Neonatal limb ischaemia is a rare disease entity with devastating morbidity, including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. We report a case of limb revascularisation and salvage due to intrauterine brachial artery thrombosis. Published literature is limited to case reports and case series, with various treatment modalities discussed. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life-long morbidity.A male baby at (36+6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularization was achieved with a contralateral interposition reversed great saphenous vein graft. Though extremely rare and the clinical presentation varies with the location and timing after birth, the surgeon should maintain a low threshold for suspicion of in the presence of the characteristic sequelae of ischaemia. Doppler ultrasonography can aid the diagnosis where ambiguous, and therapy should be individualised based on the clinical presentation; this case emphasises the role of surgery in limb salvage. We report a case of limb revascularisation and salvage due to intrauterine brachial artery compression. Neonatal limb ischaemia is a rare disease entity with devastating morbidity and mortality. The newborn haemostatic pathways and both intrauterine and postnatal events are felt to be precipitating factors. Cases have been reported across the literature, with various treatment modalities discussed - medical, endovascular and surgical. Consensus varies regarding management. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life-long morbidity.This article was previously presented as a poster at the ASIT x MedAll Surgical Summit on 17th October 2020.A full-term (36+6week) male baby was born to a nulliparous mother via elective caesarean section. Her antenatal history was notable for controlled gestational diabetes mellitus. There were no other pre- or peri-natal issues. All antenatal scans were normal. Family history was unremarkable - no thrombotic or ischaemic diseases. Delivery was uncomplicated. The umbilical cord and placental gross examination were normal. Birth weight was appropriate, and Apgar scores were normal. Post delivery, the patient was noted to have an oedematous, ecchymotic right forearm and hand. - With small foci of epidermolysis and dry necrosis on the dorsal forearm Figure .The limb was cool and hypovascular, with a capillary refill time of five to six seconds. Brachial, radial, and ulnar pulses could not be felt clinically or detected sonographically. The volar forearm compartment was tense, but the remaining compartments were normal. The limb demonstrated no spontaneous motor movement - asymmetric moro and grasp reflexes. Limb assessment elicited patient distress indicating no sensory deficit. The remaining examination demonstrated an innocent systolic murmur (grade 1/6). Bedside transthoracic echocardiography was normal. Additional examination was normal, including growth parameters.A plain radiograph of the chest and upper limb showed no cervical rib fracture or dislocation. Doppler ultrasound of the right upper limb showed no arterial flow from the upper 1/3 brachial artery distally - no additional findings were reported. Blood parameters indicated a normal complete blood count, C-reactive protein, erythrocyte sedimentation rate (ESR), renal profile, liver profile, coagulation, vasculitic and thrombophilia screen. Creatine kinase (CK) measured 7500 U/L .Initial management was with topical nitrates, but this was ineffective. The patient proceeded to the emergency exploration of the right arm/ forearm under general anaesthetic on day two. Findings included an anomalous Langer’s axillary arch, dense fibrotic circumferential constriction of the brachial vessels and plexus, with proximal venous engorgement and distal intraluminal brachial artery thrombosis over a 3cm segment, including the profunda brachii origin Figure .An anomalous arterial branch was noted, arising directly off the brachial artery cephalic to the pathological constricted segment supplying collateral flow to the limb. The thrombosed brachial artery segment was excised and reconstructed with a contralateral interposition reversed great saphenous vein graft. Vessel calibres were 3 mm  and 0.5 mm (great saphenous vein), respectively  grade 5 power globally).Neonatal limb ischaemia is a rare disease entity, with the incidence of symptomatic neonatal thromboembolism reported to be 0.5 per 10,000 live births [Neonatal compartment syndrome with impending Volkmann’s contracture has been reported throughout the literature. Armstrong et al. reported six cases over 12 years - the majority were managed conservatively. Ragland et al. reported on their experience of 24 cases of idiopathic unilateral forearm compartment syndrome in newborns over a 20-year period. Notably, all cases had a similar clinical presentation to our patient - soft tissue skin lesion. No obvious aetiologies were noted, and there were no patterns of risk factors in this cohort. Only one patient was evaluated and treated by a hand surgeon during the first 24 hours, with normal hand function at the one year follow-up. The remaining cases were assessed late (between the ages of 0-13), with established Volkmann’s ischaemic contracture with variable muscle, bone and neural morbidity. They all required multiple staged reconstructive procedures with variable long-term function [Neonates have different concentrations and availability of coagulation and fibrinolytic components when compared with older children and adults. The concentrations of clotting factors, thrombin production and coagulation inhibitors are lower, and they are therefore at increased risk of both bleeding and thrombotic complications .Precipitating events causing neonatal limb thromboembolism and /or ischaemia may be intrauterine or post-natal. Greater than 90% of thromboembolic cases in neonates are post-natal and associated with iatrogenic events - arterial and/or venous access devices. Additional risk factors include maternal lupus, maternal diabetes, birth asphyxia, neonatal polycythaemia, sepsis, poor cardiac output, and dehydration .Rarely the thromboembolic event occurs in the intrauterine period. The exact pathological mechanism is unknown. Both extraluminal and intraluminal mechanisms have been proposed as risk factors. Extrinsic causes range from mechanical compression to fetal posture and oligohydramnios, umbilical cord loops, amniotic band construction, and direct birth trauma. Intraluminal theories reference the abnormal haemostatic pathways discussed earlier .Clinical presentation varies with the location and timing after birth. The initial diagnosis is based on the characteristic sequelae of ischaemia. Doppler ultrasonography can aid the diagnosis, with angiography useful in certain cases for pre-planning and/or following treatment. The published literature is limited to case reports and case series of various institutions and is subsequent to positive reporting bias. To date, there are no randomised controlled trials comparing different treatment therapies. Authors have published a number of treatment algorithms -7.Therapy should be individualised based on the clinical presentation. First-line treatment consists of unfractionated heparin, with or without thrombolysis. These measures must be instituted with a high degree of caution and vigilance, and if non-surgical modalities are contraindicated, ineffective, or clinical presentation is severe, then surgery should not be delayed. The consensus regarding the criterion, timing and operative approach varies in the literature. Surgical options described by multiple authors include decompression of the affected limb to augment the residual vascular flow; open thrombectomy (linear arteriotomy with atraumatic milking of thrombus); and segment arteriectomy with interposition reversed vein graft. The use of a small Fogarty catheter has also been reported to remove embolus, but many authors have reported difficulty with this technique: vessel wall intimal damage or rupture ,9. Neonatal limb ischaemia is a rare disease entity with devastating morbidity- including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The newborn haemostatic pathways and both intrauterine and postnatal events may be precipitating factors. Clinical presentation varies with the location and timing after birth. The initial diagnosis is based on the characteristic sequelae of ischaemia. Doppler ultrasonography can aid the diagnosis. Therapy should be individualised based on the clinical presentation. With advances in neonatal anaesthesia and, notably, the evolution of microsurgery, surgical treatment is now a safe and effective option. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life-long morbidity.


Perforated peptic ulcer disease is a serious complication of peptic ulcer disease (PUD) that presents as acute abdomen. It is very uncommon during pregnancy, but its diagnosis in pregnancy is very challenging in general, and more so in the third trimester. Timely diagnosis and prompt surgical intervention can prevent maternal and fetal mortality, but delayed diagnosis is linked with poor maternal and fetal outcomes. The aim of this case report is to emphasize the need for healthcare professionals to consider the differential diagnosis of perforated PUD when presented with cases of acute abdomen in pregnancy and to involve a multidisciplinary team in management for better feto-maternal outcome.A 35-year-old pregnant Ethiopian woman, Gravida 7 and Para 6, presented with a sudden onset of right upper quadrant pain, nausea, and vomiting of 7 hours duration at 36 weeks of gestation. She also had contractions and leakage of liquor of two hours duration. Her abdomen was grossly distended, rigid, and diffusely tender, and showed limited movement with respiration. An upright abdominal X-ray demonstrated air under the diaphragm. She was diagnosed with perforated peptic ulcer disease. Labor was augmented, and a 2.9-kg live male neonate was delivered vaginally. Two hours after delivery, laparoscopic omental patch repair was performed. The patient was discharged 7 days after the omental patch repair surgery in stable condition.Perforated PUD in pregnancy is a rare occurrence, which may account for the delay in diagnosis and management. Obstetricians should keep a high index of suspicion when a pregnant woman presents with acute abdomen. Care provided by obstetricians should be coupled with care provided by other disciplinary teams, in order to reduce maternal and fetal morbidity and mortality. Peptic ulcer disease (PUD) and its complications, including perforated peptic ulcer, during pregnancy are very uncommon, ranging from one to six in every 23,000 pregnancies –3. PeptiA 35-year-old Ethiopian woman, Gravida 7 and Para 6, with no significant past medical history presented to Dilchora Referral Hospital at gestational age of 36 weeks with a sudden onset right upper quadrant pain of 7 hours duration that radiated to her back. She had experienced nausea and vomiting during the night prior to her presentation at the hospital coupled with inability to tolerate oral intake. Her presentation at the hospital was driven by worsening of these symptoms. She had history of intermittent burning type of epigastric pain prior to pregnancy. She also had contraction and leakage of liquor of 2 hours duration which started while on the way to our hospital. There was no history of vaginal bleeding.Upon arrival, the patient was in acute distress, with the following vital signs: blood pressure, 95/60 mmHg; pulse rate, 132 beats per minute (bpm); respiratory rate, 32 breaths per minute; and body temperature, 35.9 °C. Abdominal examination showed a grossly distended, rigid, and diffusely tender abdomen, which showed limited movement with respiration. Uterine fundal height was consistent with the gestational age. There were three uterine contractions in 10 minutes, each lasting for 35–40 seconds. The fetal heart beat (FHB) ranged from 120 to 158 bpm. Digital vaginal examination revealed a cervix of 3-cm dilation, a ruptured membrane, clear liquor, and high station. An upright abdominal X-ray demonstrated air under the diaphragm , it might be quite difficult for patients to localize the pain. Perforated PUD presents as an acute abdomen, and its diagnosis can be very challenging, and possibly delayed, especially in women in their third trimester. Factors contributing to the delayed diagnosis of perforated PUD include rarity of the disease in pregnancy and the non-specific symptoms of the disease. The symptoms are mimicked by other common gastrointestinal problems in pregnancy, such as nausea and vomiting during pregnancy, hyperemesis gravidarum, gastroesophageal reflux disease, and cholecystitis. In our patient, the pain was sudden in the onset right upper quadrant pain that radiates to the back. She also had nausea and vomiting on the night prior to arrival at the hospital with an inability to tolerate oral intake.Uncomplicated PUD presents with minimal physical signs, but when complicated with perforation, it presents with signs of peritonitis, including tachycardia, abdominal tenderness (or even guarding), and rebound tenderness. At presentation, our patient was in acute distress, with a pulse rate of 132 bpm and a respiratory rate of 32 breaths per minute; abdominal examination revealed a grossly distended, rigid, and diffusely tender abdomen that limited respiration movement.In pregnancy, the use of diagnostic radiography modalities, such as an upright abdominal X-ray to establish the diagnosis of perforated PUD, are limited due to the potential deleterious effects of ionizing radiation on fetal safety . HoweverManagement of perforated PUD in pregnancy requires a multidisciplinary team that includes obstetricians, surgeons, gastroenterologists and pediatricians. The management includes initial resuscitation with crystalloids, correction of electrolyte imbalance, nasogastric suction, administration of intravenous broad-spectrum antibiotics, and medications for PUD, such as proton pump inhibitors, followed by laparotomy after patient stabilization. The recommended surgery for perforated PUD is omental patch (Graham’s patch) repair which involves primary closure with the placement of an omental patch for support . Non-obset al. described 14 cases of perforated duodenal ulcer in pregnancy in which all 14 mothers lost their lives [Although perforated PUD is extremely rare during pregnancy, when this occurs, survival of both mother and child is unusual. In their literature review published in 1962, Paul Perforated PUD in pregnancy is rare, which may account for the delay in its diagnosis and management. Therefore, obstetricians should have a high index of suspicion when pregnant mothers present with acute abdomen. Management must be coupled with coordinated care by other disciplinary teams to reduce maternal and fetal morbidity and mortality.


We describe a case of superficial acral fibromyxoma arising within the germinal matrix of the index finger. This is an uncommon localisation of this relatively newly described benign soft tissue tumour. Herein, we discuss the varied clinical presentation, distinguishing histopathological features and important differential diagnoses for this condition.  It has a host of differentials including benign and malignant tumours, and is distinguished by its histological and immunohistochemistry features (strong positive for CD34 and CD99).What does this study add?This case describes the clinical presentation and pathological features of a case of SAF affecting the germinal matrix which has rarely been reported.2Superficial acral fibromyxoma (SAF), also known as digital fibromyxoma, is a rare benign soft tissue tumour with a predilection for the digits, first described in 2001 in a series of 31 cases.3A 48‐year‐old woman presented with a 3‐month history of changing pigmentation on the nail of her right index finger. She reported a history of a narrow band of longitudinal melanonychia present for at least 5–6 years prior, which became more noticeable as the colour darkened and widened. She described occasional discomfort at the base of the nail but did not recall any history of trauma. She has frequent manicures, and works as an artist with regular contact with wet surfaces, fibres and soils. The patient had a history of a benign breast lump and benign ovarian mass; but was otherwise healthy. She was of mixed South American and European ancestry and had Fitzpatrick phototype IV skin. She had no personal history of melanoma but a family history of melanoma in a second degree relative. On examination, there was localised nail dystrophy with trachyonychia and subungual haemorrhage. Hutchinson sign was negative Figure .Due to the history of previous melanonychia, progressive nail dystrophy and recent rapid change, the patient underwent nail matrix biopsy to rule out melanoma. A pedunculated lesion in the germinal matrix was evident, which was excised and sent for histology. Histopathology showed a polypoid tumour based within the superficial dermis, composed of bland spindle and stellate cells within a myxoid and collagenous stroma Figure . The cel4Superficial acral fibromyxoma is an emerging differential diagnosis for benign soft tissue tumours affecting the digits. Although incidence data is lacking, it has been increasingly described and may be more common initially assumed. Clinically, up to 97% of finger tumours grow in close proximity to the nail apparatus, and subungual lesions have been reported in 43% of finger cases, others being periungual.The description of longitudinal melanonychia prior to onset of the mass is unusual and warranted concerns of a malignant differential diagnosis. This however was most likely explained by haemorrhage rather than true melanin deposition. Superficial acral fibromyxoma associated with haemorrhage has previously been reported to mimic a pigmented differential.Histologically, the tumour is characterised by stellate, ovoid or spindle shaped cells, in a storiform, lobular or fascicular growth pattern. The stroma is myxoid or myxocollagenous and the tumour is non‐encapsulated. Margins may be irregular, and some may extend into subcutaneous tissue, underlying fascia or even bone.Clinical differential diagnoses of subungual tumours presenting with nail dystrophy include the benign glomus tumours, subungual keratoacanthoma, subungual exocytosis, digital mucous cysts, onychomatricoma and onychopapilllomaNeurofibroma (distinguished by S100 positivity), dermatofibrosarcoma protuberans of myxoid type (prefers trunks and extremities and EMA negative), superficial angiomyxoma , low‐grade fibromyxoid sarcoma and myxofibrosarcoma . These should be distinguished by clinical, histological and immunohistochemistry features.Surgical excision is the recommended management, however pre‐operative imaging with radiological assessment  may be required to assess for bony involvement.There are reports of recurrence in 20%–25% of cases, although no reports of malignant transformation are noted to date.The authors have no conflict of interest to declare.Genevieve Ho: Conceptualization (lead); data curation (lead); writing – original draft (lead); writing – review & editing (lead). Caroline Kurek: Data curation ; Investigation ; Writing – review & editing . David Stewart: Conceptualization ; data curation ; Writing – review & editing . Linda K Martin: Data curation ; Supervision (lead); Writing – review & editing .The patient has consented for use of de‐identified clinical images and information in this report; ethics review was not required as it is a retrospective case report.


Langerhans cell histiocytosis (LCH) was first proposed in 1987 to define the disorder characterized by the proliferation of abnormal Langerhans cells. It is more likely to occur in children younger than 15 years of age. Single-site and single-system LCH of rib is rare in adults. We present a rare case of isolated rib LCH in a 61-year-old male patient and expound the diagnosis and treatment of the disease. A 61-year-old male patient who presented with a 15-day history of dull pain in the left chest was admitted to our hospital. PET/CT image showed obvious osteolytic bone destruction and abnormal fluorodeoxy-glucose (FDG) uptake  in the right fifth rib with local soft tissue mass formation. The patient was eventually confirmed the diagnosis of LCH by immunohistochemistry stain and treated with rib surgery. A thorough review of the literature regarding diagnosis and treatment of LCH is presented in this study. Langerhans cell histiocytosis (LCH) was first proposed in 1987 to define the disorder characterized by proliferation of abnormal Langerhans cells . DependiLCH is rare. It is more likely to occur in children younger than 15 years of age; the incidence in adults is about 1/10 of that in children .The cause of LCH remains unknown; however, the suggestion that LCH is either a reactive or neoplastic process has been widely accepted. The tumor hypothesis suggests that the disease is associated with the BRAF gene mutation, and it typically responds to chemotherapy. Another hypothesis implies that LCH is a reactive disorder, which leads to abnormal reactions of Langerhans cells and T lymphocytes . The dia99mTc-methylene diphosphonate single photon emission computed tomography, 99mTc-MDP SPECT and 18F-fluorodeoxy-glucose positron emission tomography/computed tomography, 18F-FDG PET/CT.We present here a rare case of a 61-year-old male patient with a solitary LCH lesion in the rib evaluated by 99mTc-MDP SPECT was performed. A lesion with high uptake of 99mTc-MDP in the left fifth rib was revealed and no other lesions were found in the image  in the left fifth rib with local soft tissue mass formation  was positive and other laboratory indicators were normal. No obvious abnormalities were found in physical examination. Plain chest CT showed an osteolytic lesion in the left fifth rib. To evaluate the extent of skeletal lesions, he image . These tormation . With noormation . The patLCH is a rare disease characterized by the proliferation and infiltration of Langerhans cells. It commonly occurs in children, and the incidence in adults is about one to two cases per million. In the case we presented, the patient was 61 years old, and it is a rare case for the age.Classically, LCH was defined as three different kinds of syndromes: eosinophilic granuloma, Abt–Letterer–Siwe disease, and Hand–Schuller–Christian disease. Currently, LCH has been described as a broad spectrum of diseases ranging from local single-system lesions to disseminated multisystem diseases based on the number of involved sites, the site of lesions, and whether the disease is involving “risk organs” . The skull is the most commonly involved of the skeleton system, which occurs in more than two-thirds of patients, followed by the spine, limbs, and pelvis . The lesA biopsy of the involved site is suggested to confirm the diagnosis. The histological features of LCH are various, and the primary lesion is granulomatous with polymorphic infiltrate of mixed LCs, T lymphocytes, macrophages, multinucleated giant cells, and eosinophils . The cel18F-FDG PET/CT has been proven to have a greater accuracy in identifying active lesions and is now being routinely used to monitor the disease in the initial evaluation and follow-up  are involved or in the case of single-system disease with multiple lesions or multisystem diseases, systemic chemotherapy is suggested . Accordi18F-FDG PET/CT is useful for the diagnosis, staging, and prognostic evaluation of LCH, especially for identifying occult multiorgan involvement. 18F-FDG PET/CT has been routinely used to monitor diseases during treatment. Although single-site and single-system LCH of the rib are rare in adults, it can be treated well with surgery and systemic chemotherapy is not suggested. LCH should not be neglected in the diagnosis of an adult with a lytic rib lesion.In conclusion, we present here a rare and unusual case of an adult with isolated rib LCH. LCH most frequently occurs in children while our patient is a 61-year-old male. Differential diagnosis should include osteomyelitis, osteochondroma, plasmacytoma, and Ewing's sarcoma before the results of histopathology especially immunohistochemical phenotype.


Herniation of the thoracic intervertebral disc (HTD) is a rare disease that accounts for <1% of all disc herniations. Physicians may make diagnostic errors due to the variable clinical features and limited experience of HTD. In this report, we present 2 unusual cases of HTD.A 72-year-old woman (case 1) visited our pain clinic because of chronic abdominal discomfort with visible bulging on the left side. Atrophy of the abdominal wall muscle and quadratus lumborum was observed. The therapeutic effect of interfascial plane block to exclude the possibility of truncal neuropathy following muscular atrophy was temporary. The other patient, a 75-year-old man (case 2) complained of aggravation of previously diagnosed postherpetic neuralgia. An extension of the previously symptomatic area of the forward upper dermatome was observed. Radiofrequency treatment on the symptomatic dorsal root ganglion failed to relieve symptoms.Two patients underwent magnetic resonance imaging of the spine for further evaluation. The patients were diagnosed with multilevel HTD and foraminal herniated disc, compatible with their symptoms and without myelopathy.Two patients were conservatively treated with a fluoroscopy-guided transforaminal epidural block.The 2 patients experienced significant pain reduction up to 50% on a numeric rating scale after repeated treatment.Multilevel HTD of the mid- to lower-thoracic spine may present as abdominal bulging with atrophy of the abdominal wall muscles. We also report another case of concomitant symptomatic thoracic radiculopathy from HTD and postherpetic neuralgia at the adjacent level. Thoracic transforaminal epidural block may be considered a conservative therapeutic approach for HTD. The sensory and motor symptoms may be equally common in cases of myelopathy accompanied by spinal cord compression. In a recent study, Ahi and Goktan suggested that the neuropathic nature of chronic back pain radiating to the chest and abdomen may be highly predictive of HTD.Herniation of the thoracic intervertebral disc (HTD) is a rare disease that accounts for < 1% of all disc herniations, Therefore, the differential diagnosis of thoracic radiculopathy from these more prevalent diseases is complicated for physicians in clinical practice. Moreover, the exact diagnosis can often be delayed because HTD often manifests with unexpected presentations, such as abdominal or pelvic pain, which may be misdiagnosed as a gastrointestinal or even gynecological condition.Radiating truncal pain and/or concomitant back pain are somewhat nonspecific presentations in several neuropathic or musculoskeletal diseases at the thoracic level, such as intercostal neuralgia, herpes zoster, diabetic truncal neuropathy, compression fractures of the thoracic spine, and entrapment syndrome of the abdominal cutaneous nerve.In this report, we present 2 unusual cases of HTD. The first patient was diagnosed with multiple thoracic disc herniations at the mid- to lower-thoracic level, which manifested as abdominal discomfort and anterolateral bulging. The second patient, who had been treated for postherpetic neuralgia at the T12 level for several months, presented with aggravation and extension of a previously symptomatic area. The patient was diagnosed with HTD at the upper adjacent level. Both patients were successfully treated with transforaminal epidural block.Written informed consent was obtained from the patients for publication of this case report.A 72-year-old woman visited our pain clinic because of abdominal discomfort for approximately 1 year. The patient complained of aching and sore anterolateral abdominal pain with a moderate intensity of 6 on the 11-point numeric rating scale. She described her pain as unpleasant abdominal discomfort with visible bulging aggravated by meals. She also complained of shooting flank pain during positional changes or coughing. Several months before presenting at our tertiary care hospital, the patient had been examined for the possibility of various pathologies, such as gastrointestinal and genitourinary organ problems, but the laboratory and radiologic findings were nondiagnostic. The patient reported that analgesics, including a nonsteroidal anti-inflammatory drug, tramadol/acetaminophen combination, and pregabalin, did not relieve her symptoms. On physical examination, visible abdominal bulging, most prominent on the left side, was identified  of the abdomen and pelvic cavity showed atrophic changes in the abdominal wall muscles  on the left side without intestinal hernia Fig. A, B. TheBased on the physical and radiological findings, a pain specialist performed the transversus abdominis plane block or quadratus lumborum block several times to exclude the possibility of truncal neuropathy following muscular atrophy. Trigger point injections in the quadratus lumborum and abdominal wall muscles, where a positive local twitch response was identified, were performed concomitantly. However, symptomatic relief was temporary, and the patient’s abdominal muscle weakness persisted for months. The patient underwent sagittal whole-spine magnetic resonance imaging (MRI) for further evaluation. Based on this evaluation, she was diagnosed with multiple HTD at T8/9/10/11 without myelopathy. A foraminal herniated disc at the left T9/10/11 was also observed Fig. A, B. SubA 75-year-old man visited our pain clinic because of aggravated postherpetic neuralgia (PHN) 1 month prior to presentation. Herpes zoster was diagnosed in the left T12 dermatome approximately 7 months ago, and the patient was treated with antiviral medication during the acute stage at a local clinic. However, he was referred to our pain clinic because of persistent PHN 3 months later. Peripheral nerve blocks, such as intercostal nerve block, rather than epidural block, were planned to minimize the possibility of intraspinal hemorrhage because he was taking direct oral anticoagulants because of his recent history of pulmonary thromboembolism. The zoster-related pain markedly improved after the second peripheral nerve block. The patient was prescribed analgesics for symptomatic relief. However, 3 months later, the patient revisited our clinic with recurrent aggravated PHN for 1 month. The patient stated that he had received pulsed radiofrequency (RF) treatment for PHN at another tertiary care hospital; however, this failed to relieve his symptoms.We planned to use thermal RF for the treatment of the refractory pain. On preprocedural examination, there were no sensory abnormalities, including hypesthesia, hyperalgesia, or allodynia. However, according to the patient, the previously symptomatic area extended to the upper dermatome (most likely to be T10 and T11). During the first diagnostic block before the RF procedure, the dorsal root ganglion (DRG) block for T11 and an additional T10 produced temporary symptomatic relief. The results of the second diagnostic block for T12  were similar. During the RF procedure, a combination of thermal and pulsed RF procedures was performed. Thermal RF was performed only at the T12 DRG because this area produced strong concordant pain during sensory and motor stimulation. Pulsed RF treatment of the T11 and T10 DRG, which showed mild concordant pain during nerve stimulation, was added.One month later, hypesthesia of the T12 dermatome was confirmed using a cold swab. Sustained throbbing and aching pain at the T9/10/11 dermatomal distribution was noted. A T-spine MRI was performed to identify possible reasons. A foraminal herniated disc at the left T9/10 level with a mild degree of disc protrusion at T8/9/10 was identified, which was compatible with his current symptoms Fig. A, B. A t The clinical features of HTD are highly variable, and the localization of the involved thoracic level can be more confusing than that of the cervical or lumbar spine. The differential diagnosis of HTD is extensive and may include several spinal and nonspinal causes. Therefore, physicians often experience diagnostic errors because of their clinical complexity and scarcity. HTD may be misunderstood as a lumbar spinal pathology because it may cause leg symptoms suggestive of lumbar radiculopathy. More severe forms of HTD with accompanying cord compression may also display vague leg pain, paraplegia, hyperactive deep tendon reflexes, and positive ankle clonus or Babinski response. Early diagnosis and prompt surgical treatment are crucial for preserving and restoring function.HTD is a rare disease that accounts for <1% of all disc herniations.,12 Moreover, positive direct tenderness and local twitch responses in the quadratus lumborum and adjacent abdominal wall muscles further led to an incorrect diagnosis.In this case report, the authors present 2 patients with unusual HTD in different clinical situations. In case 1, the patient had unusual mimicking symptoms, with the chief complaint of abdominal discomfort and bulging aggravated after meals rather than pain. Therefore, the patient was primarily evaluated for the possibility of operable causes, such as abdominal hernia, by using abdominal CT. Regretfully, the authors did not focus on abdominal wall muscle atrophy, which was a consequence of denervation changes derived from more proximal pathology. The authors initially thought that the abdomen enlargement and abdominal wall muscle atrophy may have stretched the abdominal cutaneous nerve, leading to nerve irritation, due to the “push” mechanism in developing nerve entrapment syndrome.,14 Therefore, physicians should always check the level of herpes zoster involvement in a single dermatome, especially for guiding interventional pain management. However, currently used dermatomal maps are variable and inaccurate. The reason for this variability is due to the skin area being innervated by 2 or more spinal roots, and the presence of an intersegmental anastomosis between the spinal nerve roots. This phenomenon confounded the diagnosis in case 2. This case highlights the importance of careful history-taking and physical examination. This may include determining the nature of the pain and characteristic relieving or aggravating factors, such as the Valsalva maneuver, to discriminate radiculopathy from other pathologies.In case 2, symptomatic thoracic radiculopathy due to HTD was misinterpreted as PHN. It is well known that herpes zoster generally involves a single DRG unilaterally, although multiple ganglia involvement has been reported in herpes zoster developing in the cranial nerve, such as in Ramsay Hunt syndrome. In this case report, both patients were successfully treated with epidural block. Several guidelines for lumbar and cervical disc herniations suggest a favorable level of evidence for transforaminal epidural steroid injections in radiculopathies.,19 For HTD, there are no consensus guidelines, and the literature on the topic is sparse.,21 Further investigations and evidence-based consensus guidelines are necessary. Our 2 patients experienced considerable symptomatic relief of a 50% reduction in NRS following thoracic transforaminal epidural blocks with steroid or hypertonic saline. We identified the appropriate contrast flow reaching the nerve root and the anterior epidural space using fluoroscopy. For the epidural block to be effective, the drugs must reach the anterior epidural space because the disc–nerve interface is located there. Target-specific epidural blocks were therapeutically effective, and HTD and accompanying radiculopathy were considered the main causes of patient’ complaints.In addition to diagnostic difficulty, HTD has therapeutically challenging issues owing to the relatively higher complication rates of surgical treatment.Multilevel HTD of the mid- to lower-thoracic spine may present as abdominal bulging with atrophy of the abdominal wall muscles. Concomitant PHN and HTD at adjacent thoracic levels may also occur. Thoracic transforaminal epidural block should be considered as a conservative therapeutic approach for HTD.Data curation : Yu Jin Oh and Seon Hwa NamMethodology : A Ram Doo and Cheol Jong WooWriting- original draft : Min Jong KiWriting- review & editing : A Ram Doo


In patients with obstructive pancreatitis due to choledocholithiasis, endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care. ERCP-induced inflammation or infection of the common bile duct  is a rare complication with a high mortality rate in severe cases. We report an unusual case of incidental findings of intense FDG uptake in the common bile duct one month post-ERCP without clinical features of acute cholangitis, indicative of inflammation of CBD associated with or exaggerated by ERCP. Endoscopic retrograde cholangiopancreatography (ERCP)-induced cholangitis is rare, with a rate of 1% or less , but it We present a case of intense fluorodeoxyglucose (FDG) uptake in the common bile duct (CBD) one month post-ERCP in a patient who initially presented with acute pancreatitis.A 67-year-old male with a remote history of colon cancer post-proctocolectomy and cholecystectomy presented with a 24 h history of abdominal pain radiating to the back. He felt generally unwell and denied any fever or chills. The patient had prior ERCP.Initial laboratory testing showed critically elevated lipase and elevated white blood cell count with low sodium. ALP, ALT, AST, and bilirubin were normal. There was no evidence of bacteremia or sepsis. Initial ultrasound was equivocal for gallstones. Initial CT of the abdomen and pelvis demonstrated peripancreatic fat stranding and heterogenous appearance of the parenchyma consistent with acute pancreatitis  was performed approximately one month post-ERCP. In addition to a moderately hypermetabolic left upper lobe pulmonary nodule, which was later proven to be a metastasis from colon cancer, there were incidental findings of increased uptake in the CBD, with a SUVmax of 13.3, suspicious for cholangitis , which in most cases is a consequence of biliary obstruction . Diagnoscriteria ,6. In adAcute cholangitis could co-exist with acute pancreatitis. In a single-center study, 32 (23%) patients presented with both conditions over 10 years (the diagnosis of acute cholangitis was based on Charcot’s triad), and the majority were treated with ERCP . It is pIncreased uptake in the CBD associated with malignant and benign neoplasm has been reported. Cholangiocarcinoma and invasive intraductal papillary neoplasm of the bile duct are FDG avid ,9,10. FD18F] FDG PET is a molecular imaging modality commonly indicative of various cancers. It is also indicated in identifying the cause of fever and inflammation of unknown origin [[n origin ,17,18. Fn origin ,20. Nagan origin  reportedIn our center, FDG PET is only performed for oncology indication. In this patient with a solitary lung lesion referred for FDG PET with incidental findings of CBD uptake post-ERCP, there was no indication for FDG PET follow-up. The etiology of the intense FDG uptake is speculative, based on the available radiological and FDG PET imaging, as well as clinical follow-up. The intense FDG uptake could possibly be due to CBD smooth muscle peristaltic spasm, although no such findings have been documented. The incidental findings of intense FDG uptake in the CBD in our case could be representative of a resolving inflammatory process due to ERCP or exaggerated by ERCP, supported by the patient’s lack of symptoms and normal follow-up MRCP. This is different from typical acute cholangitis caused by introduction of enteric bacteria through a contaminated endoscope.Increased FDG uptake along the CBD in patients post-ERCP could be due to an inflammatory process caused or exaggerated by ERCP. This should be distinguished from acute infectious cholangitis, as the two have different etiology and clinical presentation.


Bull gore injuries are not uncommon in regions where bulls are commonly used for agriculture or as part of sporting culture. Most bull gore injuries occur in the trunk and extremities. Cervical bull gore injury might be due to penetrating or blunt trauma. In the neck, it may injure vital structures such as the trachea, esophagus, and carotid artery. Traumatic cervical esophageal injury is a rare entity. Prompt diagnosis and early intervention are essential for better outcomes. Delayed diagnosis (>24 hours) is associated with a mortality of 40-66%. Here, we report a case of a bull gore injury to the neck where the patient presented to our trauma bay after seven days. On evaluation, he was diagnosed with cervical esophageal injury and treated with primary repair of the esophagus over a T-tube and a feeding jejunostomy. He recovered well and was doing well on follow-up. Bull gore injuries are not uncommon in rural areas of tropical countries where cattle are used for agriculture. Most bull gore injuries occur to the trunk and extremity, with head and neck injuries varying from 3.1% to 19% . TraumatA 39-year-old gentleman, a farmer by occupation, sustained a bull gore injury to the neck. He presented seven days later to our hospital with a complaint of swelling in the neck and purulent discharge from the wound. On the primary survey, his airway, breathing, and circulation were normal at presentation. On examination, erythema around the neck wound was present, and crepitus was noted on palpation. His vitals were stable, and cross-sectional imaging (CT scan) without oral contrast of the neck and chest revealed pneumomediastinum and paraesophageal collection with air foci Figures , 1B. EsoPostoperatively, the patient was kept nil per oral and enteral feed was given through FJ. On postoperative day three, he developed febrile spikes, and a high-resolution CT scan of the chest showed a paraesophageal collection, which was drained percutaneously. The mediastinal drain was removed when the output was minimal, and the T-tube was removed on the 10th postoperative day. After two weeks, an oral gastrografin study was performed, which showed no contrast extravasation or any narrowing of the esophagus Figure . The patBull gore injuries to the neck can result in penetrating or blunt trauma. The contamination of bull gore results in a higher incidence of wound complications . PatientEsophageal injuries are rare, and traumatic esophageal perforation constitutes 15% of esophageal injuries . DelayedBull gore injuries are not uncommon in areas where bulls are used for agriculture or sporting purposes. Sometimes, they can be life-threatening, leading to increased morbidity among patients. Bull gore injuries leading to penetrating or blunt trauma of the neck are infrequent. A high index of suspicion is needed to rule out cervical esophageal, tracheal, and vascular injuries in case of neck trauma by a thorough evaluation. Delayed diagnosis leads to increased morbidity and mortality. Our patient presented late with cervical esophageal injury. In such scenarios, as the esophageal wall will be friable, primary repair over T-tube with an FJ for enteral nutrition is a good option for optimal clinical outcomes.


We report a case of a benign gastric ulcer (GU) complicated by gastrojenunal (GJ) fistulization which healed with proton-pump inhibitor (PPI) therapy. It presented in an elderly malnourished patient.To highlight this rare complication of benign peptic ulcer disease, as only 13 similar cases are reported. Additionally, our case is one of the few demonstrating medical treatment can effectively heal both the ulcer and GJ fistula, thus obviating the need for surgery.A detailed chart review was conducted to summarize all salient clinical data. Using PubMed database, a comprehensive literature review identified similar cases using MeSH terms such as “gastrojejunal”, “fistula”, and “ulcer” under the case report filter.An 83-year-old previously healthy woman presented with four weeks of weakness, abdominal pain, and nausea. She denied any overt GI bleeding or NSAID use. Physical exam demonstrated cachexia (36.6kg) with benign abdominal and rectal examinations. Initial workup revealed anemia (hemoglobin of 38g/L), iron deficiency, hypoalbuminemia (20g/L) and depleted B12 (108pmol/L). She was started on IV pantoprazole and transfused 3 units of red cells.A gastroscopy revealed a giant, penetrating gastric ulcer at the lesser curvature. The ulcer base showed protruding tissue consistent with a segment of intestine . Examination to the distal duodenum was normal. Biopsies of the ulcer edge were negative for neoplasia. Urease testing of antrum and body samples were negative. CT scan demonstrated a 3.1 cm gastric ulcer with a linear tract communicating with the proximal jejunum, confirming the endoscopic impression.Surgical consultation was obtained; conservative treatment was advised given her age and cachexia. Calorie intake was optimized and the patient commenced twice daily PPI. She rapidly gained 7 kg in the community, accompanied by normalization of albumin (33g/L) and B12 (293 pmol/L) levels. Hemoglobin remained stable near 100g/L after initial transfusion. At month three, repeat gastroscopy was performed. The ulcer and fistula had completely healed. .Gastro-enteric fistulas complicating benign ulcers are rare. When described, other sites, such as gastroduodenal, are more common. Direct gastrojejunal fistulization is less favorable due to the anatomy of the mesentery. The literature reports only 13 gastrojejunal fistulas complicating benign ulcers. In other cases, unique risk factors are reported . Only 3 of 13 reported cases resolved with medication alone. The overwhelming majority required surgery. Notably, many of the case reports pre-date the introduction of proton-pump inhibitors.The etiology of our patient’s ulcer was benign but remains undefined. ASA use was excluded on history, and H. pylori sampling was negative. We speculate profound malnutrition placed her at risk for poor healing and thus contributed to the extensive disease complicated by fistula.NoneNone Declared


Anastomosing hemangioma is an uncommon benign vascular tumor that may be mistaken for a malignancy. The imaging findings of anastomosing hemangioma are not well provided from the previous reports. Herein, in the study, we discuss the imaging findings for one case of retroperitoneal anastomosing hemangioma.One 64-year-old female patient had a left retroperitoneal mass that was incidentally detected upon physical examination. A hypoechoic mass with abundant blood flow signals was found by US in the perirenal space. CT and MRI detected a large cystic and solid lesion in the left retroperitoneal space. Plain CT indicated that the internal density was uneven, and the pattern of enhancement was obvious and progressive. MRI-T2WI showed high intensity, DWI showed isointensity, and the mass also showed obvious progressive enhancement. Finally, anastomosing hemangioma was diagnosed via histopathological studies.As a rare and benign tumour, anastomosing hemangioma is easily misinterpreted. We suggest that the observation of “genitourinary tract related, well defined, hyperintensity or isointensity on T2WI, isointensity on DWI, and obvious progressive enhancement patterns likely to the vascular enhancement” may consider the diagnosis of AH. Anastomosing hemangioma (AH) is an extremely rare and benign vascular tumor that was first described in the genitourinary tract by Montgomery and Epstein . Cases o3 in size, well-defined and irregular, uneven and low density. Additionally, the pattern of enhancement was obvious and progressive. The plain CT value was approximately 17–36 Hounsfield units (HU). Contrast-enhanced CT scanning showed an inhomogeneous enhancement, and the CT value was approximately 111–173 HU in the arterial phase and 232–265 HU in the venous phase. The focal enhancement was likely to the vascular enhancement. Magnetic resonance imaging (MRI) also showed a well-defined and irregular, cystic and solid tumor lesion in the left retroperitoneal space. The T1-weighted image (T1WI) showed low intensity, the T2-weighted image (T2WI) showed iso- and high intensity, the diffusion-weighted image (DWI) showed iso-intensity. Likely to the pattern of enhancement of CT, the mass showed obvious and progressive enhancement on MRI. There was no evidence of invasion of the surrounding organs and no retroperitoneal lymphadenopathy been found. The preoperative diagnosis was diagnosed as being a retroperitoneal paraganglioma. Finally, endoscopic resection was performed after the surgical evaluation, and the histopathological diagnosis was anastomosing hemangioma. To date, the patient has been followed up for 24 months and there is no recurrence and transference of tumor.A 64-year-old Chinese female patient was observed to have a tumor lesion in the perirenal space by US, and was admitted to our hospital. The patient had hypertension, which was controlled well. Laboratory testing including routine blood examinations, serum electrolytes, and tumor markers were normal. The lesion exhibited a hypoechoic mass with abundant blood flow signals in colour Doppler flow imaging (CDFI) on ultrasonography (US) Fig. . ContrasDuring the operation, one tumor was found locate in the left retroperitoneal space, and it exhibited a clear boundary. The tumor had a complete capsule, and no lymph node metastasis. Regarding microscopy Fig. , the lowAH is an uncommon benign vascular tumor, especially occurred in retroperitoneal space. At present, only 18 cases of AH occurring in the retroperitoneal space have been reported in the literatures. Ours is the first radiological case report of AH including US, dynamic CT and MRI findings. From the previous literatures, most of the patients were incidentally identified without related symptoms, and no sex predilection has been previously reported . The ageOn US, AH is usually observed as being a hypoechoic mass with a clear boundary, and some cases have shown rich blood flow signals detected by CDFI , 22, 23.Considering the differential diagnosis, the paraganglioma or other malignant tumours were considered as possible diagnoses. In this case, several characteristics, including, irregular morphology, clear borders, heterogeneous density and signal, and obvious enhancement, were similar to those of a large extraadrenal paraganglioma. Large extraadrenal paragangliomas are often accompanied by necrosis and haemorrhage, sometimes with increased fluid levels caused by the haemorrhage. Additionally, the paraganglioma has a rich blood supply, and thickened tumour vessels can be seen around the mass or in the solid components , 33. AnoAH is a benign tumour, and no recurrence has been reported. To date, the patient presented in this report has been followed for 24 months and has remained disease free. In a number of AH cases, after an accurate core biopsy diagnosis, the patients did not receive further treatment, and follow-ups showed no progression of the disease . From ZhAH is an extremely rare and benign vascular tumour that can involve a large variety of internal sites. Correct diagnoses via imaging remain difficult to produce. We suggest that the observation of “genitourinary tract related, well defined, hyperintensity or isointensity on T2WI, isointensity on DWI, and obvious progressive enhancement patterns likely to the vascular enhancement” may need to be alert to the possibility of AH and may prevent unnecessary surgery for patients with this diagnosis.


Nodular lymphoid hyperplasia of the lung is a rare disease of polyclonal lymphoid proliferation. The incidental finding of a solid nodular lesion with irregular margins adjacent to the visceral pleura in the reported case was highly suggestive of malignancy. The present report underscores the typical immunohistochemical findings and the benign course of nodular lymphoid hyperplasia. The current knowledge about disease aetiology and the value of different diagnostic tools to distinguish nodular lymphoid hyperplasia from other pulmonary lymphoid lesions are summarized by a review of the literature. Surgical resection is not only diagnostic but also curative with no evidence so far that NLH can regress without operation. The present case shows the spontaneous regression of NLH after CT-guided biopsy indicating that an alternative, less invasive diagnostic approach has curative potential. Low-grade lymphoid proliferations in the lung, including those with reactive germinal centers, were commonly classified as low-grade B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) . Howeverκ- and λ-light chain immunoglobulins supporting a polyclonal population  showing a solid nodular lesion with irregular margins adjacent to the visceral pleura with a diameter of 1.2 inches in the upper right lobe . Under spulation , and lympulation . CD3-pospulation . These hThe present case underscores the typical immunohistochemical findings and the benign course of NLH, a rare pulmonary disease with morphological features which are highly suggestive of malignancy. The disease was first described by Kradin and Mark in 1983 and is characterized by one or more benign nodules or localized lung infiltrates composed of reactive lymphoid cells .In these mostly asymptomatic patients, the nodules are typically incidental findings in subpleural, occasionally peribronchial location . Large aThe lesion is usually detected first in an X-ray or CT from the chest. However, there is no radiographic sign specific for NLH, especially in the distinction to malignant tumours. Based on a series of 67 patients, Fang et al. described the typical radiological manifestations of pulmonary NLH as solitary, or multinodular, solid or subsolid nodules with a wide array of additional radiographic findings, including lobulation, spiculation, vessel convergence, and pleural indentation as well as mediastinal or hilar lymph node involvement . Due to To date, there is only little evidence of spontaneous regression of pulmonary NLH without operation. Some studies reported the regression of remaining lesions following the surgical resection of one nodule , 10 and κ- and λ-light chain expression and T cells in the lymphoid infiltrate [The histological picture of NLH is characterized by a dense nodular infiltration of mature, polyclonal lymphocytes and plasma cells with multiple reactive germinal centers, sharply demarcated from surrounding parenchyma and with central areas of scarring. Immunohistochemical staining shows a mixture of B cells with polytypic filtrate . These hfiltrate –14. Howefiltrate . In addifiltrate –18. LIP filtrate . In addifiltrate . Some caNLH is a benign pulmonary disease with morphological features which are highly suggestive of malignancy. To date, the diagnosis is based on the typical histopathological findings with dense nodular infiltration of mature, polyclonal lymphocytes and plasma cells. Surgical resection of the tumour is the standard diagnostic and therapeutic approach to date, and there was no evidence so far that NLH can regress without operation. The present case shows the spontaneous complete reduction of NLH after CT-guided biopsy highlighting an alternative, less-invasive diagnostic approach with curative potential.


The diagnosis of diffuse-type gastric cancers may be challenging due to their submucosal infiltration. A male in his early 60s was diagnosed with signet-ring cell adenocarcinoma of the diffuse type based on a biopsy from a perforated gastric ulcer. Postoperative workup was negative, including repeated esophagogastroduodenoscopy, gastric biopsies, tumor markers, computed tomography (CT), and positron emission tomography (PET). Six months after the operation, the patient presented to our center with abdominal discomfort and nausea. The clinical examination showed an enlarged visible stomach due to gastric outlet obstruction. The patient underwent total gastrectomy after confirmation of malignancy using an intraoperative frozen section. However, the tumor was already advanced locally and regionally. Confirmed malignancy in biopsies from perforated gastric ulcers should be never considered false positivity. To avoid missing a diffuse gastric cancer, endoscopic biopsies should be obtained using advanced techniques such as submucosal dissection under endosonographic guidance. The manifestations of gastric cancer include epigastric discomfort, anorexia, weight loss, gastrointestinal bleeding, and gastric outlet obstruction in advanced cases, among others . Peptic The diagnosis of gastric cancer is based on histological examination. However, the diffuse type may elude diagnosis because the mucosa may appear endoscopically normal given the submucosal infiltration . This caIn this article, we report a patient who was diagnosed with gastric cancer based on a biopsy from a perforated ulcer. The negative postoperative study resulted in a considerable delay in the diagnosis and treatment. In the discussion, we present important pitfalls in approaching the diagnosis of gastric adenocarcinoma.The history of the patient dates back to about six months before his presentation to our center. A male in his early 60s with controlled arterial hypertension and diabetes mellitus presented to a local hospital complaining of acute-onset abdominal pain with a rigid abdomen. Based on the clinical and radiological findings, the patient was diagnosed with perforated viscus. The emergency laparotomy showed a perforated prepyloric ulcer with diffuse peritonitis. The ulcer was excised with primary repair, and the patient had an uneventful recovery. The histology showed signet-ring cell adenocarcinoma of the diffuse type according to Lauren’s classification. The diagnosis was confirmed using immunohistochemistry with a positive reaction for pan-cytokeratin and cytokeratin 7 in the muscular layer.A staging study was initiated based on these results. In the upper gastrointestinal endoscopy up to the descending part of the duodenum, the entire gastric mucosa was intact, and no lesions could be found. The multiple gastric biopsies showed no evidence of malignancy. Similarly, there were no obvious abnormalities in the computed tomography (CT) of the abdomen. Using positron emission tomography with 2-deoxy-2-[fluorine-18]-fluoro-D-glucose integrated with computed tomography (FDG-PET/CT), a whole-body scan was performed from the skull base down to the midthigh. This showed “reactive inflammatory abdominal lymphadenopathy” with otherwise no evidence of malignant activity. A second endoscopy one month later showed no findings, and the biopsies were once again negative. Close clinical follow-up by the general practitioner was arranged. The last endoscopic examination was performed one month before the presentation, and chronic gastritis in the pyloric region was described, again with negative biopsies.The patient presented to the emergency department of our hospital about six months after the initial operation. The presenting complaints included progressive abdominal heaviness and nausea, “which are becoming gradually intolerable” according to the patient. Self-induced vomiting provided some relief. Bowel movements were reported only once every 3-4 days. Further questioning revealed weight loss of about 20 kg in the last six months. Abdominal inspection showed an enlarged visible stomach as a spot diagnosis Figure . A nasogInvestigationsAll laboratory values, including tumor markers (cancer embryonic antigen (CEA), cancer antigen (CA) 19-9, and CA 72-4), were within the normal limit. The esophagogastroduodenoscopy showed an extensively enlarged stomach. After aspiration of about 2.5 L of turbid fluids, careful inspection of the gastric mucosa up to the prepyloric region showed no abnormalities. Passing the pyloric canal was impossible due to the severe stenosis. In addition to the giant stomach, the computed tomography of the abdomen showed a suspicious mass in the pyloric region  could also be ruled out in the gastroscopy up to the pylorus. Therefore, intramural lesions are the most probable cause of the obstruction. These have two main causes in adults: either gastric tumors or benign peptic ulcer disease with pyloric hypertrophy. The differentiation between the two entities based on the CT scan, the endoscopic and histological findings, or the laboratory results was not possible. Given the proven malignancy six months previously, stenosing gastric cancer is the most probable diagnosis. Therefore, an explorative laparotomy was decided for both diagnosis and treatment.TreatmentFor preoperative optimization, the patient received total parenteral nutrition over a central line with continuous nasogastric decompression for five days. The initial plan included a distal gastrectomy with an intraoperative frozen section Figure . This coThe final histological examination showed a poorly differentiated adenocarcinoma of the pylorus with invasion of the perigastric tissue and involvement of 32 out of 37 lymph nodes . The patient was referred to adjuvant therapy according to the recommendations of the multidisciplinary tumor board.Gastric ulcer disease is a common entity that may shield malignancy in less than 1% of cases . GastricAccording to Lauren’s classification, gastric cancer can be divided into intestinal and diffuse types. The diffuse type accounts for about 30% of cases, and it is characterized by aggressive behavior and poor outcomes .Tissue diagnosis using endoscopic biopsies is the standard diagnostic modality for gastric cancer. This is usually straightforward in the presence of mucosal lesions or ulcers, but it can be challenging in the diffuse type, which spreads submucosally and evades detection . In thesThe results of immunohistochemistry play an important role in the histological evaluation of malignant tumors. In the initial biopsy obtained from the perforated ulcer in this patient, the muscular layer showed a positive reaction to pan-cytokeratin and cytokeratin 7. Although these markers are not specific to gastric cancer and can also be reactive in other epithelial neoplasms, their presence confirms malignancy and leaves no room for assumptions . TherefoEndosonography is another important investigation that was unfortunately not performed in the workup of this patient. In their study of 32 patients, Will et al. reported an accuracy of 87.5% in detecting diffuse gastric cancers compared to only 58% when using endoscopic biopsies alone . The repSerum tumor markers can be used for follow-up after the treatment of gastric cancer, but they have no role in the preoperative diagnosis or staging because of their low sensitivity and specificity . For exaPositron emission tomography is a useful modality for detecting regional and distant metastasis in gastric cancer, and it can upgrade the staging and change the treatment plan compared with CT scan alone . HoweverDelayed diagnosis of gastric adenocarcinoma was discussed extensively in the literature. Missing gastric cancer on upper endoscopy is reported in 5%-10% of cases, most commonly with the diffuse type . In theiBecause of its lower morbidity, diagnostic laparoscopy is recommended in advanced gastric cancers to exclude peritoneal metastasis, as it may help avoid an unnecessary laparotomy in about one-third of patients . We omitThe diagnosis of gastric cancer can be sometimes delayed, which results in disease progression and poor outcomes. All gastric ulcers found on endoscopy should be adequately biopsied. Full-thickness biopsies should be generously obtained from every perforated gastric ulcer to exclude malignancy. Positive results should be considered a proven malignancy even when the endoscopic biopsies are negative. In suspected cases, advanced sampling techniques should be applied. Endosonography is also a useful adjunct to endoscopy for diagnosing suspected gastric cancer in the absence of mucosal lesions, especially if a previous biopsy demonstrated malignancy. Lastly, serum tumor markers or imaging modalities such as positron emission tomography cannot reliably exclude suspected gastric cancer.


Primary Gallbladder hydatid cysts are a very rare phenomenon caused by Echinococcus granulosus. Hydatid cysts usually present as hepatic or pulmonary lesions, but in our case, it presented in the gallbladder with three symptomatic daughter cysts in the CBD. Echinococcus caused by E.granulosus Is the most common parasite causing the disease, accounting for 95% of the cases.75 - year - old male presented with colic pain, jaundice, itching, vomiting, nausea, insomnia, Positive murphy's sign, and elevated AST and ALT. Total bilirubin was also elevated with no hepatomegaly or splenomegaly.This disease is endemic in Mediterranean countries due to high contact with the host of the parasite the lumen or on the external surface of the gallbladder. Which can come from the portal system or the spreading of brood capsules through the biliary tract.The method of investigation used was USG, CT, ERCP which are affordable and accessible in low-income countries including Syria. we would like to highlight this rare presentation and the possibility of using laparoscopic surgery. •Primary hydatid cyst is usually found in the liver, lungs and brain in our case it presented in the gallbladder and common bile duct which is very rare.•We can encounter primary hydatid cyst in unexpected organs especially in countries with high prevalence.•Jaundice in our case was the main presenting symptom.•The role of laparoscopic surgery in treatment because of its less invasive nature and the low spillage possibility. This is the second case treated via laparoscopic surgery. The incIn our case, we present the first case of primary gallbladder hydatid cyst with symptomatic daughter cysts in the CBD in Syria. This article aims to raise awareness about a rare presentation of a common disease as there is only a single similar case that presented with jaundice. This case is the second ever case to be treated via laparoscopic surgery, therefore, we believe that our success in treatment could be of a great help for surgeons facing similar cases.This case report has been reported in line with SCARE 2020 criteria .2A 75-year-old male was admitted to the outpatient clinic complaining of frequent colic pain which started one month ago. other symptoms were jaundice‚ itching, vomiting, nausea, anorexia, and Insomnia.There was no fever. urinary and bowel habits were normal.The patient has diabetes mellitus type II treated with hypoglycemic agents and a smoker with an average of 20 cigarettes/day for 15 years.Physical examination showed slight paleness of the skin. Neurological and cardiovascular examinations were normal.Abdominal examination showed a positive Murphy's sign. There were no hepatomegaly or splenomegaly.Laboratory examinations revealed an elevation in hepatic enzymes. Total bilirubin was elevated (4.4 mg/dl) and direct bilirubin was 3.2 mg/dl. Amylase and lipase enzymes were also above normal levels the differential diagnosis were cholecystitis and gallbladder stone.Abdominal ultrasonography (USG) revealed a dilated gallbladder measuring 5 × 10 cm.The common bile duct (CBD) was enlarged as well (1.7 cm).The obstruction was at the end of CBD. An ERCP was conducted to treat the obstruction. Three daughter cysts were extracted from the CBD.The patient was followed up for three weeks. hepatic enzymes regressed dramatically. bilirubin decreased as well An abdominal CT was performed, revealing a dilation in CBD (1 cm). Inside the gallbladder, a 13 × 5 cm cystic mass was detected too.A gallstone was found as well.Those entities applied pressure on the beginning of the CBD. The potential diagnosis was a hydatid cyst of the gallbladder.Laparoscopic surgery was performed, in which the cystic duct and artery were isolated. dissectThe patient was prescribed Albendazole after the surgery, however, it was not administered before the surgery. He was discharged on the third postoperative day.The follow-up period was uneventful.3Hydatid disease is a zoonotic disease described as having cysts in a certain location of the body.Echinococcus.This disease is caused by a parasite, a tiny worm of the genus echinococcus multilocularis that causes alveolar echinococcosis and echinococcus granulosis that causes cystic echinococcosis [Two types have been proved to have a direct causal relationship with the disease, coccosis .Dogs are the definitive host and the disease is endemic in areas of sheep and cattle raising therefore this disease is more prominent in agricultural and Mediterranean countries due to high contact with the hosts of the parasite ,8.Hydatidosis cases were due to Echinococcus granulosis [Even though echinococcus granulosis is not the only type of this parasite, it is the most common type causing the disease. 95% of all Ingestion of this parasite's eggs causes the disease. These eggs eventually develop into six-hooklet embryos that penetrate the mucosa of the small intestine and into the portal circulation reaching the liver where filtering occurs, consequently, 70% of all cysts are found in the liver. The lung represents the second filter, with 20% of all cases . DespiteCysts can be situated in the lumen of the gallbladder or on the external surface.Several theories have emerged to explain the exact pathogenesis. The most well-documented theory states that the parasite reaches the gallbladder through the portal system, from the hepatic veins, and into the inferior vena cava reaching the heart. Another theory suggests the spread of the brood capsules through the biliary tract and into the cystic duct. However, this theory struggles to explain how can cysts develop on the surface of the gallbladder. Thus, another theory arose suggesting the lymphatic tract as a potential route, this theory explains both the intraluminal and the external surfaces scenarios ,7.When it comes to symptoms, it is known that cysts grow slowly over years before they cause any clinical symptoms, this is mainly true regarding relatively large organs such as the liver. However, since our case is an intraluminal cyst in the gallbladder, it takes less time compared to other locations to be clinically explicit . Fig. 3Fig. 3FigAbdominal pain is the main complaint present in all cases (100%), nausea and vomiting are common too 64.53%), some cases reported a positive murphy's sign (38.46%), fever is also possible (23.07%) and jaundice is the least common symptom (7.69) [.53%, somIn our case, excluding fever, our patient presented with all symptoms mentioned in addition to anorexia and insomnia. Jaundice was caused by CBD obstruction by three daughter cysts.Obstructive jaundice is possible in case of primary cyst rupture or migration of daughter cysts into the biliary duct.This presentation was only reported in a single case . HoweverHydatidosis, including ultrasound, abdominal CT, and MRI. However, USG proved to be the most convenient due to its affordable nature and practicality. And in areas where the disease is endemic, it has a reasonably high diagnostic sensitivity [A variety of tests can be conducted to investigate sitivity . Howeversitivity .Generally, USG is the most common (76.92%), followed by abdominal CT 46.15%), and MRI which is the least common method conducted only in (15.38%) of all cases of PGBHC [6.15%, anIn our case, we conducted an USG, and following the discovery of daughter cysts, an abdominal CT was conducted, and from its findings, we were able to diagnose the disease Fig. 4CT:As per the treatment, surgery is always required . open chIn our case, laparoscopic surgery was chosen, mainly because of the low spillage possibility and the expertise of the surgeon . Overall4In conclusion, PGBHC is a rare presentation that is quite elusive to diagnose due to its non-specific symptoms and signs. However, it should be kept in mind in areas with high prevalence rates, as it could be more possible to present in these areas, even though there are only a few numbers of documented cases.We would like also to emphasize the role of ERCP, CT, and ultrasound in establishing the diagnosis, and the role of laparoscopic surgery in treatment, as this is only the second case treated via laparoscopic approach.An ethical approval was obtained and we can provide it upon request.There are no funding sources.Conception and design: Ranim Kazzaz, Dana Nashed, Ghaith Izz Aldeen Sattout, Analysis and interpretation of the data: Ranim Kazzaz, Ghaith Izz Aldeen Sattout, Drafting of the article: Ranim Kazzaz, Dana Nashed, Ghaith Izz Aldeen Sattout, Nourelhuda Issa, Ahmad Aldakhil, Critical revision of the article for important intellectual content; Aghyad Kudra Danial, Ousama Bitar, All authors read and approved the final version of the manuscript.We have no Conflict of Interest.1.Name of the registry:2.Unique Identifying number or registration ID:3.Hyperlink to your specific registration (must be publicly accessible and will be checked):Aghyad Kudra Danial.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-In-Chief of this journal on request.Not commissioned, externally peer-reviewed.


Primary dysautonomia is a disorder of the autonomic nervous system with nonspecific manifestations, mainly affecting blood pressure and heart rate.We report the diagnostic odyssey in an 11-year-old girl starting with arthralgia and leading to the final diagnosis of a rare dysautonomia.A 13-year-old girl, with no pathologic history, was admitted to pediatrics for diffuse arthralgia without clinical inflammatory signs.Biological exploration unmasked a morning proteinuria without hypoalbuminemia and with a normal electrophoretic profile, microcytic anaemia and orthostatic hypotension authenticated during his hospitalization.Exhaustive explorations were undertaken , without any conclusive result.The development—after one year of follow up—of arterial hypertension, associated with orthostatic hypotension and proteinuria, points toward the extremely rare defect in baroreceptors.The management, in collaboration with the cardiology department, enhanced the patient’s quality of life with a reduction in hypertensive peaks. An appropriate lifestyle also amended the intensity of orthostatic hypotension.The close multidisciplinary follow-up over >48 months is reassuring.The peculiar baroreceptor defect in a context of dysautonomia should be kept in mind in the (long) list of differential diagnosis of arthralgias, as joint pain can be triggered by dysautonomia. Management is mainly symptomatic.


Percutaneous US-guided biopsy of perinephric infiltrates and the kidney showed infiltration by CD68(+), CD1a(-), Langerin(-), PS100(-) foamy histiocytes with BRAFV600E mutation. The combination of the different radiological abnormalities and the result of the biopsy confirmed the diagnosis of ECD. Many clinical and radiological descriptions are available in the literature, but few authors describe vestibulo-ocular abnormalities in patients with ECD. Here, we report on a case of ECD and provide a precise description of the instability related to central positional nystagmus, which led to the diagnosis of ECD.Erdheim-Chester disease (ECD) is a rare histiocytic disorder, recently recognized to be neoplastic. The clinical phenotype of the disease is extremely heterogeneous, and depends on the affected organs, with the most frequently reported manifestations being bone pain, diabetes insipidus and neurological disorders including ataxia. In this article, we report on a case of a 48-year-old woman, whose initial symptom of gait instability was isolated. This was associated with positional nystagmus with central features: nystagmus occurring without latency, clinically present with only mild symptoms, and resistant to repositioning maneuvers. The cerebral MRI showed bilateral intra-orbital retro-ocular mass lesions surrounding the optic nerves and T2 hyperintensities in the pons and middle cerebellar peduncles. A subsequent CT scan of the chest abdomen and pelvis found a left “hairy kidney”, while  Although Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytic disease, over the past decade more than 1,000 cases have been reported in the literature (RAS-RAF-MEK-ERK) pathways  was detected. There was no distal hypopallesthesia, deep tendon reflexes were globally present and symmetrical, with signs of pyramidal involvement . Abdominal reflexes were normally present on the right and absent on the left. The patient also had no vesico-sphincteral disorders. There was no dysarthria, no dysmetria or dysdiadochokinesia and no extrapyramidal syndrome. She reported mild dysarthria and transient aphasia that were undetectable.There was no ocular instability, and no spontaneous nystagmus in the light or in the dark. There was no saccadic intrusion, normal smooth pursuit and no ocular misalignment. Head shaking caused intense instability, concomitant with nystagmus with a down beat component, which was low and transient (5 s). During the supine roll test, we noted very discrete geotropic horizontal nystagmus on the left side, without any concomitant vertigo, occurring without latency, and of 30 s' duration. During the right supine roll test, we noted geotropic nystagmus, occurring without latency, and of short duration (5 s), without any concomitant vertigo. The Dix-Hallpike test was negative. Bedside or video head impulse test was not performed. With this atypical positional nystagmus (PN), a central nervous system cause was suspected. Actually, the fact that vertical downbeat nystagmus was caused by head shaking and the roll maneuver immediately triggered pure horizontal nystagmus , without latency or vertigo but only dizziness, which was persistent despite 10 repositioning maneuvers, were not in favor of PN of peripheral origin.Subsequently, the patient had a brain MRI  which shThe patient also reported that she had been experiencing blurring in the left eye for a few months, after she was informed of the presence of an intra-orbital mass. A complete ophthalmologic examination was performed and was normal .The presence of these lesions led us to consider the possibility of ECD. Therefore, we performed further tests, including whole body FDG-PET/CT, blood tests and cardiac MRI, as recommended . She was18F-DFG PET/CT found multifocal radiotracer uptake in the long bone marrow, predominantly on the distal half of the femurs , no diabetes insipidus, and normal CRP (C reactive protein), but thrombocytosis.BRAFV600E mutation , CD1a(-), Langerin(-), PS100(-) foamy histiocytes bearing the mutation .Based on established diagnostic recommendations , ECD was- progressive neurological disorders via the brainstem, with disorders of balance, and brain MRI images18F DFG-avidity on PET/CT- Bone BRAFV600E mutation.- Unilateral left hairy kidney and perirenal infiltration with CD68(+), CD1a(-) foamy histiocytes bearing the Our patient was treated as soon as the diagnostic was confirmed (end of September 2021) with vemurafenid (480 mg x 2 per day). In fact, the recommendations for first-line therapy is BRAF-inhibitor therapy with vemurafenib or dabrafenib . She devExcept for side effects, clinically the patient is perfectly stable. The patient continues to complain of isolated instability, with no other manifestations (except for those related to the reported secondary effects of the treatment). Wide base persist, and controlled MRI in February 2022 showed the same lesion as initial.To our knowledge, this case of ECD is the first to present solely with gait disorder symptoms, with central positional nystagmus (CPN) that led to the discovery of a static cerebellar syndrome (isolated wide base).ECD is a rare disease that usually appears in people aged 40 to 70 years, with a slight male predominance . The sym99mTc bone scintigraphy or 18F DFG-PET/CT scan . This anomaly is best depicted by the absorption of a radiotracer in /CT scan . Bone paECD mass formations have been reported in various tissues, such as the retroperitoneum, neck, orbit and breast . Intra-oDense infiltration of perinephric adipose tissue, described as “hairy kidney” is also common (68% of cases) , and wasNeurological signs are reported at the time of diagnosis in 25% of cases and in 50% during progression. Pituitary impairment which causes diabetes insipidus (DI) is also common (22 to 47% of cases), as well as cerebellar or pyramidal impairment, found in 25% of cases. Neuropsychiatric symptoms are reported in up to 21% of cases, and cardiovascular manifestations in 22–36% of cases. Retroperitoneal fibroinflammatory lesions affects 30% of cases, ureteral obstruction being the most frequent complication. In addition, 10% of the patients have myeloid disease, in particular myelomonocytic leukemia (n = 17), headache (n = 11), cognitive changes (n = 6), dysarthria (n = 6), diplopia (n = 5), dysphagia (n = 4), focal sensory deficit (n = 4) and focal motor deficit (n = 2)  . Laurice (n = 2) . Na et aagia n = , focal s (n = 2) . The cenache n = , cogniti (n = 2) . HoweverDue to the non-specific clinical presentation, ECD is often difficult to diagnose, and a few cases involve isolated balance disorder as a mode of discovery. Our patient had very few clinical signs, but the presence of CPN led to encephalic imaging, and thus enabled the discovery of typical intra-orbital masses, associated with T2 hyperintensities of the pons and middle cerebellar peduncles, which led to a suspicion of ECD.PN is defined as nystagmus caused by a change in position, with respect to gravity . It is tOur case of ECD is the first that concerns a patient with only a complaint of instability, and offers a precise description of vestibulo-ocular abnormalities in this setting. A clinical examination identified CPN, and an associated static cerebellar syndrome. Together with suggestive imaging, these manifestations made it possible to diagnose ECD. Gait disturbance might be an underestimated entry sign of ECD. Therefore, the ability to differentiate CPN from peripheral PN might be crucial for early discovery of some complex neurological diseases.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Toulouse University Hospital. The patients/participants provided their written informed consent to participate in this study.AW had the idea of case reporting, analyzed the case, and drafted the manuscript to provide intellectual content. YG revised the figures and critically reviewed the manuscript. RD, BE, LT, FV, and DC critically reviewed the manuscript. DB prepared the MRI scans for figures and critically reviewed the manuscript. FB critically reviewed the manuscript and revised the MRI sequences for interpretation. All authors contributed to the article and approved the 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.


A pericardial cyst is a rare and benign cause of a mediastinal mass. They are frequently asymptomatic and are usually incidental findings on imaging. Symptoms may include persistent cough, atypical chest pain, dysphagia, and dyspnea. Diagnosis is usually established with the aid of imaging, including a chest x-ray, a computed tomography (CT) scan, and magnetic resonance imaging (MRI). Therapeutic options include surgical resection or aspiration for large and/or symptomatic cysts, whereas conservative management with routine follow-up is advised for small or asymptomatic cysts. We herein describe the case of a 48-year-old lady, who presented with clinical features suggestive of acute cholecystitis, with an incidental finding of a pericardial cyst, measuring approximately 10.1 cm x 8.7 cm x 10.7 cm. The patient underwent video-assisted thoracoscopic surgery (VATS) for excision of the pericardial cyst. She had an uneventful recovery and was discharged on the second post-operative day. At six months, there was no evidence of disease recurrence. Pericardial cysts are rare and benign lesions typically located in the anterior or middle mediastinum. They account for approximately 33% of all mediastinal cysts and 6% of all mediastinal masses . They ar9/L. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm. A plain chest x-ray showed a soft tissue mass in the right mid-and-lower hemithorax with obliteration of the heart border  tenderness with a negative Murphy's sign. Blood investigations were unremarkable with a C-reactive protein (CRP) of 1 mg/mL and a white-cell count (WCC) of 6.5 x 10A computed tomography (CT) scan of the chest and liver was performed to determine the nature of this soft tissue mass. CT showed a large, homogenous, well-circumscribed, water-density mass, measuring approximately 9.9 cm x 8.8 cm x 11.5 cm, sitting at the right lower hemithorax, and abutting the right cardiac border Figures -2F. TherThis study was supplemented with a magnetic resonance imaging (MRI) scan of the chest with gadolinium enhancement. MRI showed a cystic lesion abutting the right side of the heart, isointense to the myocardium, on T1-weighted sequences. The cystic lesion was hyperintense on T2-weighted sequences. It measured approximately 10.1 cm x 8.7 cm x 10.7 cm. The cyst was thin-walled with two thin septations, and no solid component Figures -3H. Therth ICS), slightly anterior to the mid-axillary line. Upon entering the chest cavity, a large cystic lesion was identified, adherent to the pericardium. There was no solid component and no obvious communication with the pericardium. The pericardial cyst was excised using the so-called "piecemeal" resection. A remnant of the pericardial cyst was left in situ, which was tethered to the right phrenic nerve. All specimens obtained were sent for histopathological analysis. The patient made an uneventful recovery post-operatively and was safely discharged from the hospital on the second post-operative day. A chest x-ray, performed prior to her discharge, showed that both lung fields were clear with no obvious masses, nodules, consolidation, or collapse visible. The heart was not enlarged and the cardiomediastinal contours were normal  for excision of the pericardial cyst. The procedure was performed under general anesthesia with the use of a 35 French left-sided double-lumen endotracheal tube (ETT). Surgical access was obtained via a 3 cm skin incision through the fifth intercostal space  stained the mesothelial lining only. The lymphoid infiltrate contained a significant amount of CD20 positive B cells, alongside CD3 and CD5-positive T cells. Overall, the cyst was composed of a thin fibrous wall lined by mesothelial cells. Underlying this was a lymphocytic cell infiltrate composed of primary and secondary follicles. There were no phenotypically abnormal B-cells, and the rate of proliferation was low. These features were suggestive of a post-infectious etiology for the pericardial cyst. At six months, a follow-up chest x-ray demonstrated no features of disease recurrence.Pericardial cysts are rare, benign, congenital causes of a mediastinal mass with an incidence of one in 100,000 . They acPericardial cysts are usually asymptomatic and are frequently an incidental finding on a chest x-ray performed to investigate an unrelated disease. Symptoms may include atypical chest pain, worsening dyspnea, dysphagia, or persistent cough, and is due to compression from the cyst itself on the surrounding structures . Rarely, it may cause life-threatening complications such as cyst infection, cardiac tamponade, obstruction of the right main bronchus, arrhythmias , right ventricular outflow tract (RVOT) obstruction, and sudden cardiac death. The peak incidence is between the age of 30 to 50 years with no gender preference ,3.On a chest x-ray, a pericardial cyst appears as a well-defined, soft tissue mass, usually at the right cardiophrenic angle . The chaOnce the diagnosis of a benign pericardial cyst has been established, the therapeutic options include surgical excision or percutaneous aspiration for large and/or symptomatic cysts. Alternatively, a small or asymptomatic cyst is best managed conservatively with routine chest x-ray or CT scans to monitor for growth in the size of the cystic lesion . HoweverIn this patient, the soft tissue mass identified on the chest x-ray was diagnosed as a post-inflammatory pericardial cyst, based on the histopathological and immunohistochemical findings. Other rarer causes of an acquired pericardial cysts include echinococcosis (causes a hydatid cyst to form) or trauma. This patient denied any history of chest trauma. Echinococcosis was ruled out in our patient based on her geographical location, the number and nature of the cyst itself, and the absence of echinococcosis on histopathology . PericarIn the case described above, the patient was asymptomatic from a cardiopulmonary point of view, and the pericardial cyst was found incidentally on a routine chest X-ray. The diagnosis was confirmed with the aid of CT and MRI scans. Although a pericardial cyst is a rare entity, it should be considered in the differential diagnosis of mediastinal masses. Moreover, they are clinically heterogeneous; they are largely asymptomatic, however, may present with rare, but serious, complications, including obstruction of the right main bronchus/RVOT, cardiac tamponade, and sudden cardiac death. VATS is a minimally invasive procedure, which provides a curative treatment and is associated with minimal pain and a shorter post-operative recovery period.


Pott’s puffy tumor (PPT) is a localized forehead swelling with underlying subperiosteal abscess formation and osteomyelitis of the frontal bone. It is a rare complication of frontal sinusitis, and it is especially rare in adult females. A careful review of existing literature identified only 17 cases in adult females. Treatment requires antibiotic therapy and often surgical drainage/debridement. Here, we present a case of a 76-year-old female diagnosed with PPT. She was placed on amoxicillin-clavulanate 875 mg twice daily for six weeks. Her symptoms resolved with the antibiotic course, and she is scheduled for otolaryngology (ENT) follow-up, including dedicated sinus computed tomography (CT). While Pott’s puffy tumor is a rare manifestation of chronic sinusitis, it is important to recognize and treat to avoid serious intracranial complications. Pott’s puffy tumor (PPT) is a localized forehead swelling with underlying subperiosteal abscess formation and osteomyelitis of the frontal bone. It is a rare complication of frontal sinusitis, trauma, or previous surgery ,2. It moA 76-year-old female presented to the emergency department with syncope resulting in hospital admission to the medical service. Head computed tomography (CT) performed in the emergency department during the patient’s syncopal workup incidentally revealed opacified maxillary and frontal sinuses and resultant absence of the anterior wall of the frontal sinus consistent with a Pott’s puffy tumor Figure . Follow-The otolaryngology service (ENT) evaluated the patient. Nasopharyngeal scope revealed patent nasal passageways without evidence of swelling along the ostiomeatal complexes. Left-sided purulent yellow drainage was noted draining into the nasopharynx from the frontal sinus. Purulent drainage was accumulating along the posterior pharyngeal wall. No polyps or masses were identified. The patient was placed on Augmentin 875 mg twice daily for six weeks. Her swelling and tenderness resolved with the antibiotic course, and she is scheduled for ENT follow-up including a dedicated sinus CT.Pott’s puffy tumor (PPT) can present at any age but is more common in children ages 6-15 and in males ,8. Our pStreptococcus, Staphylococcus, and anaerobes [The diagnosis in our case was readily apparent as an incidental finding on head CT and brain MRI upon admission. However, in a patient with midline forehead swelling in which PPT is suspected, a thorough history accompanied by a physical examination and nasopharyngeal endoscopy should be performed to confirm the diagnosis and delineate the inciting cause of PPT. A differential diagnosis should include hematoma, more superficial skin and soft tissue infections, and soft tissue tumors and masses . Infectinaerobes . Other enaerobes . The difnaerobes ,2.Our patient’s presentation may represent an early diagnosis considering her relatively benign physical examination and symptomatology. She reported typical, but mild, tender midline forehead swelling. However, midline swelling was not readily apparent upon physician examination. Cutaneous swelling may have been reduced by previous outpatient incision and drainage. She had no other symptoms. A complete physical examination revealed no erythema, cutaneous drainage, or neurologic symptoms. The nasopharyngeal examination did reveal purulent drainage and supported a diagnosis of chronic sinusitis. Previous case reports describe presentations similar to our case in which external drainage was performed repeatedly to target what was suspected to be a more superficial soft tissue infection . To avoiStreptococcus, Staphylococcus, and anaerobes [Treatment often requires surgery and antibiotic therapy. In most cases, it is recommended that broad-spectrum intravenous antibiotic therapy be initiated promptly to cover naerobes . If intrPott’s puffy tumor is a rare diagnosis, especially among older females. Given the low number of reported cases in this demographic, treatment strategy and follow-up appear to be based largely upon experience and research with younger patients. Previous literature suggests intravenous antibiotics, but this case shows that oral antibiotics can be appropriate in select cases. While Pott’s puffy tumor is an uncommon manifestation of chronic sinusitis, the severity of the complications warrants early recognition, followed by prompt treatment and follow-up.


Schwannoma is a benign tumor of nerve sheath of any myelinated nerve. The most frequent site affected in the head and neck is the eighth cranial nerve, other sites include: scalp, face, oral cavity, pharynx, larynx, trachea, parotid gland, middle ear and external auditory meatus. Schwannomas almost always occur as solitary lesionsA 35 year old female patient presented with 10 month history of swelling in the left nasal cavity, which slowly increased in size. She complained of pain and unilateral (left sided) nasal obstruction. There was no history of epistaxis, facial numbness, anosmia or facial swelling. Past history was insignificant.General physical examination was normal. Otorhinolaryngological examination of the nasal cavity revealed a smooth, cystic swelling of approximate size 1.5 × 1.0 cm on the left side of the membranous nasal septum. On palpation it was soft, painless, and slightly mobile .Figure 1The routine radiological and blood investigations were normal. After anesthetic fitness the patient was taken up for surgery under local anesthesia. The swelling was excised. The excised specimen was yellow colored tumor with a soft consistency measuring 1.5 × 1.0 × 1.0 cm. Histopathological examination showed Antoni A pattern with nuclear pallisading, confirming the diagnosis of schwannoma. Postoperative period was uneventful and after a follow up of 6 months, patient has no recurrence.Schwannomas are lesions that arise from the neural sheath of peripheral, autonomic, or cranial nerves. Nerve sheath tumors of the head and neck region mainly involve the eighth cranial nerve with only 4% occurring in the paranasal sinuses. Preferential locations have been reported as being the ethmoid sinuses, followed by the maxillary sinus, the nasal pits, and the sphenoid sinusNasal schwannomas mostly occur between the ages of 20 to 60 years with no sex or racial predilection. In nasal vestibule they usually present with unilateral nasal obstruction, epistaxis, pain, and occasionally localized facial numbness. The tumor is slow growing, and reaches a considerable size; however nasal vestibular schwannomas tend to become symptomatic earlier and are comparatively smaller in size at presentation. As a result, they are usually excised without the need for radiologic imagingMacroscopically, schwannomas appear as gelatinous or cystic, well encapsulated masses. Microscopically, schwannomas are classified into two types. Antoni A is characterized by areas of high cellularity with spindle shaped cells, often arranged in bundles, palisades, or whirls. Groups of compact parallel nuclei are also seen and are known as “verocay bodies”. Antoni B is typified by loose myxoid stroma with spindle cells running in a haphazard mannerThe differential diagnosis of a nasal tumour includes a wide variety of pathology including inflammatory polyps, juvenile angiofibroma, inverted papilloma, meningioma, neurofibroma, melanoma and olfactory neuroblastomaTreatment is surgical excision, the surgical approach is determined according to the location and extent of the lesion. Recurrences are rare.Schwannoma arising as a cystic mass from the membranous nasal septum is very rare. This case adds nasal Schwannoma to the differential diagnosis of cystic lesions of this area.