secondary to Cushing syndrome). There was no known history of any hematological disorder, nor any abnormality on initial full blood count.CT abdomen also identified multiple hepatic lesions, unable to be characterized in part due to marked background hepatic steatosis. A subsequent hepatic magnetic resonance imaging (MRI) confirmed the presence of multiple lesions for which the differential diagnosis included metastases, adenomata, or multifocal hepatocellular carcinoma. The adrenal lesion was visualized on this MRI, with no change in size from the CT performed 26 days prior. The areas of interest within the lesion demonstrated high T1 and T2 signal with loss of signal on fat-suppression sequences and chemical shift artifact at their margins on opposed-phase imaging, consistent with macroscopic fat [A hepatic core biopsy was obtained, with morphology and immunohistochemistry consistent with metastatic adrenocortical carcinoma. The patient proceeded to palliative treatment with mitotane (4.5 g daily in divided doses), chemotherapy , and trans-arterial embolization of hepatic metastases. Cortisol excess required additional management with metyrapone (titrated to 4.5 g daily in divided doses) and ketoconazole (titrated to 1200 mg daily in divided doses). There was an initial response, with normalization of urine cortisol and stability of lesions on surveillance CT; however, the disease subsequently progressed and she died 14 months after the initial diagnosis was made.A 72-year-old man presented initially with abdominal pain and was found on CT to have a retroperitoneal lesion, contacting and possibly arising from the left adrenal gland. The lesion measured 7.6 cm in maximal dimension; however, there was associated acute retroperitoneal hemorrhage, limiting assessment of the true size and contours of the underlying mass. No prior imaging was available for comparison. A single hypodense focus was identified, measuring 7 mm and on later retrospective review calculated as comprising < 1% of the overall lesion. The focus was visible to the eye and of similar density to fat elsewhere (later retrospectively measured as −20 Hounsfield units) and was therefore thought to represent macroscopic fat. Representative images are presented in Plasma normetanephrine was elevated  in the context of acute illness. Cushing syndrome and primary aldosteronism were not formally excluded. Past medical history included hypertension controlled on candesartan, and hemochromatosis managed with regular blood donation. At presentation blood pressure was 127/75 mmHg and full blood count was normal.The patient presented again 1 month later with ongoing abdominal pain. Repeat CT demonstrated a new small central hyperdense component to the lesion, suspicious for active extravasation. He proceeded to embolization of the left inferior adrenal artery. He was seen again 1 month after embolization, at which time a further CT showed the lesion to have enlarged to 9.0 cm.The patient proceeded to open left adrenalectomy, left nephrectomy, and colonic resection. Histology was consistent with an undifferentiated spindling sarcoma, possibly representing a malignant peripheral nerve sheath tumor. Areas of tumor necrosis were noted. Intra-tumor macroscopic fat was not specifically identified.Surveillance CT 4 months after surgery unfortunately showed widespread disease recurrence with extensive retroperitoneal and peritoneal metastases. The patient declined palliative chemotherapy and died 7 months after the mass was first identified.The presence of macroscopic fat on imaging of an adrenal lesion has been traditionally thought to indicate benign myelolipoma. American College of Radiology recommendations for management of incidental adrenal masses regard this finding as essentially diagnostic for myelolipoma, with no additional workup or follow-up imaging generally required, although that recommendation was presented with a caveat that it should not be termed a formal “guideline” and that “Radiologists should feel comfortable deviating from the algorithm” .A recent systematic review described 7 cases of adrenocortical carcinoma where macroscopic fat was seen on preoperative imaging . Four caA 2009 pathologic case series of 3 patients with adrenocortical neoplasms, classified as either adrenocortical carcinoma or of uncertain malignant potential, described foci of myelolipomatous and lipomatous metaplasia . This phAlthough adrenocortical carcinoma has not been described with fat > 5%, the yield of using percentage fat to discriminate between myelolipoma and adrenocortical carcinoma is uncertain. Histologically, myelolipoma comprises a mixture of mature fat and hematopoietic cells, however the relative proportion of these elements can vary significantly. Consequently, radiological appearances range from tumors that appear to almost entirely consist of macroscopic fat to tumors where visible fat is nonexistent .In both cases described here, macroscopic fat comprised a very small component of the lesion, raising a question of whether, in retrospect, the possibility of malignancy could have been given greater weight at the outset. However, the rarity of adrenocortical carcinoma with macroscopic fat, compared to the well-described phenomenon of myelolipoma containing only a small proportion of fat, suggests that myelolipoma remains the more likely diagnosis even where fat is < 5%. Radiologists must weigh providing an exhaustive differential diagnosis, including very rare entities, with the potential risks of this approach, including harm and costs generated by overinvestigation. Of note, the initial radiologist report for case 2 suggested malignancy in the differential diagnosis.Adrenal tumor size can be used as an indication of the likelihood of malignancy; however, it is unlikely to be a reliable discriminator when specifically differentiating adrenocortical carcinoma and myelolipoma. One study, using data from patients undergoing adrenalectomy, estimated the population rate of malignancy as 10% in tumors ≥ 4 cm, 19% in tumors ≥ 6 cm, and 47% in tumors ≥ 8 cm .Our second case was found to have a poorly differentiated sarcoma. We are not aware of previous descriptions in the literature of this manifesting as an apparent adrenal tumor with macroscopic fat. Even if the reporting radiologist had provided an exhaustive differential diagnosis for the initial CT, it would almost certainly have not contained the final diagnosis in this case.These factors collectively suggest caution in using isolated radiology findings  to classify an adrenal tumor as likely benign, without factoring in the broader clinical context. Both cases described had elements to their presentation raising suspicion of malignancy.Case 1 had evidence of endocrine functionality. This is well-described in adrenocortical carcinoma, with 62% reported to be functional in one review, of which Cushing syndrome was the most common abnormality . Of noteOf more significance, both of our patients had clinical suspicion of malignancy prior to histological diagnosis, with hepatic lesions suspicious for metastases in case 1 and possible growth of the mass in case 2. Although frequently large in size, adrenal myelolipomata are typically slow growing. One series of 69 patients with radiographically diagnosed myelolipoma described growth in 11, at a median rate of 0.16 cm/year . In contIt is important to note that histology did not identify macroscopic fat in case 2, and that macroscopic fat was unable to be histologically confirmed in case 1 . There were, however, multiple radiological features present that were consistent with macroscopic fat. Although tumor necrosis or cystic change may result in hypodense foci, radiologically these would be expected to manifest as fluid density rather than fat density. Ultimately, the decision to proceed to adrenalectomy due to suspicion of malignancy rests on clinical and radiological factors, rather than on histological findings which are only known once adrenalectomy has occurred.The radiological finding of macroscopic fat in an adrenal lesion is highly suggestive of benign myelolipoma; however, it does not completely exclude malignancy, particularly when the proportion of fat is < 5%.Tumor size is not useful in discriminating between adrenal myelolipoma and adrenocortical carcinoma; however, rapidly growing lesions are more likely to be malignant.Ongoing vigilance is important when a clinical presentation has suspicious features for malignancy, even if isolated radiology findings are seemingly reassuring.


A 64-year-old man presented with symptoms indicative of superior vena cava syndrome. Imaging work-up revealed an obstructing right atrial mass, which was subsequently excised and diagnosed as primary cardiac lymphoma. Post-surgery, the patient showed significant clinical improvement and was started on a chemotherapy regimen with complete remission at 1 year. A previously healthy 64-year-old man, presented to the emergency department with 2 weeks of increasing exertional dyspnea, worsening orthopnea, facial and arm swelling, and a nonproductive cough. Vital signs on admission were within normal limits. On physical examination, the patient demonstrated marked facial and upper extremity edema, as well as distended neck veins. Additionally, signs of plethora and cyanosis of the face were noted, with an increase in jugular venous pressure on cardiovascular examination.The patient had no significant past medical history.Given the patient's symptoms suggestive of superior vena cava syndrome (SVC), a broad differential diagnosis were considered. Malignant causes included primary or secondary cardiac tumors, lung cancer, mediastinal tumors, or lymphoma, which may obstruct or compress the superior vena cava. Non-malignant etiologies encompassed SVC thrombosis, aortic aneurysm, or fibrosing mediastinitis. Cardiopulmonary conditions such as heart failure, pericardial disease, and pulmonary hypertension were also suggested, given the symptoms of dyspnea and orthopnea.The patient underwent a chest CT-scan, followed by a confirmatory transesophageal echocardiogram (TEE) which revealed the presence of a prominent, heterogeneous, partially non-enhancing, right atrial mass, measuring 66 × 41 × 37 mm, partially disrupting inferior vena cava flow and obstructing the superior vena cava . A filliGiven the high risk of deteriorating clinical condition, surgical removal of the mass was planned and successfully executed. The surgical specimen  was thenWhile secondary cardiac lymphomas are relatively frequent and can contribute to 20% of extra nodal non Hodgkin lymphomas (NHL), primary cardiac lymphoma (PCL) is extremely rare and represents only 1%–2% of all heart tumors . All heaDifferential diagnoses include benign myxoma (the most common type of cardiac tumor), intracardiac thrombi (in the setting of hypokinetic dilated cardiomyopathy) and angiosarcoma,  . InitialThe mainstay of PCL treatment relies on chemotherapy, using the combination of Rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP regimen), which has shown a response rate of 79%–87% . Prompt The patient is currently in remission at 1-year follow-up.PCL is an extremely rare neoplasm. While chemotherapy remains the mainstay of treatment, surgery could be considered for urgent symptomatic relief.


Teaching Point: Giant cell tumor of bone may show a moderate to high FDG uptake, and attention should be paid to differentiate from malignant tumors. Giant cell tumor (GCT) is a common benign bone tumor, accounting for 5% of all primary bone tumors 2. Verteb34518F-FDG PET/CT scan showed the expansile bone destruction of the second lumbar vertebra with increased FDG uptake (SUVmax: 11.8) (A 45-year-old man with pain and numbness in the right lower limb for more than one year was referred for magnetic resonance imaging (MRI). MRI showed a large expansile lesion of the second lumbar vertebra . 18F-FDGx: 11.8) . The corThe patient underwent vertebral resection. Pathological diagnosis was a benign fibrous histiocytoma (BFH) (now considered GCT) 8. Light BFH shares common clinical symptoms, location, radiological characteristics, and histological features with GCT 9, causin10Despite benign in nature, GCTs generally exhibit high FDG uptake. A retrospective study of 20 patients from a single center showed that the SUVmax of spinal GCT ranged between 7.6 and 13.7, and the mean SUVmax was 10.4 ± 2.7 [GCT is a rare benign skeletal tumor. It shares features with some other malignant bone lesions on MRI and PET-CT and should be included in the differential diagnosis.


Fetal meconium periorchitis (MPO) is rare prenatal diagnosis associated with meconium peritonitis. The prenatal ultrasound finding consists of an enlarged fetal scrotum with echogenic fluid and debris. In this report, we describe a case in which a prenatal diagnosis of MPO was accurately made at 32 weeks of gestation. The neonate delivered without complications, underwent immediate evaluation followed by major surgery, and ultimately had a favorable outcome. An accurate prenatal diagnosis is important to counsel the patient in a multidisciplinary approach. This case highlights the prenatal ultrasound findings as well as the neonatal presentation and the possibility for conservative management by pediatric urology. Ultrasound image of an enlarged fetal scrotum in axial plane. On ultrasound, an enlarged fetal scrotum, with a large volume of echogenic fluid, debris, and calcifications was seen (Figure 2.2A large scrotum was noted upon physical examination Figure , and pos3Fetal meconium periorchitis is a rare complication that occurs secondary to meconium peritonitis.In cases where bowel perforation does not heal neonates may develop bowel distention and an acute abdomen requiring immediate surgery.Ahmed S. Z. Moustafa: Conceptualization; writing – original draft; writing – review and editing. Sarah Araji: Conceptualization; writing – original draft; writing – review and editing.The authors declare no conflict of interest.No funding to declare.Written informed consent was obtained from the patient's parent to publish this report in accordance with the journal's patient consent policy.


The coproliths of the appendix are accumulations of fecal remnants within its lumen. They are categorized based on their size into coproliths < 1cm, which are the most common, and giant coproliths, with a diameter > 2cm. It's important to note that the pathophysiology of acute appendicitis is characterized by the obstruction of the appendix lumen. This leads to distension due to the inability to expel secretions, ischemia, and ultimately rupture of its wall. This presentation discusses an interesting case of acute appendicitis caused by a giant coprolith. It also covers the clinical approach and information according to international literature. A 38-year-old man presented with sudden-onset right lower quadrant pain. Clinical examination revealed tenderness, a positive McBurney's point, elevated inflammation markers, and a radiopaque finding on an X-ray. A CT scan revealed a 2.5cm coprolith in the appendix. An exploratory laparoscopy revealed appendix wall rupture, followed by subumbilical incision appendicectomy and cleansing of purulent collection. The patient was discharged from the hospital on the fourth postoperative day without any complications, demonstrating a smooth recovery process. The presence of a coprolith predisposes the development of acute appendicitis. This condition is associated with a worse prognosis, as it increases the likelihood of perforation and the formation of intraperitoneal abscesses. This case underscores the clinical significance of giant coproliths as a potential etiology for acute appendicitis. Early recognition and timely surgical intervention are pivotal in achieving favorable patient outcomes. Appendicitis, a condition marked by inflammation of the vermiform appendix, emerges as a significant medical concern with multifaceted clinical implications. It is characterized by the obstruction of the appendiceal lumen, often resulting from various factors encompassed within its etiology. The obstruction instigates an elevation in pressure within the appendiceal lumen due to the continuous secretion of fluids and mucus from the mucosa, coupled with the accumulation of these substances . This inIn terms of epidemiology, appendicitis displays a distinctive pattern. It most commonly arises between the ages of five and 45, with an average age of onset around 28 years. Males exhibit a slightly higher predisposition to developing acute appendicitis compared to females. The lifetime incidence rates stand at 8.6% for men and 6.7% for women, respectively. Notably, this condition contributes to approximately 300,000 hospital visits annually in the United States alone [Central to the etiology of appendicitis is the phenomenon of appendicoliths. These are masses formed by the aggregation of calcified deposits within the appendix, primarily composed of tightly packed stool and, at times, mineral deposits. Appendicoliths are notable in medical scenarios, being present in about 3% of the general population and found in roughly 10% of appendicitis cases . DespiteA 38-year-old male, with no known past medical history and no history of previous surgeries, presented to the emergency department with a complaint of acute right lower quadrant abdominal pain that had been ongoing for the past 12 hours. The pain had a sudden onset and gradually worsened, without any associated symptoms such as loss of appetite, vomiting, changes in bowel habits, or fever. In clinical examination, the patient exhibited tenderness on deep palpation of the right lower quadrant of the abdomen, along with positive signs of peritoneal irritation . Laboratory findings showed a hematocrit (Hct) of 38.4% , hemoglobin (Hb) level of 12.9 g/dl , white blood cell (WBC) count of 14.78 k/μL , and C-reactive protein (CRP) level of 11.18 mg/dl . Urinalysis was negative upon general examination. Subsequently, a plain abdominal X-ray was performed in an upright position, revealing a radiopaque finding in the right lower quadrant of the abdomen, precisely in the region where the patient reported pain  scan of the upper and lower abdomen Figure . The resAfter obtaining the patient's informed consent, they were prepared for surgery and taken to the operating room. We initiated the procedure with an exploratory laparoscopy, during which we encountered several challenging aspects. Anatomical landmarks, including the appendix's tip, the exact site of rupture, and its base, were not clearly identifiable during the laparoscopic procedure.To optimize the patient's recovery and minimize potential complications, we made a subumbilical incision. The base of the appendix, where it connects to the cecum, appeared healthy and was readily visible with the open access. This observation significantly influenced our surgical approach. Subsequently, we performed the appendectomy, meticulously cleansing the area, and took steps to excise the affected portion of the appendix, including the appendix artery, while preserving the healthy base of the appendix. Figure The patient responded well to treatment, with resolution of symptoms, normalization of laboratory parameters, and clinical improvement. On the fourth postoperative day, due to the low quantity and good quality of drainage, the abdominal drain was removed. The patient's condition remained stable, and he was discharged from the hospital on the fourth postoperative day without any complications.Clinical significance of appendicoliths in acute appendicitisAcute appendicitis, a common surgical emergency affecting approximately 7% of the general population, is often triggered by the obstruction of the appendix lumen. Factors contributing to lumen obstruction include lymphoid hyperplasia, fecalith, stricture, and appendicolith. Appendicoliths, composed of firm stool and mineral deposits, represent a subset of obstructions and have been implicated in the pathogenesis of acute appendicitis .Role of appendicoliths in appendicitis severityAppendicoliths are known to influence the clinical course of appendicitis. The location and size of appendicoliths appear to be significant determinants of disease severity. Studies suggest that appendicoliths are more likely to be associated with complicated cases of appendicitis, including gangrenous appendicitis and perforation . NotablyClinical presentations and diagnostic challengesAppendicoliths may not always manifest as acute appendicitis. Asymptomatic cases are common and can be incidentally detected through imaging, such as CT scans, in otherwise normal appendices. However, symptomatic presentations of appendicoliths can mimic urolithiasis, posing diagnostic challenges. Abdominal pain, leukocytosis, and hematuria are shared symptoms, making it important to distinguish between these conditions for accurate management .Radiological evaluation and managementAbdominal X-rays, ultrasonography (USG), and CT scans play pivotal roles in diagnosing appendicoliths and related conditions. In a retrospective review by Lowe et al., an appendicolith detected on CT had a sensitivity of 65%, specificity of 86%, and positive predictive value of 74% for the diagnosis of appendicitis [Variability in appendicolith characteristicsAppendicoliths' prevalence and clinical implications exhibit significant variability. They are found in about 10% of acute appendicitis cases and are more frequently associated with perforation and abscess formation. The case of a giant appendicolith, exceeding 2 cm in size, is an unusual occurrence but can have pronounced effects on the severity of appendicitis .Conservative management of asymptomatic giant appendicolithsGiant appendicoliths, exceeding 2 cm, are rare findings in acute appendicitis. Typically, they are associated with symptomatic presentations and are managed through surgical removal. However, the report from Scroggie et al. presents a unique case where an asymptomatic patient with a giant appendicolith opted for conservative management due to medical history and patient preferences . This caFuture implications and researchThe interplay between appendicoliths, disease severity, and treatment outcomes warrants further investigation. While appendicoliths are recognized as potential exacerbating factors, a comprehensive understanding of their mechanisms and effects is essential. Future research could explore the predictive value of appendicolith characteristics in determining the risk of complications, aiding clinicians in making informed decisions.Physicians should be mindful of the possibility of appendicoliths and utilize all available diagnostic tools for a swift and accurate diagnosis, enabling a tailored treatment plan. Appendicolith-related acute appendicitis carries the potential for serious complications, including perforation and peritonitis. Therefore, the surgical approach should remain individualized, with a focus on timely intervention to mitigate these risks. CT imaging remains pivotal in diagnosing appendicolith-related acute appendicitis, offering valuable insights into the condition's severity and guiding appropriate management strategies. Embracing a patient-centric approach, which includes personalized surgery and prudent CT utilization, stands as the cornerstone for optimizing outcomes in this context. As our understanding of appendicoliths and their implications continues to evolve, it reinforces the importance of a tailored, patient-centered approach in the management of appendicitis.


The mature cystic teratoma of the ovary (MCTO), is composed of mature differentiated elements, thus showing highly differentiated tissue and highly morphological heterogeneity. Although gastrointestinal epithelium can be identified in 7% to 13% of cases of MCTO, the occurrence of visible, functional, and fully developed loop tissue is rare in clinical practice.A 17-year-old female patient presented with persistent abdominal pain.The patient was diagnosed with MCTO where a visible, functional intestinal loop was observed during laparoscopic surgery. Microscopy of the intestinal structure indicated a well-organized, intact layer of intestinal wall.An emergency single-port laparoscopic excision of the right ovarian cyst and histopathology were performed.After 2 years of follow-up, there were no signs of recurrence in the patient.The immune signature of CK7−/CK20+ is characteristic of tumors of gastrointestinal origin and can be used to distinguish tumors associated with mature cystic teratoma. Besides, gynecologists should keep an eye on the possibility of malignant transformation malignant transformation of MCTO. The degree to which it is benign or malignant depends on the maturity of the tumor tissue. Among all teratomas, the mature cystic teratoma of the ovary (MCTO) is the most common benign germ cell neoplasm of the ovary and has an incidence of 14.2 cases per 100,000 people yearly. MCTO most frequently occurs in women of reproductive age. MCTO is a slowly growing tumor, and its long-term recurrence rate after surgery is 4.7%. Hence, fertility - sparing surgery has been performed on adolescent and reproductive female with MCTO.The term “teratoma” refers to a neoplasm made up of somatic cell populations differentiated from germ cell populations in the ectoderm, endoderm and mesoderm. Previously, gastrointestinal wall or epithelium within the MTCO that was identified at the microscopic level has been reported. Herein, we report the first case report of the formation of a grossly visible, completely developed and peristaltic gastrointestinal tract in the MCTO.Histologically, 7% to 13% of MCTO cases include intestinal epithelium.A 17-year-old girl, with persistent pain in her right lower abdomen for 2 days, was admitted to the emergency department of the Second Hospital of Jilin University  on December 11, 2020.The patient is an adolescent female, no sexual intercourse, with regular menstruation, 13 4-5/28, moderate menses volume, dysmenorrhea (−), blood clots (−), LMP on October 30, 2020. On December 10, 2020, the patient noted dull lingering pain in the right lower abdomen without obvious cause. On the same day, she went to a local hospital for an abdominal ultrasound scan, which demonstrated a moderate echogenic cluster measuring approximately 13.0 × 7.8 × 12.0 cm, which was considered to be a teratoma, with uneven internal echogenicity: a small amount of anechoic and patchy strong echogenic accompaniment and a mass of moderate echogenicity was seen. The following day, the abdominal CT was performed, which revealed that a mixed density shadows were seen in front of the uterus, and fat density and high-density shadows were seen inside this mass , large tumors (>10 cm) or elevated serum tumor markers, or an uneven border on a CT scan that forms an obtuse angle with the inner cyst wall. Therefore, pathologic examination by frozen sections is necessary. However, we were unable to frozen section pathological examination, because the patient underwent an emergency operation at night.Malignant transformation occurred in approximately 2% of all MCTO cases, arising from any of the constituent tissues of the teratoma; Among malignant transformations, squamous cell carcinoma has been reported to occur in approximately 80% of cases, and adenocarcinoma account for 6.8%. Ovarian mature teratoma originates from germ cells, but its abominations occur in somatic cells of teratoma. Therefore, Den Bakker et al suggest that adjuvant chemotherapy for patients with malignant transformation of MCTO cannot simply be transferred to chemotherapy regimens for malignant germ cell tumors and should be targeted according to the pathologically distinct sources of the sinister components. To determine the histological type of secondary malignancy in MCTO, a combination of histology and immunophenotype is required. A CK20 positive/CK7 negative pattern has been reported to be characteristic of tumors of gastrointestinal origin. Gastrointestinal adenocarcinomas secondary to MCTO most often exhibit diffuse expression of CK20 as well as negative expression of CK7. It has also been documented that CDX-2, choriocapillaris and CK-20 were strongly positive and CK-7 was negative as its characteristic.The surgical stage and tumor histology determine the current course of treatment for mature cystic teratomas that have undergone malignant transformation.In this case, it is extremely rare for MCTO to develop a visible, fully developed and active intestinal loop tissue, which has excellent peristalsis function and secreted intestinal fluid in the intestinal tube. In fact, it expands the data for the cases of MCTO. At the same time, the intestinal tissue of mature cystic teratoma of ovary may become cancerous, so the discreetly follow-up of patients should be emphasized. However, the question to be resolved is whether histological shifts in MCTOs should influence chemotherapy options. Ultimately, further accumulation of clinical case evidence data is needed to find a more mature diagnostic and treatment plan.We have obtained a signed consent form from the patient and her guardian and this form will be filed with my records. We would like to thank the patient for their participation in this study.Conceptualization: Bihui Wang, Zanhui Jia.Data curation: Yuanyuan Cao, A-Ran Jia, Liuqing Yang.Formal analysis: Yuanyuan Cao, A-Ran Jia, Zanhui Jia.Investigation: Xuejian Li, Zanhui Jia.Methodology: Yuanyuan Cao, Xuejian Li.Project administration: Bihui Wang, Zanhui Jia.Resources: Liuqing Yang.Software: Bihui Wang.Supervision: Zanhui Jia.Writing – original draft: Yuanyuan Cao.Writing – review & editing: Bihui Wang, Zanhui Jia.


Neuroendocrine tumors comprise a range of neoplasms with varying spectra of origin, biological activity, clinical features, and histological appearance. In this case report, we present a pregnant 33-year-old female who was brought to the emergency department (ED) complaining of acute right iliac fossa pain accompanied by diarrhea and vomiting. Initial management showed no improvement. Lab results, clinical history, and physical exam were suggestive of appendicitis, so an exploratory minimally invasive laparoscopic exam was performed. The histopathological analysis of the excised appendix confirmed the diagnosis of acute appendicitis and periappendicitis. Incidentally, a 0.6 cm neuroendocrine tumor (carcinoid tumor) was identified on the wall of the appendiceal tip. The tumor extended at multiple points into the subserosal fat, and the serous surface and the resection margin were negative for the tumor. After seven days of the initial procedure, the patient presented with abdominal pain and a fever. An abdominal ultrasound was performed, revealing the presence of free fluid. A second exploratory laparoscopy revealed adhesions between the fallopian tubes and cecum, as well as a collection of purulent fluid. The management consisted of adhesiolysis, cavity lavage, and drainage, along with antibiotic therapy, pain management, and close monitoring of the mother's and fetus's status. The patient had a successful recovery and was discharged home a week after surgery. She gave birth to a full-term, healthy baby and remains free of tumor relapse. This case highlights the importance of obtaining histopathological interpretation of any extracted tissue during surgery. Guidelines regarding the management of carcinoids during pregnancy are not available, and when considering surgical intervention, an open or laparoscopic approach must be carefully evaluated. Neuroendocrine tumors comprise a range of neoplasms with varying spectra of origin, biological activity, clinical features, and histological appearance. These neoplasms commonly arise from the digestive and pancreatic systems, causing recurrent abdominal pain . HoweverThe rate of neuroendocrine neoplasms (NEN) in the United States is 6.98 per 100,000 people. In Australia, the documented rate in 2006 was 3.3 per 100,000. Norwegian registries reported a rate of 21.3 per 100,000 in 2010, while Taiwanese registries recorded a rate of 1.51 per 100,000 in 2008 . AppendiThe earliest malignant tumor of the appendix was described in 1882, and the first reports about appendiceal tumors and pregnancy are dated from 1965 [A 33-year-old female at 19 weeks of gestation, with a prior surgical history of cholecystectomy 11 weeks before, was brought to the emergency department (ED) complaining of acute right iliac fossa pain accompanied by diarrhea and vomiting. An urgent pelvic ultrasound revealed a gravid uterus adequate for gestational age, with no pathological findings in the abdomen or pelvis. Initial management with IV fluids, ceftriaxone 1 gram twice a day, and clindamycin 300 mg every 8 hours for three days showed no improvement. Magnetic resonance imaging (MRI) was not available at the time, but lab results, clinical history, and a physical exam were suggestive of appendicitis, so an exploratory minimally invasive laparoscopic exam was performed. During the procedure, abundant purulent fluid was found in the pelvic region and right paracolic side, as well as an inflamed, distended appendix with abundant fibrin but without perforation. Therefore, an appendectomy and cavity drainage were performed.The histopathological analysis of the excised appendix, as shown in Figure Incidentally, a neuroendocrine tumor (carcinoid tumor) was identified on the wall of the appendiceal tip. Maximum diameter of 0.6 cm Figure . Tumor nThe patient was discharged on post-operative day two without complications, and no drain was placed. After seven days of the initial procedure, the patient showed presenting abdominal pain and fever. An abdominal ultrasound was performed, which revealed the presence of free fluid. However, percutaneous drainage was not possible due to the position of the bowels. A second exploratory laparoscopy revealed adhesions between the fallopian tubes and cecum and a collection of purulent fluid. The management consisted of adhesiolysis, cavity lavage, and drainage. In addition, the patient received antibiotic therapy, including clindamycin 450 mg three times a day for seven days and cefuroxime 250 mg every 12 hours for 10 days. Pain management measures were implemented, and close monitoring of the mother and fetus's status was maintained. The patient had a successful recovery and was discharged home one week after surgery.Weekly follow-up was conducted for a period of four weeks, during which no further complications related to her pregnancy were observed. She gave birth to a full-term healthy baby. Additional follow-up visits were scheduled for the first and second years after surgery, and during these visits, no symptoms or signs were reported. Furthermore, there were no alterations observed in subsequent tumoral and inflammatory markers.Appendiceal neuroendocrine tumors (NETs) can be categorized into two main types: typical carcinoids and goblet cell carcinoids. These types of tumors make up only approximately 5% of neuroendocrine tumors found in the gastrointestinal tract. According to the pathology description in this case, a rare, typical carcinoid was diagnosed in this patient . HoweverLaparoscopic appendectomy is a common procedure in the surgical realm that can be performed during all trimesters of pregnancy. The advantages of this approach help avoid high complication rates and result in shorter hospital stays compared to an open appendectomy . HoweverWell-differentiated neuroendocrine tumors are relatively rare, but their incidence has increased over time in the United States and globally . The annThere are no reported studies that establish an association between acute appendicitis and incidental carcinoid tumors. Carcinoid tumors in the appendix are typically submucosal and tend to obstruct the distal third of the appendix. They are often asymptomatic, which makes early diagnosis challenging . AppendiAppendiceal carcinoids have a slow growth rate, and the overall prognosis is excellent . Tumor sThe prognosis and treatment of appendiceal carcinoid tumors are influenced by various factors, including tumor size and location ,13. AccoA large cohort study reported that patients with local disease (without metastasis) have a five-year survival rate of 92%. In comparison, those with regional metastases (spread to nearby lymph nodes or tissues) have a five-year survival rate of 81%. The minority of patients with distant metastases (spread to distant organs) have a significantly lower five-year survival rate of 31% . These fOur case highlights the importance of closely monitoring histopathological findings after an emergent appendectomy. Follow-up for neuroendocrine tumors typically involves regular serum marker tests and imaging. These assessments are usually performed three months after the surgery, followed by subsequent evaluations every six months for 1 to 3 years. If necessary, annual blood tests and imaging studies can be conducted thereafter . Our patAppendiceal neuroendocrine neoplasms are uncommon and typically exhibit less aggressive behavior compared to other gastrointestinal tumors. In this case, we present the incidental discovery of a biologically inactive neuroendocrine tumor during routine histopathological examination following an appendectomy in a young female at 19 weeks of gestation. The literature reports that abdominal pain and the presence of an abdominal mass are the most frequent presentations for diagnosing this type of tumor. However, inflammatory signs observed during surgical evaluation and pathological analysis assured us that appendicitis was the primary cause of this patient's presentation, and the concomitant low-sized carcinoid tumor of the appendix was merely present incidentally in this pregnant woman. We believe that pregnancy is not related to the appearance or growth of this tumor; therefore, we were able to diagnose it incidentally in the patient. This highlights the significance of a thorough histopathological analysis in identifying unexpected diseases and facilitating prompt investigation and management. A multidisciplinary approach is crucial in cases like this to ensure the patient's good prognosis.


Taenia solium, hence requiring prompt, aggressive intervention to alleviate the increased intracranial pressure to prevent imminent lethal complications. Ventricular neurocysticercosis can involve any brain ventricle but with a paramount preference for the fourth ventricle, causing non-communicating hydrocephalus and symmetric ventriculomegaly. However, in this clinical report, we present an uncommon case of trapped (locked-in) lateral ventricle caused by an isolated cysticercus trapped at the ipsilateral foramen of Monro, which is an atypical location for neurocysticercosis, adding more challenges to diagnosis and during the process of surgical extraction. We additionally provide a comprehensive, evidence-based review of the clinical course and management options relevant to the entity of ventricular neurocysticercosis, besides recent relevant clinical updates.Human neurocysticercosis is one of the most prevalent parasitic infestations of the central nervous system. It is considered the most frequent underlying etiology of acquired epilepsy in endemic areas in Central and South America, East Europe, Africa, and Asia, with over 50 million people affected globally. Ventricular involvement is a severe form of neurocysticercosis commonly manifests as arachnoiditis, raised intracranial pressure, or hydrocephalus, secondary to CSF flow obstruction of the ventricular system by cysts of  •Neurocysticercosis (NCC) is the most prevalent CNS parasitic infestation globally.•Ventricular NCC (vNCC) typically presents as hydrocephalus.•An isolated (locked-in) ventricle is an uncommon presentation of vNCC.•3D CISS MR imaging is the most sensitive and specific modality in detecting vNCC.•Endoscope-assisted extraction is now the most widely preferred method for vNCC. Taenia solium tapeworm (cestode), which develops after ingesting eggs from the feces of a tapeworm carrier  or eating meat from an infected intermediate host As the name suggests, cysticercosis is a parasitic infestation caused by the larval stage of A 42-year-old man presented to the emergency department after waking up with a severe generalized headache and profuse vomiting. He reported a 2-week history of progressive headaches and blurry vision, partially controlled with OTC analgesics. On neurologic examination, he had preserved motor, sensory, and autonomic functions with unremarkable neurologic reflexes throughout. However, his clinical manifestations were suggestive of increased intracranial pressure (ICP); therefore, it was prudent to proceed with head imaging before any laboratory investigations or further clinical examinations. A CT scan of the head demonstrated an expanded lateral ventricle on the right side without any significant mass effect, consistent with an isolated, right-sided non-communicating hydrocephalus. However, no identifiable cause was evident. Therefore, we scheduled the patient for urgent MR imaging, which revealed a well-delineated, thin-walled, non-enhancing cystic lesion with an eccentric mural nodule in the right-sided lateral ventricle, causing outflow obstruction through the ipsilateral interventricular foramen of Monro . AnalysiGiven the data obtained thus far, we made a preliminary diagnosis of neurocysticercosis-induced hydrocephalus. The patient was then taken to the OR, where an endoscopic transventricular approach was performed to extract the cystic lesion. Concurrently, an external ventricular drain (EVD) was placed on the ipsilateral side, which instantly alleviated the high ICP manifestations. The cyst was subsequently transferred to the histopathology department. Upon opening the cyst by cutting its membrane, an elongated whitish structure, in continuity with a certain point on the inner surface of the membrane, was observed, consistent with the scolex  of the tapeworm. Histopathological studies on the excised cysticercus demonstrated a nonviable, almost necrotic, vacuolated scolex with a still-viable cystic membrane . Based oT. solium after ingesting raw or undercooked meat-containing cysticerci from infected pigs, which act as intermediate hosts. However, humans might act as intermediate hosts if the infection has occurred through the ingestion of eggs rather than cysticerci via a fecal-oral route. Within the intermediate host, the egg hatches and transforms into an oncosphere, which is the larval form of T. solium , given its most dependent location, followed by the third ventricle (∼27%). The lateral ventricle and Sylvian aqueduct accounted for only 11% and 9%, respectively Ventricular involvement accounts for approximately 20% of all intracranial neurocysticercosis. Oncospheres, by the general circulation, reach the ventricles via the choroid plexus, where they transform into cysticerci. Apuzzo et al. reported that a combination of elevated lactate, choline, alanine, and succinate levels, on top of suppressed creatine and NAA levels to be characteristic of parenchymal lesions Brain imaging plays a pivotal role in neurocysticercosis diagnosis. Due to the readily availability of CT scans in most healthcare centers, it is widely used as the initial diagnostic modality. CT scans have shown higher sensitivity and specificity for parenchymal neurocysticercosis, compared to ventricular lesions, which are hard to visualize via brain CT because they appear as thin-walled lesions, exhibiting isodense signal changes similar to the CSF T. solium-related antigens in serum and CSF. However, available data demonstrate that standard enzyme-linked immunosorbent assays are neither sensitive nor specific for neurocysticercosis diagnosis et al., the authors demonstrated that the presence of a 15 kDa reactive band on EITB is highly sensitive and specific for the diagnosis of neurocysticercosis, although the presence of a 35 kDa band might be associated with infection by multiple cysticercus lesions Several serological tests are currently available to diagnose neurocysticercosis by detecting antibodies to et al., the authors reported that albendazole at 30 mg/kg/day plus dexamethasone for eight days was both safe and effective in the clearance of intraventricular and subarachnoid cysts Neurocysticercosis can be treated medically with cysticidal agents and corticosteroids or surgically to remove the cyst(s). Praziquantel and albendazole are the commonly used cysticidal drugs that have demonstrated high efficacy against all forms of neurocysticercosis. However, they should be preceded by steroid administration, especially in patients with the ventricular and subarachnoid subtypes, to reduce the resultant inflammation from the parasitic degradation and the subsequent risk of shunt obstruction Neurocysticercosis generally possesses a favorable general prognosis after initiating treatment. However, parenchymal involvement might lead to epilepsy and recurrent seizures, while subarachnoid and ventricular subtypes might lead to permanent hydrocephalus, intracranial nerve entrapment leading to cranial nerves palsy, or cerebrovascular complications such as ischemic infarction, transient ischemic attacks, and brain hemorrhages •Neurocysticercosis is the most prevalent parasitic infestation of the CNS, with approximately 50 million people affected globally.•It develops after ingesting eggs from the feces of a tapeworm carrier  or eating meat from an infected intermediate host.•Seizures are the most commonly observed complication in cases with brain parenchymal involvement.•Hydrocephalus, symmetric ventriculomegaly, and increased ICP are the most common presentation of ventricular neurocysticercosis, while an isolated ventricle is uncommon.•The 3D constructive interference in steady-state MR imaging modality is more sensitive and specific than routine MRI sequences in detecting intraventricular cysticerci.•FLAIR MR imaging modality, preceded by a five-minute 100% oxygen inhalation, provides a feasible, inexpensive method for detecting cisternal and subarachnoid cysticerci; however, further modifications are still required to enable the visualization of the intraventricular cysts.•EITB is considered the current serological test of choice for neurocysticercosis.•A VP shunt is warranted in ventricular neurocysticercosis if associated with increased ICP or if ependymitis is suspected.•Transventricular endoscopic extraction is now the most widely preferred method for ventricular neurocysticercosis.•Cerebrovascular complications of neurocysticercosis are more common than expected and typically associated with the subarachnoid and cisternal subtypes.The ethics committee at Al-Azhar University hospitals officially approved all the performed procedures and the followed guidelines under the reference number of HSZ-22–001446.M.M. was responsible for the conception of the work, data collection, drafting the article, critical revisions, and obtaining approval of the final version of the manuscript. M.T. and Z.A. contributed by drafting the article, and critical revisions. All authors were involved in direct patient care.The patient provided a written consent to publish the case and related data.None declared.None.


Bladder rupture is a rare condition often seen in trauma patients that is associated with a high mortality.Bladder rupture, urological emergencies, spontaneous bladder rupture. Rupture of the bladder is a rare condition due to the protected location of the bladder within the bony pelvis.2Bladder rupture is associated with a mortality of 22%.The patient is a 40-year-old female with a history of cervical cancer who underwent chemotherapy, radiation, and brachytherapy 8 years prior. Patient was now in remission presenting to the ED with abdominal pain, dysuria, urgency, and the need to strain to void or have a bowel movement. She had previously been seen by urology two months before in the ED with the complaint of gross hematuria with clots. At this prior visit she was found to be in clot retention, had a 24 French 3-way hematuria catheter placed, and admitted to the hospital, where she underwent manual bladder irrigation with large amounts of clots irrigated as well as continuous bladder irrigation (CBI). After her urine was cleared of clots, she was discharged with a Foley catheter and an appointment to see urology for cystoscopy. Unfortunately, she was lost to follow up by urology, and it is unknown when the Foley was removed. At the present ED visit, she was tender on abdominal exam with gross hematuria following Foley placement. Urinalysis was grossly bloody with no leukocyte esterase, nitrites or white blood cells. The patient’s basic metabolic panel, including creatinine, was normal. A CT of the abdomen and pelvis was concerning for nonspecific stranding around the urinary bladder, which radiology stated may be related to her prior cancer treatment versus bladder rupture. A CT cystography revealed an intraperitoneal bladder rupture at the bladder dome.On regular CT scan imaging, the urinary bladder is partially distended with contrast with no focal wall thickening or intraluminal hematoma. There is an intraperitoneal bladder rupture with site of rupture likely at the dome of the bladder. The bladder is outlined in red, and the bladder rupture boundaries are outlined in yellow, showing the urine as free fluid escaping into the intraperitoneal space. We also provide these findings in an axial CT in video format. On CT cystography, there is a significant amount of contrast-enhanced urine noted within the visualized peritoneal spaces. The small amount of air present anteriorly is related to the catheterization because a Foley balloon is present within the bladder. These findings are annotated with the peritoneal spaces outlined in yellow, the air in the blue outline, and the bladder in the red outline. All of these CT cystography findings are also presented in an axial view in video format.With the imaging-confirmed diagnosis of intraperitoneal bladder rupture, urology was consulted, and the patient underwent exploratory laparotomy, and the rupture was repaired. Postoperatively, her course was uneventful. At discharge, she was tolerating a regular diet, ambulating, her pain was controlled on oral medications, and she remained afebrile with normal vital signs. Her Jackson Pratt creatinine value was 0.4 on post-operative day three, and the drain was removed. This value is obtained from testing the creatinine of the fluid from the surgical drain, signifying the absence of surgical site urine leakage. She was discharged home with a Foley catheter for three weeks. Follow up was arranged for her in the urology clinic for a CT cystogram and a voiding trial to assess her post-operative bladder function.Bladder rupture is relatively rare and occurs most often in cases of blunt trauma, and even then only about 1.6% of patients with blunt abdominal trauma will have a bladder rupture.5Patients with a ruptured bladder can present in a variety of ways, with gross hematuria seen in 67–95% of cases.6Spontaneous bladder rupture can be the result of a large variety of etiologies; however, the literature consists mainly of case reports. In past literature, spontaneous rupture has been attributed to bladder wall pathology (42%) and retention (35%).9Extraperitoneal bladder rupture is usually managed conservatively, with Foley catheter drainage and surgery if the injury is not healed in four weeks.3The patient in this case presented with difficulty voiding, gross hematuria, and a urological history. A speedy and accurate diagnosis of bladder rupture as a result of CT imaging in the ED, with an immediate, successful surgical repair, prevented the fatal complications that are associated with bladder rupture. The etiology of her condition was likely multifocal, possibly due to her recent urological procedures including continuous bladder irrigation, and her prior radiation and brachytherapy for cervical cancer. Bladder rupture, though rare, should be a part of the differential diagnosis even when there is no reported trauma.


A 9-year-old neutered female domestic shorthair cat was presented for investigation of a cranial mediastinal mass. Moderate peripheral eosinophilia and mild-to-moderate polyclonal gammopathy were identified. A thoracoabdominal CT scan documented a cranial mediastinal mass encircling the trachea. Ultrasound-guided fine-needle aspiration and core-needle biopsy were performed, but cytology and histopathology were inconclusive. Surgical debulking was performed. Further histological samples identified severe pyogranulomatous and eosinophilic fibrosing mediastinitis, consistent with feline eosinophilic sclerosing fibroplasia. Gram staining and fluorescence in situ hybridisation (FISH) identified numerous Gram-positive coccoid bacteria. Eosinophilia and hyperglobulinaemia resolved after surgery and combined antimicrobial and immunosuppressive therapy. The cat died 3 months later after developing acute haemorrhagic diarrhoea and dyspnoea.Eosinophilic sclerosing fibroplasia is reportedly mainly confined to the gastrointestinal tract in cats. Less commonly, extragastrointestinal cases have been described. Lesions in the mediastinal or sternal lymph nodes have been reported, all in association with evident gastrointestinal involvement. The presence of pleural effusion was variable in these cases. To the authors’ knowledge, this is the first report of eosinophilic sclerosing fibroplasia presenting due to lower respiratory signs in a cat. Intralesional bacteria were identified using Gram staining and FISH examination. The presence of intralesional bacteria in the normally sterile mediastinal tissue may support the involvement of penetrating injuries in the pathogenesis of the disease. Eosinophilic sclerosing fibroplasia should be suspected in any cat with abdominal and/or thoracic masses, particularly if associated with peripheral eosinophilia and polyclonal gammopathy. The pathogenesis is unknown, but antigenic stimulation triggering abnormal inflammation in genetically predisposed cats is suspected. Infectious agents (mainly bacteria) are commonly, but not always, identified in these lesions.15 Infection may be the inciting cause of dysregulated inflammation. However, due to the GIT location, mucosal alteration in a non-sterile environment may alternatively promote secondary infection. Treatment includes surgical resection, and immunosuppressive and antimicrobial therapies with variable prognoses.5Feline eosinophilic sclerosing fibroplasia (FESF) is an emerging clinical entity,To the authors’ knowledge, this is the first case of FESF presenting due to lower respiratory signs caused by a mediastinal mass. Intralesional bacteria were documented in this case, supporting that primary infection could be the driver for a dysregulated immune-mediated response in the pathogenesis of FESF.A 9-year-old neutered female domestic shorthair cat was referred for investigation of a cranial mediastinal mass identified on thoracic radiographs after a 5-week history of cough and a 3-day history of acute-onset dyspnoea characterised by expiratory effort, tachypnoea and open-mouth breathing. Rapid immunoassays for the detection of feline immunodeficiency virus (FIV) antibody and feline leukaemia virus (FeLV) antigen were negative. Non-steroidal anti-inflammatory and antimicrobial therapies were administered, resulting in the resolution of clinical signs. Repeat thoracic radiography demonstrated persistence of the mass 1 week later, prompting referral.9/l, reference interval [RI] 0–1.5 × 109) and hyperglobulinaemia  confirmed as polyclonal by serum protein electrophoresis. The remaining parameters were within their respective RIs. Toxoplasma serology was not consistent with active infection .On presentation, the physical examination was unremarkable. Full haematology and biochemistry  identified eosinophilia  surrounding the cranial thoracic trachea . The thoGiven that an underlying neoplastic process could not be ruled out, further invasive investigation was recommended. The mass was surgically debulked after exploratory sternotomy. As the mass was adherent to the trachea, complete removal was not performed. Impression cytology of the mass identified mixed neutrophilic and eosinophilic inflammation, and extracellular particles resembling cocci in size and shape.Histopathology identified dense streams of collagenous tissue multifocally disrupted by numerous eosinophils, lymphocytes, plasma cells, neutrophils, macro-phages and multinucleated cells, and associated numerous proliferating blood vessels with necrotic areas . These fZiehl–Neelsen stain was negative for acid-fast organisms. Periodic acid Schiff stain did not highlight fungal agents. Toluidine blue stain highlighted only a few scattered mast cells. Gram staining  and FISH Three weeks later, the eosinophilia and hyperglobulinaemia had resolved . Antimicrobial therapy was discontinued 2 weeks later, and a repeat thoracic CT scan 2 months later was recommended.The cat was treated with broad-spectrum antimicrobials  given the bacterial infection. Immunosuppressive prednisolone therapy (2 mg/kg PO q24h) was administered after the diagnosis of FESF as a benefit of steroid therapy over surgery and antimicrobial therapy alone has been demonstrated.The cat developed severe haemorrhagic diarrhoea after a further 4 weeks. Thoracic radiographs at the referring veterinarian identified mild pleural effusion and a localised alveolar pattern in the caudo-dorsal lung lobes, without evidence of a cranial mediastinal mass. The cat died shortly after presentation to the referring veterinarian. Further investigations (including post-mortem examination) were not performed.This case report describes a cat presenting with a cranial mediastinal mass that had histopathological features consistent with FEFS, without obvious evidence of GIT involvement. FEFS presenting with lower respiratory signs has not yet been reported.10 Another cat had involvement of the pancreas and liver, although with concurrent GIT (pyloric) involvement. One further cat presented with a nasal mass. Two additional reports described an intrathoracic location with mediastinal lymphadenopathy either with or without pleural effusion. Evident GIT involvement was concurrently demonstrated in these cases, and the intrathoracic involvement was suspected to have occurred through dissemination via the sternal lymph node.7 In the case reported herein, an abdominal ultrasound was not performed. Given the initial lack of gastrointestinal signs reported, the unremarkable abdominal palpation and normal abdominal CT scan, it is unlikely that a GIT mass was missed. However, it cannot be ruled out that a microscopic lesion was missed. Before the cat’s death, it developed gastrointestinal signs. A post-mortem examination was not performed. Therefore, it cannot be fully ruled out that a GIT lesion was undetected.Extragastrointestinal cases of FESF have been reported, albeit rarely. Two such cases have been reported with intra-abdominal lesions that were confined to the mesentery or retroperitoneal space, respectively.In contrast to previous reports of intrathoracic FESF, the mass did not appear to arise from a thoracic lymph node, based on location upon CT examination and given that histologic features did not suggest that the mass was within a lymph node. However, as the mass was incompletely excised, this possibility cannot be definitively ruled out.5The cat displayed peripheral eosinophilia and hyperglobulinaemia, two of the common clinicopathological features of FESF, documented in 25–58% and 50–64% of reported cases, respectively.13 Rarely, other intralesional infectious agents (nematode and fungi) are also reported.14 The role of infectious agents in the pathogenesis of FESF is unclear. It has been suggested that they represent a primary, inciting trigger for an exaggerated inflammatory response, or alternatively could merely reflect secondary opportunistic infection in a non-sterile environment with abnormal tissue architecture and possible breach in mucosal integrity.2 The former possibility is supported by a report documenting bacterial-induced subcutaneous and mesenteric masses with histopathologic features resembling FESF. The latter is supported by the fact that intralesional bacteria are not always identified. However, cats are often presented for referral after having received antimicrobial therapy. In addition, a combination of culture, special stains  and FISH examination is not always performed, and bacterial involvement therefore cannot always be fully ruled out.11 As illustrated in this case and others, failure to identify infectious agents on standard histopathology does not rule out their presence, and additional testing such as bacterial and fungal cultures, Gram stain or FISH may be required. In the case presented here, samples for culture were unfortunately not obtained as the initial main suspicion was neoplasia rather than infection.Intralesional bacteria were identified in this case, similar to other reports. Alternatively, mechanical/traumatic injury rather than infection may also be the initial driver of the dysregulated immune response in the pathogenesis of FESF.The primary lesion was located in the cranial mediastinum, normally a sterile environment. This may suggest that bacteria were directly involved in the pathogenesis of the disease rather than representing an opportunistic infection. We can speculate that the bacterial infection may have occurred through a penetrating wound. Although no foreign body was identified in the case, given the peritracheal location of the mass, it is possible that infection occurred secondary to a previous tracheal injury. Prior oesophageal penetration could also be considered, although the CT examination documented a normal oesophagus. Penetrating wounds from migrating foreign bodies have been suspected to be the initial insult facilitating infection in FESF, and it is suspected that in the GIT, pyloric and ileocolic localisation of the lesion is more common because these areas are more likely to be injured by the transit of sharp foreign bodies. This is supported by the fact that prolonged survival has been identified in cats with FESF treated with immunosuppressive and antimicrobial therapies as opposed to antimicrobial therapy alone. The exuberant collagen deposition and fibrosis are likely mediated by the eosinophils and are suspected to involve dysregulation of expression of extracellular matrix protein and transforming growth factor-β1.Regardless of the presence of a suspected underlying antigenic trigger, similar to other eosinophilic inflammatory processes, an exaggerated immune response is suspected to be involved in the pathogenesis of the disease.11 More recent publications suggest a more prolonged survival (>1 year). This is likely because of an earlier diagnosis as a result of increased awareness, as well as improved understanding of the pathogenesis of the condition resulting in more appropriate management.13 A multimodal approach is currently recommended with a combination of debulking surgery, when possible, together with antimicrobial and immunosuppressive therapy (prednisolone with or without ciclosporine).14 Despite adopting this multimodal approach, in the case reported here, death occurred only 2 months after diagnosis. The cause remained undetermined. Antimicrobial therapy had been discontinued 2 weeks before death. Given the incomplete surgical resection and the previously demonstrated presence of bacteria, it is possible that residual infection remained, and that discontinuation of antimicrobial therapy resulted in sepsis. Immuno-suppressants may have also facilitated another opportunistic infection. Therefore, it may be prudent to consider repeat imaging in such cases before discontinuation of antimicrobials. Alternatively, given the reported gastrointestinal signs immediately before death, it is also possible that FESF developed in the GIT despite immunosuppression.The reported prognosis in FESF is highly variable, and likely depends on the clinical presentation. Cases presenting with locally aggressive unresectable masses have a poor reported outcome.This is the first case report of intrathoracic FESF presenting with lower respiratory signs due to a cranial mediastinal mass associated with intralesional bacteria. An infectious aetiology should be investigated through specific testing. FESF should be suspected in any cat with abdominal and/or thoracic masses, particularly if associated with peripheral eosinophilia and polyclonal gammopathy. Follow-up imaging should be considered before the discontinuation of antimicrobial therapy. The presence of intralesional bacteria in a normally sterile environment may support the involvement of penetrating injuries in the pathogenesis of the disease.


Oral lichen planus (OLP) is a chronic auto-immune disease associated with cell-mediated immunologic dysfunction whose etiology remains unknown. Malignant transformation into squamous cell carcinoma (SCC) is the most feared complication of OLP. It is actually recognized as a potentially malignant disorder with an unspecified risk of transformation, and it is suggested to closely monitor diagnosed patients.In this paper, we discuss the case of a 62-year-old female patient, a non-smoker, and non-drinker, who initially presented with painful erosive lesions on the edentulous mandibular ridge, the buccal mucosa, and the floor of the mouth. Clinical and histological findings led to the diagnosis of OLP with no signs of oral epithelial dysplasia. Malignant transformation into SCC was reported eight months after the first presentation. Oral lichen planus (OLP) is a chronic inflammatory disorder of unknown etiology with characteristic relapses and remissions, displaying white reticular lesions accompanied or not by atrophic, erosive, ulcerative, and/or plaque-type areas. Lesions are frequently bilaterally symmetrical . MalignaA 62-year-old female patient presented to our department with multiple oral ulcerations and persistent burning sensations that had developed four weeks before the first consultation. The patient reported that her symptoms did not respond to local antiseptic treatments prescribed by her general practitioner. The patient was a non-smoker and did not consume alcohol. She was diagnosed with rheumatoid arthritis four years prior and was, at the time of the consultation, on hydroxychloroquine (Plaquenil®).A physical examination revealed a healthy-appearing and responsive woman. No facial asymmetry or lymph node enlargement were noted. Intraoral examination revealed bilateral erosive lesions on the edentulous mandibular ridge, the buccal mucosa, and the floor of the mouth. The lesions presented as an inflammatory base with scalloped borders, covered with multiple ulcerations partially coated with pseudomembrane. The lesions were extremely sensitive to the touch, and no induration was noted on palpation. The maxillary arch was edentulous and did not present any lesions Figure .Complete blood count (CBC), erythrocyte sedimentation rate (ESR), hepatitis B and C, and human immunodeficiency virus (HIV) serology testing did not reveal any particularities. A first biopsy was performed under local anesthesia, indicating the presence of epithelial hyperkeratosis and a dense band of lymphocytic infiltrate in the superficial lamina. The basal layer showed liquefaction degeneration. These findings concluded with an erosive oral lichen planus with no signs of epithelial dysplasia Figure . The patEight months later, the patient presented with extreme burning sensations. Oral examination revealed yellowish necrotic ulcerations with ill-delineated and slightly elevated borders. No induration was noted Figure . A seconThe chest X-ray showed no particularities. A cervicofacial CT scan revealed the presence of two irregular nodular thickenings of the mandibular gingiva infiltrating the underlying tissues and two small bilateral jugulo-carotid lymphadenopathies. No bone lysis was noted.The oncologist’s conclusion was that stage T1N1M0 was infiltrating SCC. The treatment consisted of a conservative mucosal and bone curettage, associated with radical neck dissection, under general anesthesia. Surgical margins and sampled lymph nodes were negative for SCC.The first evidence of malignant OLP transformation was published in 1910 by Hallopeau et al. . Since tIn recent studies, the malignant transformation rate of OLP ranged from zero to 3.5%. The average time from diagnosis of OLP to malignant transformation ranged from six to 156 months . In our In most reports, the rate of erosive and atrophic types was higher than in other forms, which is in accordance with our case . AghbariThe mechanism by which OLP transforms into SCC is not entirely understood. The latest findings speculate that OLP has a tumor-like microenvironment that contributes to its malignant transformation. Cellular signals and mediators of inflammation (such as interleukin 4 (IL4) and IL-6), implicated in chronic inflammation, play critical roles in increasing the sensitivity of oral keratinocytes to exogenous mutagens .Surgical resection is the common treatment for SCC. The clinical stage at presentation is an important predictor of survival. Significant histopathologic predictors of outcome include the depth of invasion of the primary tumor, positive margins of surgical resection, perineural invasion, and major extracapsular nodal extension . In our It is evident that OLP does carry a non-negligible risk of malignant transformation. Patient education and thorough clinical follow-ups are keys to early diagnosis. Dentists and oral surgeons should not hesitate to carry out a biopsy every time a structural change is noted.


Spontaneous bladder rupture is a rare cause of the acute abdomen. Alcohol has been described as one of the most common causes of spontaneous bladder rupture. We present the case of a 42-year-old male who presented to our Level I Trauma Center complaining of abdominal pain and difficulty urinating after an evening of drinking. Initial workup revealed free air and fluid within the abdomen and a Foley catheter within the peritoneal cavity. He was taken to the operating room emergently for exploration and was found to have a bladder rupture that was repaired. Post-operatively he recovered without complication. The often missed or delayed diagnosis of spontaneous bladder ruptures can increase morbidity and mortality. It is important to keep spontaneous bladder rupture in the differential when evaluating a patient with abdominal pain. Trauma is the most common cause of bladder rupture overall. Rarely, spontaneous bladder rupture can occur. Patients who present with spontaneous bladder rupture often provide a limited history and vague complaints of abdominal pain and urinary retention. Alcohol has been reported as one of the most common factors related to spontaneous bladder rupture. Here we present a rare case of a patient found to have a spontaneous bladder rupture after an evening of heavy drinking.Here we present a unique case of a 42-year-old male who presented to the Emergency Department (ED) of our Level I Trauma Center complaining of abdominal pain and inability to urinate. His pain began the evening prior after a period of heavy drinking. He says he went to sleep but woke up with pain. He attempted to urinate and noticed blood in his urine. He denied any history of trauma. He presented to the ED for evaluation.The patient has a past medical history of hypertension and a surgical history of a left Achilles tendon repair. Specifically, he denied any history of previous bladder trauma, instrumentation, diverticular or masses. He denied any previous hematuria. He is a nonsmoker, drinks daily, and denies drug use. He denied a family history of diabetes or cancer.The patient’s chief complaint upon presentation to the ED was urinary retention. A Foley was placed and two liters of blood-tinged urine returned. Initial laboratory results are presented in Table Intraoperatively, the patient underwent an exploratory laparotomy where a large, 10 cm, defect was found at the dome of the bladder. The bladder injury was repaired in layers using a chromic suture. Postoperatively he recovered and a Foley was kept in place on discharge. He followed up in the clinic two weeks post-trauma and the Foley catheter was removed after a normal cystogram. He recovered well post-discharge and has not required readmission.Spontaneous bladder rupture is a rare but potentially life-threatening condition that has been reported to occur in one of every 126,000 people .Overall, bladder rupture is most commonly attributed to trauma. Over 96% of cases have a traumatic origin . High-spThe pathophysiology of spontaneous bladder rupture includes the combination of bladder overdistention along bladder wall thinning . Causes As reported by Zhang et al., alcohol is considered the most common predisposing factor for spontaneous bladder ruptures . Heavy aBladder ruptures come in two general categories - extraperitoneal or intraperitoneal . About 6The varied causes and presentations often lead to delayed or misdiagnoses in patients with spontaneous bladder ruptures. Common differential diagnoses include acute abdomen, inflammatory bowel disease, bladder tumors or inflammation, and renal failure . Signs oMost cases are diagnosed at the time of surgery for a presumed acute abdomen. Laboratory tests may look similar to those of renal failure with elevated serum creatinine, urine nitrogen, and potassium levels . RetrogrAn early and accurate diagnosis followed by prompt surgical intervention is the key to a good outcome . SurgicaIn our case presented above, this 42 year-old-male presented with abdominal pain and difficulty urinating after a night of heavy drinking. He was taken to the operating room for an acute abdomen where an isolated bladder injury was found and repaired. The patient denied any previous trauma. His documented alcohol use makes the history unreliable.We present a rare case of a spontaneous bladder rupture after an evening of heavy drinking. The uncommon nature, often-limited history, and vague abdominal complaints often lead to a delayed or missed diagnosis. The case we present above is that of a 42-year-old male who presented to the ED with abdominal pain, later found to be caused by a spontaneous bladder rupture. He was treated with open bladder repair and recovered without additional sequala. This case adds to the body of literature on this rare disease entity. Early diagnosis and treatment are vital to a good outcome.


Postoperative portal vein obstruction could occur as a complication of portal vein reconstruction during hepatic lobectomy or pancreaticoduodenectomy. We report a case of patient with postoperative portal vein obstruction treated with percutaneous transhepatic portal vein stenting without using iodinated contrast media owing to a history of severe allergic reactions. Under ultrasound guidance, carbon dioxide angiography, and appropriate device selection, successful stenting was achieved without serious adverse events. After the operation, portal vein blood flow and clinical symptoms improved, enabling adjuvant chemotherapy. To the best of our knowledge, this is the first case report wherein percutaneous transhepatic portal vein stenting was successfully performed in a patient with an iodine allergy. In recent years, percutaneous PV stenting has been considered as a treatment option. Iodinated contrast media is generally used during the procedure; however, its use is contraindicated in patients with a history of an allergic reaction, and alternative contrast media should be considered.Postoperative portal vein (PV) occlusion could arise from a surgical complication of PV reconstruction during hepatic lobectomy or pancreaticoduodenectomy.Herein, we report a case wherein carbon dioxide was used as a contrast media to treat a patient with long segmental obstruction of the portal venous system following total pancreatectomy who had a history of allergy to iodinated contrast media.2) was considered as an alternative to iodinated contrast media. Initially, the trans-ileocolic venous approach was attempted but was abandoned due to intra-abdominal adhesions. Thus, a percutaneous transhepatic portal venous approach was planned.A 74-year-old female underwent total pancreatectomy with partial resection of the superior mesenteric vein (SMV) for advanced pancreatic head carcinoma . A curat2 gas was performed  was punctured under ultrasound guidance, and a 4-Fr sheath introducer (11 cm in length) was inserted. After a multipurpose pre-shaped catheter  was advanced to the main PV, digital subtraction angiography using COerformed . First, erformed . Second,erformed . The 4-Fectively . On prepiography , the puniography .The ascites, diarrhoea, and oedema of the lower limbs improved, permitting resumption of adjuvant chemotherapy. No obvious changes in the liver enzyme levels were observed, while a mild increase in the albumin level was observed. Anticoagulation with aspirin and clopidogrel was administered for 6 months following the intervention. Follow-up ultrasonographic examination and MRI revealed in-stent patency to date.2 was selected because it has been shown to be safe and effective in angiography. It is widely used in patients with renal impairment or iodine allergy. However, it results in poorer quality images compared with images obtained using iodinated contrast media. Although its use has been reported in percutaneous transhepatic portography, splenoportography, and renal artery stenting, this is the first case report of PV stenting using CO2 as contrast media.In this case report, the long section (6.5 cm) PV occlusion was stented without using iodinated contrast media in a percutaneous transhepatic approach because the patient had a history of a severe allergy to iodine. CORecanalisation of a long section of portal vein obstruction is often discouraged because of the associated technical difficulties; however, PV stenting was planned because of the physician and patient’s strong preference. Initially, an open surgical insertion  was planned because it was assumed that approaching the occluded PV from upstream would be easier than the percutaneous transhepatic approach. An open surgical approach is advantageous in that contrast media can be injected from upstream to check the condition of the stenosis or obstruction. However, it was impossible to place the sheath on the ileocolic vein due to intra-abdominal adhesions in our case. Therefore, the percutaneous transhepatic PV route was considered, which is reportedly more technically difficult but less invasive.2 contrast. To overcome technical difficulties, device selection is crucial. First, a 4-Fr multipurpose pre-shaped catheter and 0.035-inch guidewire were used. However, it was still difficult to cross the occlusion due to chronic total occlusion. A stiffer guiding sheath was then used, which enabled crossing the occlusion; the device used in this procedure was a penetrating micro-system for the peripheral arteries. The ascites around the liver increased the risk of persistent bleeding following sheath removal. Hence, metallic coils were placed at the puncture site of the liver at the end of the procedure under ultrasound guidance.The procedure was performed with ultrasound guidance and COe.g., PV reconstruction), recurrent malignancy, or radiation therapy. Olcott et al first reported stenting for PV stenosis in the anastomotic site of liver transplantation in 1990. Previous studies have suggested that percutaneous transhepatic PV stenting should be considered safe with few major complications. The technical success rates for benign PV stenosis were reportedly 76–100%, with symptom improvement observed in 75–100%, 80–100%, and 78–100% of cases of hepatic decompensation, variceal bleeding, and ascites, respectively. The average duration of patency is reportedly 30–67 months. On the other hand, in occlusions associated with malignant tumours, the success rate of the procedure is reported to be 80–100%, and symptom improvement is 87–100%, 80–100%, and 88–100% for hepatic decompensation, variceal bleeding, and ascites, respectively. However, the average patency period is only 3.7–6.1 months, resulting in relatively early obstruction. Malignant PV obstruction is associated with advanced cancer and has a poor prognosis. Nevertheless, symptomatic improvement may contribute to a better prognosis if anticancer therapy can be resumed.Postoperative PV occlusion may be caused by surgical intervention ( In our case, a bare stent would be better because the stenosis was suspected to be attributed to an adhesion. Taourel et al reported that portal velocity or flow on Doppler measurement had limited utility in predicting either hepatic venous pressure gradients or severity of liver failure in an individual patient because of the scattering of the data. When portal hypertension is due to cirrhosis, even an implanted PV stent may not provide good blood flow and may soon become occluded. It is not possible to predict whether the PV pressure is elevated, and it is better to measure the pressure at the SMV upstream. Even if the pressure is elevated, stenting should be performed. Due to possible stent occlusion, bare-metal stents should be used to cover necessary and sufficient area.Considering the size of the stent, the vascular calibres were significantly different between the PV trunk and ileocolic vein: 10.1 and 5.4 mm, respectively. The appropriate size of the stent should be the same as the diameter of the non-stenotic vein or 1–2 mm larger. If the reference vessel diameters are different proximal and distal to the stenosis, it is safe to conform to the diameter of the smaller vessel. In our case, owing to the long occlusion length, a 6 mm × 10 cm stent was selected as the best available. A covered stent may be used in cases of stenosis attributed to malignancy; however, the risk of occlusion or stenosis of the portal tributaries exists. of anticoagulants administered alone or in addition to antiplatelet drugs exist, there was one report wherein anticoagulation was not used. In our case, stent flow was prompt upon ultrasound examination; thus, an anticoagulant drug was not administered. Patency was maintained for at least 1 year.Postoperative medication is crucial, considering that many patients with cancer are in a state of hypercoagulability. The efficacy of anticoagulant drugs following PV stenting is controversial. Although various case reports2 angiography, and appropriate device selection, successful stenting was achieved without serious complications, allowing the patient to resume adjuvant chemotherapy.We report a case of percutaneous transhepatic PV stenting for postoperative PV obstruction without using iodinated contrast media in a patient with iodine allergy. With ultrasound guidance, COCO2 contrast media is useful for portal stenting in patients with iodine allergy.


The emergency room management of a patient with external signs of cranial trauma and imaging showing brain hemorrhage can be dangerously misleading. This case of a patient with glioblastoma could only be timely diagnosed because of cautious evaluation of imaging findings. A 60-year-old patient presented to the emergency room after being found down with external signs of cranial trauma and a reduced level of consciousness. Computed tomography revealed a right frontal polar cortical hemorrhage of around 12 mm diameter with no perilesional edema or contrast enhancement. Likewise, the MRI showed no contrast enhancement. Before the scheduled MRI follow-up was performed the patient became symptomatic leading to an earlier repeat that showed massive progression. She underwent surgical resection that revealed the lesion to be an aggressive glioblastoma. High suspicion of an underlying neoplastic lesion in atypical brain hemorrhage in trauma patients is paramount. Short MRI follow-up is recommended as soon as the hematoma resorbs to prevent delays with potential impact or patient outcome. Glioblastoma multiforme typically presents with seizures, headache or focal neurological deficits . SymptomA 60-year-old female presented to the emergency room after being found down. Emergency medical service reported a brief generalized tonic-clonic seizure en route. Upon ER arrival, her Glasgow coma score was 9 E3+ V1+ M5) and the neurologic exam had no localization signs. Supraorbital laceration and periorbital hematoma were observed. Brain CT revealed a frontal polar cortical hemorrhage of around 12 mm diameter with no perilesional edema (Figure + M5 and The hypothesis of a cortical venous thrombosis was brought by the contrast-enhanced CT scan, hence a brain MR venography was performed. The thrombosis was not confirmed and the frontal lesion showed to be hyperintense in T2 and hypointense in T1 with mild perilesional edema, with abnormal susceptibility and no diffusion restriction or contrast enhancement (Figure Two weeks later, a CT scan showed reabsorption of the blood with persistent perilesional edema Figure . After tIntratumoral hemorrhage has an incidence of 6.5-8% in glioblastoma, much lower than in metastatic brain tumors ,3. When Some features of this case allowed a correct and timely diagnosis in spite of the bleeding as a confounding factor. The most important was the perilesional edema, evidenced in the first MRI and progressive in the ensuing imaging studies. Considering the anamnesis with possible trauma, a CT scan was certainly the indicated imaging modality at presentation, but the possible postictal status with a later short seizure in the presence of the paramedics would later require an MRI either way.The finding in the initial CT scan, when interpreted as cerebral contusion, had no sure surgical indication. However, in the case that a resection had been performed, a histopathological examination of the hematoma may have detected the glioblastoma. This reinforces the need for neuropathological examination of every specimen resected from the brain, specially hematomas, even when a hypertensive intracerebral hemorrhage in a typical location is the most probable diagnosis.The diagnosis of a brain tumor in this case was not possible at the presentation when following a reasonable decision-making process. The early MRI showing no contrast enhancement lowered the possibility of a brain tumor at that moment and the recommendation of a follow-up after resolution of the bleeding was adequate. MRI is important in the investigation of an atypical hemorrhage, but it does not always indicate its cause, as in this case. As an investigation tool, it should be primarily indicated when the cause of the bleeding is not clear.This patient suffered from a de novo IDH-wild-type glioblastoma, which is the most aggressive form of this tumor . The unfThis case highlights the challenges in diagnosing a brain tumor in the setting of suspected traumatic brain injury. Hemorrhagic transformation may mask a plethora of important differential diagnoses for intracerebral hemorrhages. The presence of progressive perilesional edema in this case raised suspicion for an underlying pathology. If contrast studies are normal, selected patients may benefit from shorter follow-up imaging after resolution of the bleeding in selected cases.


We present a case of a thoracic mass causing chest pain that was initially attributed to coronary artery disease due to his comorbidities. However, during the Lexiscan stress test, a thoracic spinal mass was incidentally found. This case showed the importance of being cognizant of other causes of chest pain and a rare presentation of multiple myeloma. Multiple myeloma (MM) is a malignant disorder involving plasma cells in which abnormal immunoglobulin is overproduced . MM is aThe patient is a 72-year-old white male with a significant past medical history of obesity, diabetes, hypothyroidism, hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease, unspecified chronic anemia, and obstructive sleep apnea who presents with chest pain. The chest pain is midline, pressure-like, four out of 10 in severity, nonradiated and aggravated with movement of the arms upwards. The patient mentions having experienced mild chest pain associated with exertional shortness of breath with just a block for more than a year; however, the chest pain has exacerbated since yesterday. Moreover, the patient denies fever, unintentional weight loss, headache, diaphoresis, nausea, vomiting, and abdominal pain. Laboratories were relevant for a white blood cell count of 7.2 k/uL, hemoglobin of 11.1 g/dl, blood urea nitrogen (BUN) of 24 mg/dl, creatinine of 1.3 mg/dl, and troponin was negative twice  Figure , which wAs a result, a thoracic magnetic resonance imaging (MRI) with and without was ordered and revealed a thoracic (T) 8-centered, restrictive, solid, destructive mass lesion that compressed the spinal cord Figure . Therefore, neurosurgery and hematology-oncology were consulted for further management. Subsequently, an MRI of the lumbar spine revealed multiple enhancements in L1 (lumbar) and S1  regions, indicative of metastasis Figure . Thus, aConsequently, a computed tomography (CT)-guided core needle biopsy of the 5.6×3.5×3.2 cm mass lesion of the T8 vertebral body Figure . So immuThis case presents an interesting case of a 72-year-old male with chest pain. Due to his significant cardiovascular risk factors, a lexiscan stress test was initially performed, but it was negative for ischemia. Nonetheless, it revealed a thoracic mass that was diagnosed as multiple myeloma, which usually presents with elevated calcium, renal failure, anemia, and bone lytic lesions . In thisThis patient is a 72-year-old male with significant cardiovascular risk factors who presented with chest pain that was initially attributed to an ischemic nature; however, after a negative ischemic work-up, non-cardiac etiologies were considered after a thoracic mass was incidentally discovered during the non-cardiac imaging part of Lexiscan. Finally, the patient was diagnosed with multiple myeloma with metastasis to the lumbar spine. This case showed the importance of being cognizant of other causes of chest pain.