Teratomas are germinal cell neoplasms containing tissues from all germinal layers ; however, they may show varying stages of maturity. We present a case of a 10-month-old Sudanese male patient who presented to the Khartoum Teaching Dental Hospital with a tumor occupying the hard palate since birth, causing reduced oral intake and failure to thrive. CT images showed soft and hard tissue masses originating from the hard palate and extending to the oral cavity. The treatment was initiated with nutritional support and consultation with pediatric physicians. The oral teratoma was successfully treated with surgery. The patient was regularly followed up and he fully recovered eventually. As defined by Weaver et al., teratoma is a tumor composed of multiple tissues and foreign to the part in which it arises . TeratomThese tumors are histologically benign ordinarily, although they result in significant morbidity and potential mortality due to their size and anatomical site, leading to airway obstruction and respiratory distress . They frA 10-month-old Sudanese male child who weighed 5 kg presented to the Oral and Maxillofacial Department at the Khartoum Teaching Dental Hospital with his parents, reporting an oral swelling in the hard palate and protruding extra-orally . A CT head with contrast Figure  showed tHistopathological results showed a benign tumor, well-differentiated tissue consisting of glial and adipose tissue, skin appendages muscle, minor salivary gland and sweat gland, and bone trabeculae with the focal area showing undifferentiated tissue (mature teratoma grade I) Figure . A pediaThe term "teratoma" comes from the Greek word "teraton" meaning monster and was initially used by Virchowin in 1863 . The hisThe WHO classification of germ cell tumors distinguishes between two separate entities: teratomas with different maturity levels and teratomas with malignant transformation . In immature teratomas, primitive neuroectodermal structures predominate. According to the grading system , mature teratomas (G0) are more frequent (54.5%) than immature teratomas . Only 7.8% of all teratomas show the highest grade of immaturity (G3). The frequency of additional microscopic foci of malignant yolk sac tumors correlates with immaturity grade [While prenatal diagnosis is possible by ultrasonography , our patThe most typical finding associated with head and neck teratomas antenatally is polyhydramnios; however, it is mainly observed with large teratomas involving the cervical and nasopharyngeal regions rather than isolated oral teratomas. A baby with suspected congenital oral teratoma should be electively delivered through cesarean section.Oral cavity teratomas are predisposed to protrude outside the mouth upon growth rather than posteriorly toward the oropharynx. Given that newborns are necessary nasal breathers, oral obstruction would gradually impact the feeding process rather than causing acute airway compromise. Concomitant anomalies could be associated with oral teratomas, like cystic hygroma, cleft lip/palate, and other multifocal teratomas . Other aThe primary treatment of teratoma is complete surgical excision, which depends on the tumor site. Unless the teratoma expands massively into the cranial area, the tumor bulk resection may be attempted. Initial treatment should be directed toward airway management and nutrition. Surgical airway and feeding should be considered early -18. In oThe prognosis for teratoma is excellent. Recurrences are rare and occur predominantly due to incomplete surgical resection . FurtherCongenital palatal teratoma is a rare entity with several morphological and histological subtypes, and it is associated with numerous congenital anomalies. However, early intervention with complete resection results in excellent outcomes and substantially low recurrence rates.


Myeloid sarcoma (MS), a tumor consisting of myeloid blasts with or without maturation, occurs at anatomical sites other than the bone marrow. MS of the gastrointestinal tract presenting with jaundice in children is rare. We report the case of a 4-year-old boy with a 6-week history of symptoms of obstructive jaundice due to a peripancreatic mass compressing the common bile duct. Six weeks later, blasts were found in a peripheral smear prior to surgical biopsy; bone marrow evaluation and flow cytometry results led to a diagnosis of acute myeloid leukemia (AML) with MS. No further invasive testing or temporary drainage was performed. He was started on induction therapy with full therapeutic doses of cytarabine, dose reductions of etoposide, and escalating doses of daunorubicin. His liver enzymes normalized, and he completed subsequent cycles of chemotherapy with full doses. The abdominal ultrasound showed resolution of the mass after the second cycle of chemotherapy. He is currently in remission three years after completing therapy. AML-directed chemotherapy in patients with obstructive jaundice secondary to MS may be beneficial without requiring invasive testing or temporary drainage procedures. Daily follow-up is crucial for chemotherapy dose modifications. Management plans should be individualized according to the patient’s clinical condition. Myeloid sarcoma (MS), a subtype of acute myeloid leukemia (AML), is defined as a tumor mass consisting of myeloid blasts, with or without maturation, occurring at an anatomical site other than the bone marrow . DusenbeA 4-year-old boy, previously healthy, presented to a peripheral hospital with a 2-week history of progressive jaundice. His initial complete blood count at the referring hospital was reported as normal with no abnormal cells seen. He was initially diagnosed clinically with Hepatitis A and treated conservatively. No virology studies were reported at the time. However, his symptoms persisted over subsequent weeks, along with the development of fever, dark urine, pale stools, and severe pruritus. Physical examination revealed no palpable masses, lymphadenopathy, or hepatosplenomegaly. An abdominal ultrasound showed a mass at the peripancreatic head region causing biliary obstruction. Abdominal computed tomography showed a well-defined retroperitoneal mass which was displacing the pancreatic head anteriorly and compressing the common bile duct with biliary dilatation A,B.9/L, hemoglobin level 93 gm/L, platelet count 426 × 109/L, and 32% blasts in the peripheral smear. His liver function tests (LFTs) revealed the following levels: total bilirubin 17.9 mg/dL (306 μmol/L), direct bilirubin 16.6 mg/dL (284 μmol/L), gamma-glutamyl transferase 209 IU/L, alanine transaminase 136 IU/L, aspartate aminotransferase 88 IU/L, and alkaline phosphatase 851 IU/L. His initial LDH was 503 mmol/L and uric acid 87 μmol/L. Virology studies showed Hepatitis A IgM antibodies were nonreactive while IgG was reactive. Bone marrow aspirate showed 46% blast infiltration, with flow cytometry results positive for MPO, CD13, CD33, and CD117 diagnostic for AML with monocytic differentiation (AML-M5) and cytogenetics positive for t  and loss of chromosome Y. NPM1 and FLT1 mutation were both negative. Cerebrospinal fluid was negative for malignant cells. The conclusion was that the peripancreatic mass was an MS causing obstructive jaundice. The patient was to receive chemotherapy treatment as per the AML Medical Research Council-15 protocol [The patient was referred to the pediatric surgeons in our cancer center to biopsy the mass with the impression of an isolated pancreatic tumor. Upon admission, 6 weeks after his symptoms started, initial investigations showed a white blood cell count 20 × 10We sought to relieve the common bile duct obstruction before starting chemotherapy. Endoscopic retrograde cholangiopancreatography (ERCP) was not available in the hospital, surgical intervention was associated with concerns of complications and delayed chemotherapy, and radiation therapy-associated complications outweighed the benefits. We, therefore, proceeded with systematic chemotherapy without a biopsy of the mass. The patient was started on induction therapy with ten days of full doses of Ara-C and five days of 50% dose reduction of etoposide. His bilirubin level gradually decreased after starting chemotherapy, reaching 4.6 mg/dL (79 μmol/L) by day 9 of treatment. He received 50% of the dose of daunorubicin on day nine and then full doses on days 10 and 11. He tolerated chemotherapy well, and his LFTs gradually improved. Bone marrow evaluation after the first cycle of chemotherapy showed that the patient was in remission with negative minimal residual disease. Sequential abdominal ultrasonography showed interval size regression of the mass C. Once tMS reportedly occurs in four situations: as a herald to AML in a non-leukemic patient, as a sign of impending blast crisis in chronic myeloid leukemia or leukemic transformation in myelodysplastic disorders, as an additional manifestation in patients with known AML, or as an isolated event . The etiMS shows no sex, age, or site predilection, and the symptoms at presentation are diverse, depending on the size and site of the mass . The diaThere is no consensus on the treatment protocol of MS due to absence of randomized controlled trials. Isolated MS progresses to AML in 90% of untreated patients after approximately 5–12 months ,17. TherReview of the literature has shown seven cases in the pediatric age group who presented with jaundice secondary to MS . TreatmeThe most common mutation and translocation described in MS are mutated NPM1 and t(8:21), respectively ,23. TherThe prognostic effect of MS in pediatric AML is controversial. Old studies published had variable outcomes due to inclusion of CNS leukemia with MS in the analysis ,27. Kim The risk factors for relapse include older age, increasing number of tumors, and treatment with local measures alone ,36. MostOur case report suggests that AML-directed chemotherapy with modifications in patients with obstructive jaundice secondary to MS may be feasible without requiring invasive testing, temporary drainage procedures, or upfront radiotherapy. Daily follow-up of LFTs is crucial for chemotherapy dose modifications. The management plan should be individualized according to the patient’s clinical condition, the presence or absence of other lesions, risk factors for infection, and any associated organ dysfunction.


The most common cause of neck infections is odontogenic abscesses that can often be life-threatening and require a surgical drain associated with antibiotic therapy. We present a case of the surgical management of an odontogenic sack-shaped and walled abscess arising from elements 3.6, 3.7 and 3.8 that reached the laterocervical spaces and anterior mediastinum in a 28-year-old healthy woman. Typical signs and symptoms of cervical complications of dental origin are fever, a neck mass, lymphadenopathy, trismus and odynophagia. The gold standard treatment in these situations is a multidisciplinary approach involving an oral surgeon, ENT specialist and thoracic surgeon to drain the infected material. To the best of our knowledge, this is the first described case report of a dental abscess enclosed in a sack in the deep space of the neck and in the anterior space of the mediastinum. Odontogenic abscesses are the most common cause of neck infections . The remThere are conflicting reports in the literature regarding drug therapy for the treatment of odontogenic abscesses. Empirically, when taking into account the multiplicity of the oral cavity microbiota , we tendOn the contrary, the literature unanimously agrees on the necessity of the surgical drainage of the infection.If it is not treated early enough, the infection could spread to nearby structures, such as soft tissues and the skin of the cervicofacial area, maxillary sinus, the superficial and deep space of the neck and even up to the mediastinum and thorax in more severe cases. These conditions can be life-threatening and require the removal of the primary source of infection through a surgical incision and the drainage of the abscess in deep neck spaces. Moreover, in the case of a reduction in the upper airway tract, a tracheostomy is required, ,4. The sHerein, we present the case of a 28-year-old woman admitted to our emergency department presenting with left submandibular swelling that had arisen five days earlier, and was associated with a fever, progressive dysphagia, trismus and dyspnea. The ENT examination revealed a painful left submandibular swelling covered with hyperemic and warm skin. The endoscopy of the upper airway tract showed swelling on the left side of the oropharynx and hypopharynx, and a mobility impairment of the left vocal fold. The head–neck computed tomography (CT) scan performed with and without a contrast agent showed a voluminous mass involving the left submandibular region, perimandibular soft tissues, masseter muscle, tonsillar region and the parapharyngeal space, resulting in the aerial column deviating to the right. The swelling caused the compression of the internal jugular vein and extended up to the anterior mediastinum, behind the sternal manubrium A,B.The CT showed that the probable origin of the abscess was an odontogenic infection coming from the inferior left molars C.The patient was transferred at the ENT ward and was given antibiotics (2.2 g IV (intravenous) amoxicillin every 8 h and 600 mg IV clindamycin every 6 h) and corticosteroid therapy (4 mg IV betamethasone every 12 h). We planned a double approach: an intraoral access—removing the teeth that probably caused the infection—and an extraoral one—performing a surgical drainage of the abscess in the neck. In detail, the oral surgeon realized a full thickness flap through a buccal and lingual incision of the oral soft tissue from element 3.4 up to element 3.8; he then performed the avulsion of elements 3.6 and 3.7, and, finally, through osteotomy, the extraction of element 3.8. Subsequently, the ENT specialist performed a left Paul-Andre neck incision to open the submandibular lodge and the laterocervical space. After the drainage of the deep space of the neck, we found a membrane containing the purulent material originating from the tooth roots of element 3.8, which stretched up from the submandibular and laterocervical region to the mediastinum, measuring 13 cm A,B.Once the membrane was removed, the thoracic surgeon performed an exploration of the anterior mediastinum, which confirmed the patient was free from further infected material. Then, a Penrose drain was positioned in the oral cavity, one Redon drain in the submandibular lodge, one in the laterocervical space and another one in the upper anterior mediastinum. At the end, the ENT surgeon performed a tracheostomy to protect the airways.Wound dressing changes were daily performed during the postoperative recovery. The tracheostomy was closed 10 days after the surgery, and the patient had a CT scan performed 15 days after the surgery A,B, whicOdontogenic abscesses often derive from dental plaque, caries and pulp necrosis, and in 90% of cases, the inferior molars are the focus of the infection .Streptococcus spp. (S. Mitis and S. Mutans) and Staphylococcus Aureus, which reach the periapical region through the root canal system [The most frequent bacteria responsible for caries and pulp necrosis are facultatively anaerobic, Gram-positive coccus, such as l system .Another common cause of an odontogenic abscess is untreated chronic periodontitis, leading to exacerbation. Putative pathogens include Gram-negative (G-) anaerobic bacteria, spirochetes and even viruses .The plausible different nature of this kind of infection justifies the use of double-drug therapy comprising a broad-spectrum antibiotic and another one more specific for anaerobic G- microorganisms.The long sack-shaped membrane we showed likely arose from an untreated odontogenic abscess. In this case, it was important to consider a differential diagnosis of a congenital cyst. However, this diagnostic hypothesis was ruled out on the basis of the CT images, which clearly highlighted the odontogenic origin of the infection.The typical signs and symptoms of cervical complications from dental origin are fever, neck mass, lymphadenopathy, trismus and odynophagia. Furthermore, systemic complications can occasionally occur, such as Lemierre’s syndrome, which is a rare and potentially life-threatening metastatic infection, typically characterized by the suppurative thrombophlebitis of the internal jugular vein and the subsequent sprawl—through the bloodstream—in the lungs and various other organs, such as the liver and brain .In the literature, there are no clear guidelines for the correct surgical management of odontogenic deep neck space infections; generally, these involve airway impairments, sepsis, descending infections, abscesses larger than 3 cm and the involvement of deep neck spaces . The maiIn these situations, surgery is a complex procedure, and generally requires an extended cervicotomy in order to drain the abscess. The mortality rate for this infection, in recent years, has decreased from approximately 50% to 18% ,15. The In this case report, we showed an unusual form of an odontogenic abscess. Due to the presence of purulent material, the principal diagnosis was an infected cyst of the neck. Unfortunately, we did not perform a histological examination because, in our humble opinion, during the surgery, it was implied that the sack-shaped formation arose from an inflammatory process of the broken inferior molar.


Fibrous hamartoma of infancy (FHI) is a rare soft tissue lesion arising as a subcutaneous mass involving the axilla, trunk, and upper arm in infants and children <2yrs. Sarcomatous transformation in FHI is described in anecdotal cases in the literature.ETV6-NTRK3 fusion to exclude other common differentials.We describe one such example arising as a mass in the lower back in a 3-month-old infant. On histology, the tumor contained classic triphasic morphology; however, brisk mitotic activity noted at multiple foci was diagnostically challenging to categorize. The tumor was evaluated for While FHI may be frequently encountered in infants, rare sarcomatous transformation are known to occur and merits special attention as it can be misdiagnosed. Also, a close follow-up is warranted as the lesion is known to recur locally. It initially measured 3x2 cm with a tuft of hair and gradually increased in size. There was no associated bowel or bladder disturbance, no paucity in lower limb movements, or any discharge history from the swelling. On examination, the mass measured 10x15 cm and was soft in consistency, non-tender, non-fluctuant. It extended from L1 to the right gluteal region. Anthropometric parameters were normal for his age. Investigations revealed normal hemogram and normal biochemical parameters, including alpha-fetoprotein levels . The magnetic resonance imaging (MRI) of the lumbosacral spine revealed large subcutaneous mass in the lumbosacral region on the left side measuring 6.5 x 3.7 x 5.6 cm along with intensely enhancing solid component and multiloculated cystic areas. In addition, a bifid spinous process of L4-L5, S1 was noted. The clinical possibilities considered included lipoma, lymphangioma, meningocele, rhabdomyosarcoma, or sacrococcygeal teratoma.The lesion was excised. No capsule could be identified peroperatively. On gross examination, the lesion contained both solid and cystic areas and measured 9x5x3 cm. On microscopy, a poorly circumscribed tumor was identified, which revealed immature mesenchymal cells arranged in long fascicles and trabeculae intercepted by fibrocollagenous tissue composed of bland fibroblasts and myofibroblasts. The tumor also showed lobules of mature adipocytic tissue A and 1B.Additionally, there was evidence of sarcomatous transformation with the presence of islands featuring increased cellularity and brisk mitotic activity ranging from (3-4/hpf) A-D.ETV6-NTRK3 fusion and was found to be negative. Such triphasic morphology favored FHI, albeit with sarcomatous transformation.The immature mesenchyme demonstrated immunopositivity for vimentin. Smooth muscle actin (SMA) highlighted the fibroblasts and myofibroblasts amidst the neoplastic component. CD99 showed diffuse strong perinuclear dot-like positivity. Cytokeratin, myogenin, melan A, desmin, and HMB45 were negative. S-100 highlighted the adipocytes. CD34 highlighted the blood vessels while was negative in all other three components A-F. The Subsequently, a metastatic workup of the child was done, which included a bone scan and CT chest, both of which were normal. The child was started on intermediate-risk rhabdomyosarcoma (RMS) protocol  in view of the sarcomatous component. Presently, the child has completed 8 weeks of chemotherapy and is disease-free at the last follow-up (two years from the diagnosis).,11,6A rare and unique tumor in infants, FHI commonly arises in axillary regions, upper arms, upper trunk, inguinal region, and external genital areas. Nearly 25% may occur congenitally.8ETV6-NTRK3 gene fusion reliably differentiates this tumor from other childhood spindle-cell tumors.14The common diagnostic differentials depend on age and the anatomic site. Fibromatosis, lipofibromatosis, rhabdomyosarcoma, teratoma, and congenital fibrosarcoma are differentials for a tumor arising at this location.In conclusion, the report illustrates the histomorphology of FHI, which rarely may demonstrate a sarcomatous morphology. Hence, a careful assessment of the lesion is required, and a close follow-up is warranted as local recurrences have been reported.


Hepatic steatosis is frequent; however, it may present with unusual patterns, resulting in a diagnostic dilemma. Herein, we present a case of fatty liver and multifocal nodular hepatic lesions that were found to be due to multifocal nodular fatty sparing, which mimics metastasis or primary multifocal tumors. As the differential diagnosis of such lesions can be difficult based on ultrasound alone, the knowledge of Magnetic Resonance Imaging (MRI) findings is crucial. It enables the radiologists to make the correct diagnosis and alleviate the patient from unnecessary biopsies. Hepatic steatosis is a common condition associated with obesity and types 2 diabetes, showing about 30% prevalence among adults, and is found in 70% of diabetics . As thisRadiologists should be oriented regarding different focal forms or heterogeneous patterns of hepatic fatty deposition or sparing . The MRIA 52-year-old female obese patient presented with abdominal pain and vomiting history with no prior illnesses, including malignancy or diabetes. Physical examination was unremarkable. Laboratory tests showed mildly elevated liver enzymes, including alanine transaminase (99 U/L) and aspartate transaminase (59 U/L). Borderline white blood cell count of about 10.3 x10^3/uL. AFP is not elevated. Ultrasound abdomen was done to assess the liver and to rule out cholecystitis.Radiological featuresUltrasound examination of the abdomen showed an enlarged liver measuring 20 cm in its span with increased echogenicity impressive of diffuse hepatic steatosis. In addition, there were several hypoechoic masslike focal lesions in both liver lobes; the largest lesion is in the right hepatic lobe and measures 27 x 18 mm  with several focal areas of maintained normal signal appeared relatively hyperintense in opposed-phase T1WI Figure , and T1WOn the Dynamic gadolinium-enhanced T1WI, these lesions appeared hyperintense on all three post-contrast phases and showed faint homogenous relative increased enhancement with no washout relative to liver parenchyma Figure .The patient was diagnosed with multifocal nodular fatty sparing. Her symptoms improved, and she was discharged in good condition. At 6 months follow-up, she remained asymptomatic, and a follow-up ultrasound redemonstrated of similar diffuse fatty liver with a stable number and size of the hypoechoic nodular fat-sparing areas.Fatty liver is a benign entity that may show either focal or diffuse patterns. This is usually idiopathic; however, It is almost always associated with an insulin resistance syndrome, diabetes, obesity, dyslipidemia, steroid therapy, or prolonged starvation . Focal fThe pathophysiologic mechanism of hepatic steatosis may be related to the alteration of the vascular supply, which affects the hepatocytes adjacent to central veins and force them to accumulate lipids earlier in comparison to those in the liver periphery . In contFocal areas of normal parenchyma in an otherwise diffuse fatty liver may mimic mass lesions. Typically, these pseudo lesions appear as hypoechoic areas against a background of hyperechoic parenchyma due to fatty infiltration. Ultrasound features that may differentiate these pseudo lesions from true abnormalities include their characteristic location in the quadrate lobe and the non-displacement of blood vessels. When these features are present, further investigation is unnecessary .Hepatic fat-sparing regions may sometimes show a multinodular pattern on imaging, which mimics metastases or multifocal primary tumors . MRI andThe biopsy is considered the gold standard diagnostic exam for focal hepatic lesions; however, this is limited by the interpretative variation and sampling error . Other MOn the other hand, metastases may show high signal intensity on T2WI, an enhancing rim, surrounding fat sparing, and diffusion restriction . None ofHepatic pseudotumors, on the background of fatty liver, appear as hypoechoic mass-like lesions on ultrasound. These are well seen on T1WI opposed phase, and T1WI fat sat images as areas with maintained normal signal may represent nodular fat sparing in appropriate clinical settings and other benign MRI features. Making an accurate diagnosis of nodular focal fat sparing prevents unnecessary biopsy or further intervention.


Lupus enteritis encompasses mesenteric vasculitis, enteric vasculitis, mesenteric arteritis and lupus peritonitis and is an uncommon, potentially life-threatening presentation of SLE. The prevalence in SLE patients ranges from 0.2% to 9.7% and up to 65% in SLE patients presenting with acute abdominal pain. This case brings awareness to the gastrointestinal manifestations of lupus with particular focus on the clinical and radiological features of SLE-related vasculitis of the gastrointestinal tract. It highlights the importance of recognising new ascites and hydronephrosis as a presenting feature of LE with leucopenia, low C3 and raised IgA as additional associated features.A 48-year-old female presented to hospital abdominal pain and vomiting. Abdominal CT imaging revealed small bowel obstruction with extensive mural oedema and thickening of the ileum, jejunum, ascending, transverse and descending colon. Ryle’s tube was inserted and left on free drainage. Imaging also showed ascites, bilateral hydronephrosis bilateral hydronephrosis, enlarged pelvic lymph nodes, pleural effusions and a small pericardial effusion.Past medical history included seronegative, anti-CCP positive rheumatoid arthritis for which she was on taking baricitinib 4mg daily and prednisolone 5mg daily. Otherwise she had a history of HbSC disease with previous delayed transfusion reaction, urticarial vasculitis, fully treated tuberculosis.This was the patient’s 3rd presentation with recurrent abdominal pain, vomiting and small bowel obstruction in the preceding last 6 months. 6 weeks prior to the current presentation she underwent a laparotomy, revealing a chronic dilated ∼40cm segment of small bowel and ∼800ml ascites. Histology revealed normal mucosa with no evidence to support inflammatory bowel disease, tuberculosis or infective colitis, but was significant for sub-mucosal fat necrosis with foamy histiocytes present.On this occasion, the clinical picture deteriorated with the development of hospital acquired pneumonia, acute kidney injury  and fluid overload  requiring admission to intensive care unit.Immunology results revealed ANA 1/2560 speckled, anti-dsDNA 72 IU/ml, Ro-60 positive, RNP 70 positive, C3 0.51 (ref range (0.90-1.80 g/L), C4 0.18 (ref range 0.10 – 0.40 g/L), rheumatoid factor <10, anti-CCP 154 (ref range (0-7IU/ml).A diagnosis of systemic lupus erythematosus (SLE) with lupus enteritis and probable lupus nephritis was made. Pulsed methylprednisolone and belimumab therapy were commenced followed by the addition of mycophenolate mofetil resulting in sustained improvement in clinical, biochemical and radiological parameters and no further episodes of bowel obstruction.LE is an uncommon but potentially life-threatening complication of SLE. Symptoms for LE can vary from mild intermittent diffuse abdominal pain, nausea, vomiting, bloating, diarrhoea to acute abdominal pain, with urinary symptoms present in up to 20%. LE is most likely to occur in patients with high disease activity, determined by disease activity measures such as the BILAG or SLEDAI. Abdominal computer tomography (CT) is the gold standard investigation with the typical features being diffuse or focal bowel wall thickening and oedema (‘target sign’), mesenteric vasodilation (‘comb sign’), dilatation of intestinal segments and ascites. Endoscopy may show ischaemia and ulcerative changes, but biopsies are often normal. Full thickness biopsies may be required. Urinary tract involvement and hydronephrosis have been described in association with LE.There are currently no specific available guidelines or recommendations for the treatment of LE. Rapid improvement is seen following administration of high-dose glucocorticoids and additional immunosuppression using Cyclophosphamide, Rituximab Azathioprine or Mycophenolate mofetil can be used in certain cases. The relapse rate is common with predictors of recurrence reported as bowel wall thickness exceeding 9mm and those receiving glucocorticoids alone. Potentially life-threatening complications including gastro-intestinal perforation and intestinal necrosis if left untreated.Based on the positive lupus serology, extensive bowel oedema, ascites, and bilateral hydronephrosis in addition to lymphadenopathy, pleural effusions and small pericardial effusion seen on CT imaging; LE was the top differential in this case. High dose intravenous steroids with the addition of Belimumab were promptly initiated in view of the rapid accumulation of ascites, progression of hydronephrosis and deterioration in renal function.This case highlights the importance of recognising new ascites and hydronephrosis as a presenting feature of LE with leucopenia, low C3 and raised IgA as additional associated features.The timely diagnosis of LE is crucial to preventing potentially life-threatening complications including gastrointestinal perforation and intestinal necrosis if left untreated.This case explores the importance of distinguishing LE from other differentials such as infectious colitis, TB enteritis, inflammatory bowel diseases.The diagnosis of LE can be determined through imaging studies, specifically abdominal CT scans. This case demonstrates that the typical CT findings of bowel oedema, thickening, ascites and hydronephrosis was key is identifying the diagnosis of LE.Early identification is crucial in LE to enable the timely administration of high-dose glucocorticoids, as LE is typically steroid-responsive with an overall good prognosis once treated.Although there is no specific immunological test to confirm a diagnosis of LE, it is essential to recognise that this constellation of clinical features: ascites, hydronephrosis, leucopenia, low C3 and raised IgA, are independently associated with LE and should prompt a potential diagnosis of LE.Whilst the decision for further immunosuppression following glucocorticoid may be made on an individualised basis, this case of LE demonstrates that prompt treatment with monthly intravenous Belimumab is a suitable immunosuppressive option.Prompt immunosuppression provided rapid symptomatic benefit and reversal of bowel oedema and hydronephrosis on repeat imaging.As of yet, this is the first reported case in the literature whereby Belimumab was successfully used to treat lupus enteritis. Future studies are however needed to explore this further.


The management of advanced basal cell carcinoma (BCC) can be challenging and often involves a multi-disciplinary approach with dermatologists, plastic surgeons, and oncologists. Standard therapy for advanced BCCs has historically involved prompt excision and radiation; however, in recent years, management strategies utilizing hedgehog pathway inhibitors as neoadjuvant therapy have gained popularity. While controversy regarding management recommendations still exists, we present a case of advanced BCC with cranial involvement in an immunocompromised patient where the use of neoadjuvant vismodegib led to a favorable outcome and, surprisingly, complete the pathologic clearance of the tumor. She presented to our dermatology clinic for the management of poorly controlled HS; it was unclear why this lesion had not been biopsied and treated. Her immune suppression at that time included oral azathioprine 200 mg daily for well-controlled Crohn's disease, and Humira 40 mg subcutaneous (SC) weekly for HS. She stated that the scalp lesion had been growing rapidly, had become malodorous, and was very painful. She denied unintentional weight loss, fevers, chills, or shortness of breath.. A biopsy was performed and confirmed BCC nodular type. Further workup included CT and MRI, both of which demonstrated cranial invasion [INSERT .Exam revealed that an 11.0 × 6.0 cm eroded heme-crusted mass encompassing the bulk of the vertex scalp and extending posteriorly to the occipital scalp INSERT . A biopsn INSERT  and 2b. Upon the initiation of vismodegib, the lesion measured 11.0 × 6.0 cm. At 4, 8, and 12 weeks, the lesion measured 10.0 × 6.5 cm, 9.0 × 6.5 cm, and 8.8 × 6.3 cm, respectively INSERT . At each,,In most cases of BCC, surgical excision alone is the standard of care and performed with a high degree of success.,Management of advanced BCC can be challenging and ideally involves a multi-disciplinary approach, including dermatologists, plastic surgeons, and oncologists, for best treatment results.No funding sources were secured for this study.Not required.Verbal and written consent for the publication of this case along with the photographs provided was obtained.All authors report no conflict of interest.


This retrospective case series describes imaging findings in seven dogs and two cats with a presumptive diagnosis of sclerosing encapsulating peritonitis (SEP) between 2014 and 2021. Peritoneal effusion was present in all animal patients. Sonographically, echogenic fluid with or without echogenic intraperitoneal septations, gathered or corrugated bowel loops, and abdominal lymphadenomegaly were suggesting an inflammatory process and the presence of adhesions. Gathering of the bowel with abdominal distension and/or signs of intestinal obstruction were major findings on radiographs. Abdominal fat stranding was an additional finding in animals undergoing a CT examination. Previous surgery, pregnancy, and the presence of a perforating foreign body were potential predisposing causes in 4/9 animals. Peritonitis was septic in 4/9 animals. As SEP is a rare condition but life threatening, this detailed description of imaging findings in a short case series can be useful for a presumptive diagnosis and surgical planning. Sclerosing encapsulating peritonitis (SEP), also referred as “chronica fibrosa encapsulata,” “icing sugar bowel” or “fibroplastic peritonitis” in the literature, is defined as a chronic inflammatory condition often of unknown etiology in which the small intestines are encased in a dense fibrocollagenous membrane , 2. It iThis pathological entity is uncommon in dogs and rare in cats –16. OnlyBecause imaging is a routine part of the work-up of cases with abdominal symptoms, the objective of this retrospective study is to provide a detailed description of the most common imaging findings of SEP determined from a case series of dogs and cats having a final diagnosis of SEP at surgery.Case records from the Small Animal Veterinary Clinic of the University of Liège from 2014 to 2021 were reviewed. Animals with a final diagnosis of SEP based on macroscopic findings and/or histopathological analysis of biopsies at surgery were included in the retrospective study and their data  reviewed. All included animals had undergone a comprehensive clinical examination and a diagnostic imaging investigation, including at least abdominal ultrasonography, with or without abdominal radiography or computed tomography (CT).Ultrasound examination was performed in dorsal recumbency on awake animals using a fixed ultrasound machine equipped with high frequency (7.5–13 MHz) linear and/or curvilinear probesRadiographs included at least two orthogonal views: a latero-lateral projection and a ventro-dorsal projection. All radiographs were performed on awake animals maintained by human operators using a computed or direct radiography system 150 kV/800 mAAbdominal CT angiography was performed in sternal recumbency, under general anesthesia after a transient period of hyperventilation to induce apnea and avoid motion artifacts. The animal was premedicated using butorphanol (0.3–0.4 mg/kg). Anesthesia was induced using propofol and followed by endotracheal intubation. Anesthesia was maintained using isoflurane gas and 100% oxygen. CT images were acquired using a multi-slice system with 16 or 64 slice detectorNine animals, seven dogs and two cats  2 weeks and 3 months before the diagnosis respectively. Two dogs had been pregnant, D1 with an unremarkable parturition 1 month before the diagnosis, and D2 with adhesions noticed by the referring veterinarian during C-section 10 months before. One dog had recently been adopted with an unknwon history (D6). The remaining four animals had an unremarkable clinical history.Clinical signs at initial presentation included anorexia (6/9), lethargy (4/9), weight loss (4/9), abdominal distension (3/9), diarrhea (2/9), abdominal pain (1/9) and acute vomiting (1/9). D5 developed acute vomiting and diarrhea due to intestinal obstruction 1 month after the initial presentation and underwent enterotomy and ovariohysterectomy.Bloodwork at initial presentation was available for 5/9 animals. Bloodwork was normal in one dog (D5). Four animals showed minor hematological or biochemical unspecific changes including mild to moderate neutrophilia , mild lymphocytosis and monocytosis (C1), mild hyper-  or hypoglycemia (C1), pre-renal azotemia (C2), and mild hypoproteinemia and increase in alkaline phosphatase level (D3).Two dogs  and one cat (C2) had abdominal radiographic examination and all animals underwent an abdominal ultrasonographic examination.Radiographs showed increased abdominal volume in 2/3 animals . ReducedSonographically free fluid was visible in all animals, either distributed in the entire peritoneal cavity (7/9) or focally collected (2/9). Peritoneal effusion was echogenic (6/9) and loculated or partially loculated by thin echogenic septations (3/9), suggesting an inflammatory process. Bowel loops had a plicated (7/9) and/or corrugated (7/9) appearance in all animals suggesting the occurrence of adhesions and bowel inflammation . In 6/9 Additional ultrasound findings were present in 5/9 animals. Two dogs  had thickened heterogeneous tissue mimicking a mass adherent to the abdominal wall at the site of laparotomy. D7 had an ovoid mesenteric echogenic mass unrelated to any abdominal organ and a small eccentric duodenal mass originating from the muscular layer. D4 had a small round distorted / folded spleen, surrounded by a thin echoigenic capsule. C2 had mass and nodular images (respectively ≥3 cm and <3 cm) within the clumped mesenteric fat and images of the bladder consistent with pseudomembranous cystitis.Four animals underwent an abdominal CT (including contrast examination)  for surgical planning.Abdominal CT examinations confirmed the ultrasound findings in 4/4 animals. Free or loculated abdominal fluid (3–15 Hounsfield units) and encased bowel loops were confirmed in all three animals where this distribution had already been suspected based on radiographs and ultrasound , 5. CT iStaphylococcus pseudintermedius) and C2 (Listeria monocytogenes) and a non-septic modified transudate in D6, D7 and C1. Additionally, prior to referral, D6 had a positive bacterial culture (Pseudomonas putida) on peritoneal effusion. Fibrinous adhesions were submitted for histopathological analysis in 4/9 animals and confirmed either acute (C1 and D1) or chronic (C2 and D6) fibrinous neutrophilic inflammation. Cocci and bacilli were also present on the histopathological analysis of the fibrinous material in C1. Although most animals survived several months to years after initial admission , 3/9 animals, including both cats, died or were euthanised within 7 days due to complications or lack of clinical improvement post-surgery.All nine animals underwent exploratory laparotomy. Surgery confirmed the presence of a thick capsule around the abdominal viscera (6/9), multiple serosal adhesions between small bowel loops (6/9) or between small bowel loops and ovary (1/9) or abdominal wall (2/9) . In the This case series describes imaging findings in seven dogs and two cats with confirmed SEP. Most animals included were either juveniles or young adults (<3 years old). Previous reports show a wide age distribution demonstrating that juvenile , 14, 16 idiopathic or secondary depending on previous conditions that may be identified as potential trigger of peritoneal inflammation  associated with peritoneal effusion and lymphadenomegaly. Sonographically, peritoneal fluid was often echogenic (6/9) and frequently associated with echogenic septae suggesting an inflammatory cause. This hypothesis is in accordance with previous descriptions in case reports , 15, 16 Adhesions around and between small intestinal loops sometimes with an encapsulated visceral mass (6/9) was a common surgically finding. This characteristic encapsulation was seen as a gathering of small bowel loops in the central abdomen surrounded by fluid on radiographic, CT and ultrasonographic examinations of respectively 2/3, 3/4 and 5/9 animals. In two animals a mechanical ileus developed after the first onset of symptoms and this is similar to what is described in humans where mechanical ileus is reported as a consequence of adhesions and impaired bowel motility , 2.Four cases had undergone a CT examination. Consistently with findings reported in literature , 2, 16, While the entire peritoneal cavity was involved in the majority of animals, two cases had focal ultrasound abnormalities with peritoneal effusion and hyperechoic fat being localized around an abnormal corrugated small bowel loop. These animals may either represent an earlier stage of the disease or simply better show the undergoing focal triggering process. However, if previous surgery is reported, animals with focal implication of the abdominal cavity may be difficult or impossible to distinguish from animals suffering of post-operative adhesions and not necessarily progressing to SEP.The main limitations of this study are its retrospective nature and the small sample size. The complementary examinations were at the discretion of the clinician after consideration of the animal clinical presentation and owner budget. In particular, 5/9 animals did not have CT examination, 6/9 did not have abdominal radiographs and 5/9 did not have histopathological analysis of the peritoneal adhesions and membranes. However, because of the rarity of the disease, especially in cats , and itsThis small case series confirms findings previously reported in isolated SEP cases. As clinical presentation may be nonspecific, diagnostic imaging should be considered to exclude other disorders. Imaging findings of SEP in dogs and cats include abnormal shape and distribution of small bowel loops on radiographs, plicated and/or corrugated small bowel loops with echogenic loculated peritoneal effusion on ultrasound and fat stranding on CT.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The animal study was reviewed and approved by Comission d'Ethique Animale, Université de Liège. Written informed consent for participation was not obtained from the owners because this is a retrospective study using clinical datas. The Ethical Committee retrospectively approved the study (File number 22-2459) on the 11th of May 2022.BG and VB contributed to conception and design of the study. BG and CP gathered database. BG organized the database and wrote the first draft of the manuscript. VB contributed to manuscript revision and wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Schwannoma is a benign tumor, of which degenerated schwannoma is a subtype. Retroperitoneal schwannomas are extremely rare, as they account for only 3% of retroperitoneal tumors.Degenerated schwannoma is a schwannoma subtype. However,degenerated schwannoma occurring in the adrenal glands is extremely rare.Case 1: A 42-year-old man was referred to our hospital for further examination of a left adrenal mass that was incidentally discovered during a routine physical check-up.No significant abnormalities were found in laboratory tests results. Robotic-assisted laparoscopic excision of the left adrenal gland was performed under general anesthesia. Case 2: A 47-year-old man was admitted to the hospital because of a left adrenal mass found on a routine physical examination.The patient was previously in good health, and there was no family history of a similar disorder. Left-sided laparoscopic adrenalectomy was performed under general anaesthesia. Case 3: A 62-year-old woman with hypertension and diabetes mellitus was referred to our hospital after an incidentally found left adrenal mass.There was no family history of a similar disorder. Left-sided laparoscopic adrenalectomy was performed under general anaesthesia. None of the patients had a recurrence in our study during the postoperative follow-up.Degenerated schwannoma of the adrenal glands is very rare. The clinical presentations of degenerated schwannoma are nonspecific; a small number of patients do not have any symptoms, and the mass is only found incidentally during physical examination for any number of reasons. The preoperative diagnosis of adrenal degenerated schwannoma is difficult because the diagnosis must rely on pathological examination and immunohistochemistry assays. The management is surgical excision and regular follow-up. Schwannomas are composed of Schwann cells arising from a peripheral nerve sheath. It is a benign tumor. Degenerated schwannoma is a subtype of schwannoma , 2. DegeThree cases of degenerated schwannoma were diagnosed in patients between 26 and 62 years of age .A 26-year-old man was evaluated at the hospital for a left adrenal mass that had been identified incidentally during a physical examination 5 months prior.No significant abnormalities were found in laboratory tests results. Imaging for this case was done at an outside hospital and is no longer available.Robot-assisted laparoscopic excision of the left adrenal gland was performed under general anaesthesia. On gross examination, the specimen was a greyish white and greyish red cyst, measuring 5.0 cm x 3.0 cm x 1.0 cm. Immunohistochemistry showed:VIM (+), S100 (+), ki-67 (10%), SOX10 (+), CD34 (vascular +). The pathologic examination led to a final diagnosis of adrenal glands degenerated schwannoma. No recurrence was observed during the 15 months of follow-up  and upright positions . The ultrasound showed a hypoechoic area in the left adrenal gland, measuring approximately 4.2 cm in the right-left diameter × 2.8 cm in anterior-posterior diameter, it had clear borders and a regular morphology without apparent internal blood flow signals. The plain CT scan and contrast-enhanced CT scan revealed a a left adrenal mass, measuring approximately 4.0 cm in the right-left diameter × 2.9 cm in anterior-posterior diameter. A laparoscopic left adrenalectomy was performed under general anesthesia. Gross specimen showed that the capsule was intact with multiple incisions, and the cut surface appeared to be greyish grey-brown with congestion and necrosis. Immunohistochemistry showed:S100 (+), ki-67 (1%), SMA (-), CD56 (+), CD31 (vascular +). The pathologic examination led to a final diagnosis of adrenal glands degenerated schwannoma. No recurrence was observed during the 40 months of follow-up  is a benign tumor of nerve sheath origin. It contains multiple subtypes. For example, classic schwannoma, degenerated schwannoma, cellular schwannoma, plexiform schwannoma, etc , 3. SchwDegenerated schwannoma arising from the adrenal glands is an extremely rare entity . The cliIn gross specimen, the tumor had a complete capsule with a well-defined border. In case 1, a greyish white and greyish red cyst with a localised greyish brown cauliflower-like projection on the inner wall of the cyst. In case 2, intact pericardium, multi-sectional incision, greyish grey-brown surface appears to be congested and necrotic. In case 3, complete envelope, greyish white cut surface. Based on previous reports and the present case, it is assumed that most of the degenerated schwannoma in the adrenal gland have intact envelope with well-defined margin and greyish white cut surface.Degenerated schwannoma is benign tumor. It has a high cell count and cellular anisotropy. Multiple components can be observed: hemorrhage, mucoid degeneration, calcification, inflammatory cell infiltration, hyaline changes in the vessel wall, cystic lumen formation, and nuclear pleomorphism. Histologically, schwannoma is composed of two different types (Antoni A and B). Antoni A type shows mainly densely packed, spindle-shaped cells arranged in short, interwoven bundles and whorls. Antoni B type has a looser structure with cystic spaces mixed within the tissue. Degenerated schwannoma often shows a decrease in Antoni A type. It is mostly presented as the Antonian B type. Degenerative changes are often associated with cellular heterogeneity. It can be easily misdiagnosed as a malignant neoplasm. These two patterns may coexist, but usually, one is predominant in cellular schwannoma. Plexiform schwannoma may not always display the Antoni A and B patterns . S-100 immunohistochemistry analyses reveal positive staining for this marker, which supports the diagnosis of schwannoma . In thisImaging features are usually nonspecific. CT-guided fine needle aspiration biopsy does not appear to provide an accurate preoperative diagnosis. It is easy to diagnose malignant tumors. It is not recommended to carry out puncture biopsy , 8. The Malignant transformation may rarely occur. During this long period in which tumor volume did not change, it is feasible to observe it. Surgery remains the primary treatment modality, with complete laparoscopic resection of the tumor being preferred , 16. AftIn conclusion, the pathogenesis of adrenal glands degenerated schwannoma is unknown.The clinical presentation is non-specific. The diagnosis depends on pathology and immunohistochemistry, with positive expression of S100 in immunohistochemical markers.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.TZ, S-FY and R-LF collected data and drafted the manuscript. R-LF provided pathology results and drafted the manuscript. W-BF collected data and reviewed the manuscript. C-XK edited the manuscript and critically revised the draft. All authors contributed to the article and approved the submitted version.


Nutcracker syndrome (NCS) belongs to a group of rare vascular disorders. It refers to compression of the left renal vein (LRV) generally between the abdominal aorta (AA) and the superior mesenteric artery (SMA). It is one of the most unknown causes of chronic abdominal pain. Herein, we present the case of a young patient who came to the emergency department for acute abdominal pain. Patient's history revealed an uncharacterized chronic epigastric pain evolving for 13 years. The imaging showed acute appendicitis and NCS; the latter finding was the principal explanation for the patient’s chronic pain. We hope that the concise and synthetized structure of this case report will help physicians acquire the necessary reflexes to notice and diagnose this already underdiagnosed syndrome. Nutcracker syndrome (NCS), also known as left renal vein (LRV) entrapment, belongs to a group of rare vascular disorders . NCS encA 32-year-old woman presented to the emergency department for a history of acute pain in the right lower abdomen evolving for two days. She also complained of acute diarrhea, nausea and fever. After a thorough anamnesis, she reported a 13 years history of intermittent epigastric pain. The patient did not relate any episode of hematuria, dyspareunia or sensation of pelvic heaviness. She consulted at several structures before and received symptomatic treatment based on non-opioid analgesics. Nonetheless, no imaging was performed, the origin of the pain has never been explored and no organic cause was found. Physical examination showed normal blood pressure of 125/70 mmHg, regular pulse of 79 beats/min, low-grade fever of 38.1 °C, and respiratory rate of 17 breaths/min. There was a tenderness in the right iliac fossa with positive McBurney sign. Laboratory assessment revealed negative ß-human chorionic gonadotropin (ß-HCG), hyperleukocytosis of 12 000, C-reactive protein (CRP) of 25, sterile cytobacteriological examination of urine (CBEU), and normal lipasemia. An abdominal and pelvic Computed Tomography (CT) scan after contrast injection showed a swollen appendix (9 cm thick) surrounded by mesenteric fat infiltration and peritoneal effusion  Figure , and narThe NCS refers to compression of the LRV as it passes through the aorto-mesenteric clamp. It is a rare entity, but probably underestimated. Its prevalence is higher in young subjects between 30 and 40 years of age, with a female predominance ,5. This NCS pathophysiology is still unclear. It may be caused by some anatomical variants ,8 such aMain symptoms of NCS are hematuria; chronic abdominal pain; dyspareunia and sensation of pelvic heaviness. No correlation exists between the intensity of the symptoms and the anatomical findings. Some subjects with marked compression of the LRV are completely asymptomatic . Thus, tNCS treatment can vary based on age and the severity of symptoms. Management options range from observation to nephrectomy. Conservative treatment is the rule for minimal, moderate or absent symptoms . The posNCS is a rare vascular disorder with various symptoms and unclear pathophysiology. Patients with NCS are likely to be non-diagnosed. It can evolve for years without being recognized. This syndrome must be considered in young patients presenting unexplained chronic abdominal or pelvic pain. CT angiography is the gold standard in establishing the diagnosis thanks to characteristic imaging features. This case presents an accidental discovery of NCS during an acute appendicitis episode. Treatment remains controversial. Management options range from therapeutic abstention with observation to surgical or endovascular approach. We hope through this case to highlight main clinical presentations and typical imaging findings of this uncommon syndrome. Finally, more researches are necessary for better understanding of NCS pathophysiology, its potential associations, and to establish management guidelines.


Leishmania major agent was confirmed after culture on NNN medium followed by isoenzyme electrophoresis. Sporortrichoid leishmaniasis is a rare condition and usually due to extension of local leishmaniasis into the subcutaneous tissue via direct extension, bloodstream or lymphatics. The patient responded favorably to Meglumine antimoniate treatment. To our knowledge, sporotrichoid cutaneous leishmaniasis after an erythematous-papular onset has never been reported in Algeria, this clinical entity should be considered for an earlier diagnosis and specific therapy.A 32 year-old male was referred in our institution for painless erythematous papules on the back of the right hand, treated by various local therapies with no noticeable benefits. On examination multiples inconspicuous nodules were identified 10 days after the onset of the primary lesion. Mycological examination was done to rule out sporotrichosis, then cutaneous leishmaniasis was retained by finding amastigotes forms, and  Leishmaniasis is a parasitic vector-borne disease, inoculation occurs after a Sandfly bite. The three major clinical types are cutaneous leishmaniasis (CL), mucosal leishmaniasis (ML), and visceral leishmaniasis (VL) The lesions usually appear in non-covered regions of the body Atypical forms of CL include sporotrichoid leishmaniasis (SL), which is usually described as a primary ulcer associated with lymphagitis and nodules Sporotrichoid cutaneous leishmaniasis is considered as a dissemination of amastigotes via the lymphatics to the subcutaneous tissues We describe an unusual case of SL, the disease began as an erythematous-papular rash located on the right hand.We report on a 32 year-old male with a history of contact eczema, residing at Djelfa town, in Algeria.Leishmania sp , with no significant results, moreover, there was an extension of the lesions leading to an imperative reevaluation of the condition. After being referred to our institution, the patient presented limited erythematous-papular plaque of 8 cm of diameter, located on the dorsal side of the right hand, the lesion was formed by the confluence of several papules , with samania sp , while dThe patient was started on Meglumine antimoniate (Glucantime©) as first line treatment 60 mg/kg/day for 15 days, which induced a reduction of the lesions after 10 days , and favLeishmania aethiopica, it has been already observed in Africa, among 2059 patients with cutaneous leishmaniasis in Tunisia, 34 (1.7%) developed SL Leishmania major endemic areas like Pakistan, Morocco and Turkey SL is a rare form of Old World cutaneous leishmaniasis, mostly due to Leishmaniasis is associated to environmental changes, such as deforestation, wide urbanization, irrigation and construction of dams According to gender SL is more commonly described in female than males Leishmania major, which rarely gives sporotrichoid forms.Dissemination of CL is not a common phenomenon Often subcutaneous nodules are small, inconspicuous and difficult to visually assess Sporothrix schkenkii, atypical mycobacteria, Nocardia brasiliensis and Leishmania sp., among others Few diseases can produce a sporotrichoid dissemination of chronic foci, namely infections by Sporotrichoid dissemination of cutaneous leishmaniasis can appear after local traumatism or puncture diagnostic Culture of the scraping samples on NNN medium is not always necessary for diagnosis, but it could be contributive in pauceparasitic forms, and should be done for species typing purpose.Leishmania major species Molecular identification and isoenzymes electrophoresis typing have revealed that sporotrichoid leishmaniasis has largely been associated with Althougt sporotrichoid cutaneous leishmaniasis is uncommon in Algeria, similar presentations mainly include sporotrichosis that has already been reported in the country.According to literature, Treatment with intramuscular 20 mg/Kg/day meglumine antimoniate (Glucantime©) for 15 days, is effective Leishmania major.Sprotrichoid leishmaniasis is a rare condition, diagnosis should be guided by the patient history, physical examination and laboratory examination, especially in areas with known predominance of Authors declare no fundings., Fatma Bachi, Haiet Adjmi-Hamoudi helped equally to collect data, writing,and reviewing.Adila Bassaid, Yassine Merad, Mohand Ouali Ait Si Ali, Assya DjeridaneAuthors declare no conflicts of interests.


Anomalous facial nerve (FN) course can be found in a significant number of cases with aural anomalies. The most common anomaly of the FN involves the tympanic portion overlying the oval window.An 18-year-old male presented to the outpatient clinic with left-sided non-progressive hearing loss since childhood. Otoscopic examination revealed bundle-like structure behind the posterior portion of the tympanic membrane A. Other Most patients with FN anomaly do not have any clinical symptoms. Conductive hearing loss, mainly due to associated ossicular disruption, may be the only clinical presentation. Therefore, it is difficult to suspect middle ear mass as an unusual presentation of the FN course or even as a structural or passage anomaly, especially when other associated anomalies are not noted. Furthermore, cases of FN dehiscence shown in previous studies were mainly associated with cholesteatomas or congenital aural atresias.5However, aberrant course of FN lateral to the ossicles without accompanying auricular anomaly was reported in a prior case.CT imaging provides precise prediction of the FN course, coinciding with surgical findings in most cases of congenital aural atresia.Therefore, physicians should suspect the mass located in the posterior middle ear cavity as a variation of the FN pathway and perform imaging evaluation before planning interventions.6Unusual structure seen through the tympanic membrane should be evaluated by imaging before definitive treatment. CT is especially useful for this purpose, because the tympanic segment of the FN lying lateral to the ossicles can be easily identified. If aberrant course of the FN is suspected by symptoms and clinical findings, physicians should be cautious in determining surgical interventions, such as ventilation tube insertion or explorative tympanotomy.The authors declare no conflicts of interest.


Chondrosarcoma of the nasal septum is a rare malignancy. Its early diagnosis is difficult because of its non-specific sinonasal complaints. We report a case report of a 72-year-old woman who presented with progressive nasal obstruction and anosmia. Nasal endoscopy showed a nasal mass obstructing both nasal cavities, which was not separable from the nasal septum. Endoscopic biopsy confirmed chondrosarcoma. The tumour was operated on with complete margins by an endoscopic approach. The clinical presentation of the disease, diagnosis and treatment of this case, and a review of the literature are discussed. Sinonasal chondrosarcoma is a rare tumour that represents approximately 5%-10% of malignant primary bone tumours that occur in the head and neck region . ChondroA very healthy and fit, 72-year-old lady was referred to an Otorhinolaryngology outpatient clinic with complaints of a slowly progressive history of nasal obstruction and anosmia for a few weeks. There was no history of vision loss, diplopia, proptosis, facial pain, facial asymmetry, weight loss or epistaxis. Intra-oral and ear examinations were normal.The nasoendoscopy examination revealed a large central nasal mass occupying the nasal cavity. Both computed tomography (CT) and magnetic resonance imaging (MRI) was performed to fully evaluate the extension of the disease as well as the bone and soft-tissue characteristics of the lesion. CT scan of the sinuses showed a well-circumscribed sinonasal mass in the nasopharynx with the epicentre at the posterior nasal septum and expanding laterally that causing bowing of the medial nasal walls Figure , erodingThe MRI showed a detailed definition of the nature, extent and size of the mass. It showed an eroded and deformed nasal septum with the lesion abutting sphenoid cavernous sinuses Figures , 4 poste Endoscopic biopsies were performed and the histopathology examination confirmed grade 2 chondrosarcoma. This case was discussed by our multidisciplinary team, the decision was taken to remove the tumour by an endoscopic approach under general anaesthesia. The patient underwent endoscopic endonasal transsphenoidal surgery, a combined case with a neurosurgical team. We used a Stealth station (Medtronic ENT Neuronavigation system). Intraoperatively, middle turbinates and lamina papyracea were identified and preserved. The whole of the posterior septum from the hard palate to the skull base was removed. Anterior skull base was drilled with minor cerebral spinal fluid (CSF) leak identified and sealed with factor Xa-like protein (Haemopatch) and DuraSeal. Sphenoid and clivus bone was drilled and right ICA was identified. There was no extension into the cavernous sinus was noted and the whole tumour was resected via an endoscopic approach.Post-operatively, the case was discussed in a multi-disciplinary team meeting for postoperative radiotherapy. The patient currently opted for endoscopic and radiologic surveillance for her follow-up. Repeat MRI images after four months of endoscopic resection of the tumour were carried out and demonstrated completed resection of the chondrosarcoma Figures , 8.The patient underwent repeat biopsies and histological examination showed no disease recurrence. The endoscopic image during the time of biopsy after a few months of initial resection also revealed good healing after the operation Figure .Chondrosarcoma is a non-epithelial malignant tumour, which is a slow-growing tumour that usually involves the pelvis, ribs, long bones of the extremities, scapula, and the sternum. It affects men and age groups between 60 and 70 years old. Chondrosarcoma can be associated with conditions such as multiple hereditary exostoses, Ollier disease, Maffucci syndrome .The histology criteria are depending on the presence of many cells with hyperchromatic nuclei, two or more chondrocytes within a lacuna and giant cartilage cells with large single or multiple nuclei with clumps of chromatin and mitotic activity . ChondroThe 5-year survival rate of chondrosarcoma is about 70%-80%, with a good prognosis . HoweverComplete excision of the primary site with adequate surgical margin is important for a successful outcome as chondrosarcoma is considered a radio-resistant tumour. As highlighted in this case, the use of a navigation system in an expert hand, as part of the surgical adjunct will enable complete resection of the tumour endoscopically. It also spares the open surgical approach and avoids associated complications to open surgery.According to Lee et al., postoperative radiotherapy may have some role in the treatment of chondrosarcoma as two of the cases reported with a positive margin were successfully treated with postoperative radiotherapy . AdjuvanChondrosarcoma of the nasal septum is a rarely made diagnosis. Prompt diagnosis, surgical treatment and multi-disciplinary team involvement and discussion are paramount. Complete excision of the primary site with adequate margin can be curative. Long-term follow-up with endoscopic and radiological assessment is important due to the slow progression of the disease and the high rate of recurrence in the higher grade of chondrosarcoma.


Mature colonic teratomas are rare tumors and no case, to the best of our knowledge, has been reported from the African continent. In addition, some pedunculated teratomas in the colon have been treated by endoscopic polypectomy and classified as primary teratoma of the colon. We report a case of a distinct intra sigmoid pedunculated teratoma originating from the retroperitoneum of a 4-year-old African girl and we highlight the potential for misclassification of primary origin of endoscopically removed polypoid teratomas in the colon.A 4 year-old black African female child who presented with abdominal pain and hematochezia. On clinical assessment, she was found to be anaemic and to have a sigmoid colon mass. At surgery, there was a mobile mass within the lumen of sigmoid colon and the mass was fixed to the retroperitoneum by a stalk of tissue. Pathologist's review of the resected sigmoid segment showed a pedunculated intra-sigmoid mass with the stalk traversing the wall of the colon. The mass was histologically proven a mature solid teratoma.This, to the best of our knowledge, is the first report of intra sigmoid teratoma from the African continent. It highlights the potential for misclassification of endoscopically resected colonic teratomas. Teratomas are germ cell tumours that can occur in gonadal and extragonadal sites. The most common sites of teratoma in children, in descending order of frequency, are sacrococcygeal, mediastinal, gonadal and retroperitoneal sites . Also reA 4 year-old black African female child was referred from a district hospital with complaint of left lower quadrant abdominal pain and hematochezia of 8 weeks. This was associated with anorexia but there was no weight loss or vomiting. She had been transfused with one unit of blood at the referring hospital. On examination, her pulse rate was 120 beats per minute. She was anaemic with haemoglobin concentration of 7.9g/dl.There was a mobile intraabdominal mass measuring 8 x 8 cm located in the left side of the abdomen. Digital rectal examination revealed normal anal anatomy and soft stool in the rectum. Abdominal ultrasound showed an abdominal mass probably arising from the sigmoid colon. Patient could not afford an abdominal CT scan and was then worked-up for exploratory laparotomy. At surgery, there was a mass within the lumen of proximal sigmoid colon with a stalk extending into the retroperitoneum. Intestinal resection and anastomosis was done, patient had an uneventful post-operative recovery and was discharged home on postop day 5.Macroscopic analysis of the resected intestine showed a segment measuring 17cm in length. On opening, there was a lobulated pedunculated polypoid mass protruding into the lumen. The mass measured 7 x 6 x 5 cm and its cut surface was entirely solid. The stalk was slender, measured 0.6cm in diameter and traversed the tunics of the colon to the exterior .Histologic sections showed tissues derived from embryonic germ layers. The ectodermal derivatives were represented by cornified skin with skin appendages and mature brain tissue. Mesodermal tissues present included lobules of adipocytes, fibrous tissue, cartilage and bone. Some other foci showed glandular structures . HistoloThough documented in literature, teratomas of the gastrointestinal tracts are rare lesions,4. Most When faced with teratoma involving the large intestine, one requisite diagnostic determination to be made is the origin of the tumour in question; whether it is primarily of the colon or a secondary involvement of the intestine by a gonadal or an extragonadal tumour. There are a number of reports of benign ovarian teratomas fistulating into large intestine and it is recognized that some luminal teratomas of the colon are extra intestinal in origin .Our case was a pedunculated intraluminal mass. Most teratomas of the colon have been found to be polypoid or pedunculated and Palombini et al did hypothesize that pedunculation might arise from peristaltic traction . PeduncuIn conclusion, this case, to the best of our knowledge, is the first report of intra sigmoid teratoma from African continent. More crucially, it highlights the potential for misclassification of endoscopically resected colonic teratomas.


Erosive bony lesions are a frequent manifestation of numerous etiologies, spanning from malignancy and metabolic disorders to chronic inflammatory conditions like sarcoidosis. However, arteriovenous malformations (AVM) are a less prevalent etiology for this condition. The presentation of erosive bony lesions is diverse, influenced by factors such as age, gender, size, and extent of the lesion. Multiple imaging modalities are employed to achieve a diagnosis, including plain radiograph, Doppler ultrasound, computed tomography, angiography, and magnetic resonance imaging. Bone erosion is a condition characterized by localized bone loss, also known as osteolysis. This occurs when bone resorption by osteoclasts exceeds bone formation by osteoblasts. Radiologically, erosive bone lesions appear as a break in cortical bone, with the destruction of the natural barrier between the extraskeletal and tissue and the bone marrow compartment . NumerouThis case concerns a 46-year-old female who, to the best of her knowledge, had not suffered from any prior medical conditions. Despite visiting numerous hospitals seeking medical attention, she presented to our orthopedic clinic with complaints of chronic intermittent vague left forearm pain for over 10 years. Although the pain was initially treated conservatively as muscle strain, there was no incident leading to the onset of pain. There were no indications of fever, night sweats, weight loss, or other systemic manifestations. Preceding her appointment at the orthopedic clinic, the patient presented to the emergency department with sudden worsening of her left shoulder pain associated with numbness. The patient was managed conservatively with analgesia and provided an appointment with our orthopedic clinic for further management. Upon presenting to the orthopedic clinic, the patient underwent a physical examination that revealed she had swelling over the proximal forearm, as well as engorged tortuous disfiguring veins of the left upper limb extending from the left shoulder to the left hand. Additionally, a pulsating cystic swelling was observed over the proximal forearm, with a positive thrill present. The patient also displayed restricted supination of the left forearm, although full pronation was possible. Mild pain was reported when flexing the left elbow and at 10 degrees extension in both elbows. Finally, mild tenderness was presented upon palpation of the proximal left forearm, but the distal neurovascular examination was intact.The patient’s laboratory results are listed in Table An aggressive osteopathic lesion of the proximal one-third of the radius was observed through X-ray imaging of the left forearm and elbow Figures -3.Further diagnostic testing through ultrasound (US) showed tortuous and increased diameter of superficial cephalomedullary and basilic veins measured more than 1 cm, with aliasing and turbulent flow on color and spectral Doppler analysis. However, no evidence of thrombosis was detected. No obvious soft tissue masses, collections, or subcutaneous edema were noted. To screen for malignancy, computed tomography imaging of the chest, abdomen, and pelvis was conducted, yielding unremarkable results. Meanwhile, MRI revealed significant dilation and tortuosity with the maximum diameter measuring up to 2.8 cm at the elbow level. Multiple prominent and tortuous arm and forearm vascular structures are seen mostly as flow-void structures at T1 and T2, with extensive forearm infiltration and extension to the proximal radius shaft and metadiaphysis, leading to erosion. However, no involvement of the ulna or distal humerus was noted in the imaging findings. These results are highly indicative of peripheral vascular malformation Figures , 5.A CT angiography detected a significant arteriovenous malformation nidus in the left elbow to proximal forearm region measuring 4.7X7.3X9.8 cm in maximum dimension with direct arterial feeders from the brachial artery, venous drainage through direct and indirect tributaries into the cephalic, basilic, and brachial veins, tortuous venous collaterals seen at the right shoulder and supraclavicular region draining into the cephalic vein. Cortical erosion and infiltration of the proximal radial shaft Figures , 7.The vascular surgery team was consulted to determine the optimum management for this patient. They recommended embolization by interventional radiology, but due to the high risk associated with the lesion, catheterization attempts were unsuccessful. Consequently, it was recommended that the patient be referred to a specialized center for the management of complex vascular malformation.AVMs are commonly accounted for as a rare congenital vascular lesion that typically results from faulty embryogenesis leading to an abnormal connection between the arteries and veins, creating a central nidus without intervening capillary bed. This condition is associated with various complications such as destruction of the adjacent soft tissues and bones, venous hypertension, and heart failure among others ,4. AVM mBone erosion is a complex condition that arises from an imbalance between bone resorption and formation. Its pathogenesis can be multifactorial and may involve various disease processes, including AVM, which can often be misdiagnosed as other malicious lesions like tumors. Therefore, meticulous imaging is paramount in reaching a definitive diagnosis and avoiding unwarranted biopsy or surgery. Despite the complexity of the condition, there is still some debate over the optimal treatment method, with less invasive image-guided and interventional treatments being the most commonly employed strategies to date. Nonetheless, the advancement of medical technology continues to aid in finding the most effective approach to treating bone erosion. Overall, it is essential to approach bone erosion in a holistic manner, taking into account the multifactorial nature of its pathogenesis and adopting a personalized treatment approach based on the patient’s specific needs. By doing so, healthcare professionals can provide the best possible care for those affected by this complex condition.


Paraganglioma is a rare neuroendocrine tumor and is highly associated with hereditary susceptibility genes, often occurring as part of a genetic syndrome. The genetic heterogeneity of paraganglioma poses challenges in diagnosis, counseling, and clinical management.EPAS1 mutation, specifically the c.2501A > G; p.Tyr834Cys variant, which has never been reported. The patient was diagnosed with paraganglioma and underwent successful Da Vinci robot-assisted laparoscopic resection of the retroperitoneal tumor. During a 3-month follow-up period, her blood pressure stabilized, and her symptoms significantly improved.We present the case of a 60-year-old woman with hypertension, atrial septal defect, and polycythemia, who experienced paroxysmal palpitations, sweating, headache, abdominal pain, nausea, and vomiting. Her blood pressure was severely unstable. Blood laboratory tests revealed elevated catecholamine levels, contrast-enhanced CT of her whole abdomen showed a round retroperitoneal mass with soft tissue density, and somatostatin receptor imaging (68Ga PET-CT) indicated a retroperitoneal mass with abnormally increased expression of somatostatin receptor. It is interesting to note that whole exome sequencing (WES) analyses on both blood and tumor samples revealed a novel EPSA1 mutation may be the primary driver of paraganglioma complicated by atrial septal defect and polycythemia. Additionally, the utilization of Da Vinci robot-assisted laparoscopic surgery contributed to a favorable prognosis for the patient.This case reveals that the  Catecholamine cardiomyopathy was significantly improved after the surgical removal of the paraganglioma.Paraganglioma is a rare neuroendocrine tumor arising from chromaffin tissues in the extra-adrenal sympathetic and parasympathetic nervous systems outside the adrenal glands , 2. The 2A 60-year-old woman presented at our institution with paroxysmal palpitations, sweating, headache, abdominal pain, nausea, and emesis. Approximately a decade prior, she experienced recurrent paroxysmal palpitations and diaphoresis without apparent etiology, which showed limited improvement with symptomatic management. One month ago, her palpitations and diaphoresis intensified, accompanied by headache, abdominal pain, nausea, and vomiting, without chest pain or syncope. Transthoracic echocardiography (TTE) performed at a local hospital revealed an atrial septal defect, prompting her admission to our facility. Throughout her hospitalization, her blood pressure exhibited severe instability, with the highest recorded reading reaching 251/168 mmHg and the lowest recorded reading dropping to 70/43 mmHg. Her medical history included a 2-year diagnosis of hypertension, managed with controlled-release nifedipine and irbesartan hydrochlorothiazide tablets, as well as a 1-year use of Tibetan medicine for diabetes and previous surgical treatment for gallstones. The patient is a non-smoker and does not consume alcohol. Her older brother had a history of atrial septal defect, and her parents passed away due to undisclosed causes.2. No evidence of hepato-jugular reflux with jugular venous distension was observed, and there were no signs of moist rales or wheezing in either lung field. A cardiac examination revealed tachycardia with a regular rhythm and no audible cardiac murmurs. The abdomen exhibited softness, and the presence of a mass was scarcely palpable. Furthermore, there was no evidence of edema in the lower extremities.During the physical examination, the patient exhibited a body temperature of 36°C, a heart rate of 114 beats per minute (bpm), a blood pressure of 163/115 mmHg, a respiratory rate of 20 breaths per minute, and a body mass index of 18.7 kg/mBlood laboratory tests revealed a notable elevation in catecholamine levels, including epinephrine at 7,241.6 pmol/L , norepinephrine at 69,645 pmol/L , dopamine at 575.3 pmol/L , metanephrine at 3.01 nmol/L , and normetanephrine exceeding 20.56 nmol/L . At the same time, the resin–angiotensin–aldosterone system (RAAS), adrenocorticotropic hormone, cortisol, and dehydroepiandrosterone sulfate exhibited normal values. Urinary measurements demonstrated elevated levels of epinephrine at 123.03 nmol/24 h  and norepinephrine at 2,488.95 nmol/24 h , while dopamine remained within normal limits. Additionally, Troponin-T levels were elevated at 245.8 pg/ml , CK-MB at 5.74 ng/ml , and N-terminal prob-type natriuretic peptide (NT-proBNP) at 11,411 pg/ml . Hematocrit levels in the blood routine indicated 56.7%, with a hemoglobin level of 195 g/L.The 12-lead electrocardiogram demonstrated sinus rhythm Figure 2Upon admission, the patient’s symptoms and examination results led to the diagnosis of paraganglioma, catecholamine cardiomyopathy, hypertensive crisis, atrial septal defect, and diabetes. Treatment was initiated with nifedipine controlled-release tablets, phenoxybenzamine, metoprolol sustained-release tablets, and immediate restoration of circulating volume. Subsequently, the frequency of symptoms such as palpitations, sweating, and headache notably decreased. Additionally, there was a significant improvement in cardiac function, evidenced by a decrease in NT-proBNP from a maximum of 18,128 pg/ml to 187.6 pg/ml, a reduction in Troponin-T from a maximum of 320 pg/ml to 17.6 pg/ml, heart rate fluctuations within the range of 60–70 bpm, and blood pressure maintained below 140/90 mmHg. Following evaluations by cardiologists and urologists, the patient underwent Da Vinci robot-assisted laparoscopic resection of the retroperitoneal tumor. During the operation, the grayish-white tumor measuring 4.0 cm × 3.0 cm was successfully removed with intact encapsulation. Hematoxylin–eosin staining of tumor tissue showed characteristic “Zellballen” architecture of tumor cells. Postoperative pathological examination confirmed the diagnosis of paraganglioma Figure 3EPAS1 mutations, specifically identifying the c.2501A > G; p.Tyr834Cys mutation in the 16th exon of the EPAS1 gene. Additionally, the patient presented with germline ACTN2  and DSC2  mutations. Concurrently, the patient’s brother provided oral epithelial cells through a buccal swab for WES, revealing consistent gene mutation sites with the patient. We predicted the protein structures of the EPAS1 wild type and mutant shown on the 3D model  was performed on venous whole blood and tumor samples of the patient. All suspicious mutations were identified in both sample types and thus considered as germline ones, and no additional potential somatic mutations associated with pheochromocytomas and paragangliomas were identified with a frequency higher than 5%. This analysis successfully detected germline 3D model Figure 4We conducted a 3-month follow-up after the surgery to assess the therapeutic outcomes. Throughout this period, the patient did not experience any episodes of paroxysmal palpitations, diaphoresis, or headaches. The treatment consisting of nifedipine controlled-release tablets, phenoxybenzamine, metoprolol sustained-release tablets, and sacubitril valsartan was continued, resulting in blood pressure control within the range of 125–150/78–95 mmHg, while the heart rate fluctuated between 70 and 85 bpm. Following the resection of paraganglioma, a repeat TTE demonstrated that the interventricular septal thickness had decreased from 13 mm to 12 mm, and the EF had increased from 46% to 63%. These findings indicated a significant improvement in cardiac function following the administered treatment.3Pheochromocytoma and paraganglioma are rare catecholamine-producing neural crest tumors derived from neuroendocrine chromaffin cells. According to a study conducted in Canada, the overall incidence of pheochromocytoma or paraganglioma was 0.66 cases per 100,000 people per year. The prevalence of pheochromocytoma and paraganglioma increased with age, with the highest occurrence observed among individuals aged 60–79 years . ParaganSDHD, SDHB, SDHC, VHL, and NF1  variant. Notably, these mutations were detected in tumor tissues but not in non-neoplastic adrenal tissues. Additionally, mutations of EPAS1 may contribute to the progression of this group of tumors ascribed to the association of the mutations with high tumor weight and larger tumor size (EPAS1 in four of five patients (80%) with pheochromocytoma and paraganglioma who presented with cyanotic congenital heart disease; one of the four patients had paraganglioma with c.1592C>G (p.Pro531Arg) mutation  for the publication of this case report.HY contributed to writing the original draft. KL contributed to reviewing and editing. LZ and YC contributed to data collection. KL and LZ contributed to conceptualization, resources, and supervision. HY and YC contributed equally to this work and share first authorship. KL and LZ share corresponding authorship. All authors have read and agreed to the published version of the manuscript.


Bowel obstructions can be caused by internal hernias which are protrusions of the bowel into openings within the abdominal cavity. There are various types of internal hernias including sigmoid hernias which involve the sigmoid mesentery.Sigmoid hernias are very difficult to diagnose clinically, even with the aid of radiologic imaging. Computed tomography (CT) scan findings often reveal small bowel obstructions; however, they are not sensitive to intersigmoid hernias. Most of these rare herniations are repaired by open abdominal surgery followed by the closure of the mesenteric defect to prevent a recurrence. We present the case of a 57-year-old man who presented to the emergency department with a small bowel obstruction that was caused by an intersigmoid hernia and was successfully repaired through a minimally invasive laparoscopic approach. This case demonstrates an intra-operative diagnosis of an intersigmoid hernia and reviews the benefits of a laparoscopic approach for the reduction of the sigmoid mesentery. Internal hernias are defined as protrusions of the bowel into openings within the abdominal cavity and cause 0.5%-6% of all cases of bowel obstruction ,2. WhileSigmoid hernia cases are very difficult to diagnose clinically because radiologic imaging is sensitive for the hernias but the imaging lacks specificity for cases that are not partial obstructions and require surgical management . HoweverA 57-year-old male presented to the emergency department complaining of abdominal symptoms that included nausea, emesis, diffuse constant lower abdominal pain, and obstipation. The symptoms began shortly after he strained to start a boat motor three days ago. On initial presentation, he reported 10 episodes of emesis in the last 24 hours and no flatus or bowel movements for the past three days. His past medical history included a diagnosis of schizophrenia, however, he denied having any past surgical history or previous abdominal surgeries. Complete blood count, comprehensive metabolic panel, and electrolytes on admission were within normal limits except for noted hypokalemia of 3.5 mmol/L which was subsequently corrected with fluid resuscitation. CT scan of the abdomen and pelvis with contrast demonstrated a distended stomach, air-fluid levels, and distention of the small bowel down to the region of the left hemipelvis with completely decompressed loops of the distal small bowel   interrupted suture to prevent a recurrence. The patient had a normal recovery without complications and was discharged two days following the operation. In his two-week post-operative follow-up, there were no complaints on concerns indicative of further interventions.Internal hernias are rare causes of bowel obstruction, and they are often difficult to diagnose preoperatively. Sigmoid hernias, which involve intestinal herniation through the sigmoid mesentery, account for up to 6% of all internal hernias and are responsible for roughly one out of every 800 cases of small bowel obstruction -4. The rIntestinal protrusions through openings in this mesentery, whether acquired or congenital, form an internal sigmoid hernia. Intersigmoid hernias are typically divided into three categories based on their characteristics: intersigmoid hernias, transmesosigmoid hernias, and intramesosigmoid. Intersigmoid hernias involve the incarceration of the bowel through the intersigmoid fossa -7,9-10. Since the intersigmoid fossa is a relatively common anatomical finding, there is a lot of speculation surrounding risk factors for its development. Some literature suggests that the entrapment of the small intestine in the pelvic cavity by adhesions secondary to previous abdominal surgeries is a risk factor for an intersigmoid hernia . Some liDue to the rarity and lack of clear clinical or radiological features, intersigmoid hernias are often found, as in our case, during surgical exploration of the abdomen indicated for an acute small bowel obstruction -13. CT sWhile the first successful surgical repair of intersigmoid hernias was described in 1910, there is currently still no agreed-upon standard method of repair . CurrentDebates exist surrounding the necessity to close the intersigmoid fossa after the reduction of the herniated intestine. The majority of surgeons advocate for the closure of the intersigmoid fossa in order to prevent the recurrence of herniation through the opening ,6,9,15. Our case demonstrates an intra-operative diagnosis of intersigmoid hernia and demonstrates the effectiveness of using a laparoscopic approach to reduce the herniated intestine to close the opening in the sigmoid mesentery. While there is insufficient evidence to verify superiority, we recommend a laparoscopic approach for intersigmoid hernia treatment as well as the closure of the mesenteric defect to prevent a recurrence.


Tuberous sclerosis (TS) is a multisystem neurocutaneous disorder with an autosomal dominant pattern of inheritance. It is characterized by hamartomas that damage the skin, kidneys, lungs, heart, and central nervous system, among other organs. Rhabdomyomas, benign tumors of aberrant myocytes, are common in affected patients at birth. Depending on their size and location, these lesions might create valvopathies, which can cause heart failure or malignant arrhythmias, or they can cause obstruction of the outlet or inlet tract. Before making the diagnosis, a long time-even years-often passes. Early diagnosis can help prevent permanent irreversible complications. Differential diagnoses may include neurofibromatosis type 1, Sturge-Weber syndrome, and von Hippel-Lindau disease, among others. Diagnostic aids, such as MRI, CT scans, and genetic testing, can be useful in confirming a diagnosis of TS. Histological findings may include the presence of hamartomas, which are benign tumors composed of abnormal cells. Treatment for TS is mainly supportive and may involve medications to manage symptoms, and surgery to remove tumors. We present the case of a 23-year-old woman with TS who was admitted with macroscopic hematuria and fever, with further workup revealing tumor-like cardiac lesions associated with infective endocarditis. TSC1 or TSC2). It is characterized by hamartomas that affect multiple organs, including the central nervous system (CNS), skin, kidneys, lungs, and heart. This condition affects 1/6,000-1/10,000 live births, without gender or race preferences [Tuberous sclerosis (TS) is a multisystem neurocutaneous disorder with an autosomal dominant pattern of inheritance. It occurs by deletion, rearrangement, and inactivation of tumor suppressor genes TSC or TSC2.ferences . Approxiferences . Accordiferences ,5. In a ferences ,8. ThereWe present the case of a 23-year-old woman with a past medical history of TS, diagnosed at six months of age, which had manifested as CNS and renal angiomyolipomas. In the past, her renal involvement has caused macroscopic hematuria resulting in transfusion support and the need for selective arterial embolization.On this occasion, she consulted again reporting hematuria. She was admitted to a high-complexity hospital where she was in fair general condition and was found to have a blood pressure of 100/70 mmHg, a heart rate of 110 beats per minute, and an oxygen saturation of 96%.On physical examination, a systolic ejection murmur in the aortic area was detected. Given the clinical suspicion of a new angiolipoma with hematuria, contrast-enhanced abdominal tomography was performed and bilateral renal angiomyolipomas were documented, causing dilatation of the collecting cavities.Streptococcus sanguis in all three cultures drawn, with persistence in positivity despite antibiotic treatment, and a transesophageal echocardiogram (TE) was ordered, taking into account the high risk of infective endocarditis of S. sanguis. The TE described a left ventricle with concentric hypertrophy, preserved global contractility, left ventricle ejection fraction (LVEF) of 59%, global longitudinal strain of -15.2%, preserved diastolic function, a tri-leaflet aortic valve with thickening and infiltration of the left coronary leaflet by an echo-dense image of 1 cm2 without independent movement of the leaflet , with restriction of its opening, but with a valve area of 1.3 cm2 by planimetry, with the presence of a discrete subaortic membrane that causes severe subvalvular stenosis  with moderate to severe regurgitation   criteria for surgical management  . StudiesTogether, a single surgical procedure was carried out for aortic valve replacement with bioprosthesis and resection of the aortic subvalvular membrane, with right radical laparoscopic nephrectomy Figures -2C.Histological findings showed fibroconnective tissue with inflammatory lymphoplasmacytic infiltrate, multinucleated giant cells, and extensive areas of necrosis with fibrin, abundant polymorphonuclear neutrophils that form microabscesses, associated with a neoplastic lesion made up of multiple spindle cells with an epithelioid appearance and a clear and eosinophilic cytoplasm, accompanied by vessels and smooth muscle, findings consistent with an epithelioid angiomyolipoma-type neoplastic lesion.The patient was subsequently discharged with warfarin formulation as an anticoagulant. At a three-month follow-up, she had an adequate post-surgical evolution and denied recurrence of the bleeding. In a multidisciplinary meeting, due to her considerable improvement, her anticoagulation was discontinued.There is a wide range of cardiac tumors that are classified as benign and malignant. In frequency, the number of secondary tumors is greater than that of the primary ones. When clinicians do encounter a primary cardiac tumor, 90% are benign; but despite this, they can lead to hemodynamic complications of a mechanical type or arrhythmias, depending on their location and size in the heart ,11.During childhood, the most common tumors are rhabdomyomas (45%), fibromas, teratomas, and myxomas (15% each) . During As previously mentioned, the presence of cardiac tumors in the context of TS is a well-known scenario. However, this is common during childhood. The literature mentions the existence of factors that favor disease penetrance into adulthood, associating mild phenotypes, mosaicism, and the effect of disease-modifying gene polymorphisms . The vasTS is a rare genetic disorder that causes the development of benign tumors in various organs, including but not limited to the kidney, CNS, and cardiovascular system. It can lead to symptoms such as seizures, developmental delays, and skin abnormalities. We presented the case of a woman with a history of TS, who was found to have cardiac compromise due to a valvular rhabdomyoma that required surgical intervention. In cases like this, when clinical suspicion arises, in patients with a known history of TS, and due to the risk of heart failure from delayed diagnosis and the asymptomatic nature of these tumors, echocardiography is recommended at any age, even in adolescence or adulthood. A prompt diagnosis and treatment, when feasible, can help prevent further irreversible complications and improve the quality of life for these patients.