Extrauterine leiomyomata is an uncommon lesion that can lead to several problems of differential diagnosis, especially when localized in the external genitalia. There are few reports in the English literature and a novel association with Alport’s syndrome has been investigated since the 1980s.Here, we describe the case of a premenopausal woman who presented with an indolent swelling of the right interlabial fossa that resulted in a Bartholin cyst. In addition to this cyst, a benign leiomyoma of the right side of the clitoris was also found and removed. Our patient refused any further examination, although she was informed that genetic counselling could be organized to rule out an association with Alport’s syndrome.Extrauterine leiomyomata localized in the external genitalia is an uncommon lesion arising from smooth muscle cells around vascular epithelium or erectile tissue. Since an association between extrauterine leiomyomata and Alport’s syndrome has been described, genetic testing can be proposed to these patients. Upper intestinal tract symptoms such as dysphagia should prompt a gastroenterological evaluation as an association with an esophageal leiomyomatosis has been described. Extrauterine leiomyomata localized in the external genitalia is an uncommon lesion arising from smooth muscle cells around vascular epithelium or erectile tissue . The mosA 39-year-old, Caucasian 1G0P0A0T woman at 5 Gestational Weeks (GW) consulted with a chief complaint of a non-desired pregnancy. She also complained about an indolent swelling of the right interlabial fossa measuring 7 × 3 × 3 cm. The mass has not significantly changed in 9 years. Her medical history was unremarkable. Her sexual history revealed no dyspareunia and physiological sexual response. On physical examination, we observed a soft, painless bi-lobated fluid-filled swelling of the right interlabial fossa slightly diverting the clitoris on the opposite side (Fig. A transvaginal ultrasound was performed for pregnancy datation and localization, which confirmed an intrauterine pregnancy of 5 + 3/7 GW. According to the patient’s request, surgical excision of the cyst combined with dilation and curettage was performed. Dilation and curettage were uneventful. During the enucleation of the cyst, we saw a clear mucinous fluid dripping off because the cyst wall was very thin. We applied a Foley catheter swollen with 5 cc of NaCl to maintain a proper cleavage plan of the lesion. Cystectomy was uneventful. The specimen was sent for pathological analysis which identified an 8 × 2 × 1.5-cm cyst of the Bartholin’s gland. Surprisingly, after the excision of the first cyst, we noticed a second smaller mass of 1.5 cm adherent to the right side of the body of the clitoris. The mass had an adipose aspect at sight and consistence at palpation Fig. . The immUterine leiomyomatas affect 25–30% of women older than 35 . ExtrautAs collagen type IV is also an important component of the basement membrane in the esophagus, the same mutation has been reported in familial cases of Alport’s syndrome with esophageal leiomyomatosis. We therefore asked for a gastroenterology consultation, which concluded that, as long as our patient stayed asymptomatic for dysphagia and weight loss, no more investigations were needed.Recommended imaging studies for leiomyomata are ultrasound, MRI and eventually PET-CT scan in cases of difficult differential diagnosis with sarcomas. The imaging key to diagnosis at MRI is a low T2-weighted signal intensity, similar to that of smooth muscles .The treatment of choice of symptomatic leiomyomata is surgical excision because it allows for pathological examination. Leiomyomata presents a classical microscopic aspect of spindle-bundled cells: immunohistochemistry for smooth muscle markers, such as desmin and smooth muscle actin are positives. Moreover, hormone-induced growth can be demonstrated by targeting estrogen and progesterone receptor. According to Nielsen et al., malignancy criteria are a size of more than 5 cm, more than 1 mitosis per 10 high power fields, nuclear atypia, necrosis and margin infiltration , BartholThis is an original case report, whose strength point is to outline the management of an extrauterine leiomyoma, to raise awareness about the possible association with the Alport’s syndrome or esophageal leiomyomatosis. The limitation of this paper is that, in our case, we were not able to explore these associations as the patient refused any genetic testing.Nevertheless, in the event of an extrauterine leiomyoma a genetic testing should be proposed and discussed with the patient.With this article we want to improve recognition of extra uterine leiomyoma by the care givers confronting a fibromuscular para-clitoridean mass. Differential diagnosis in this case should include a para - clitoridean leiomyoma, in addition to other benign or malignant tumors. Should an extrauterine leiomyoma be diagnosed, we advise to extend the familial history in order to detect other women affected.


Chilaiditi‘s syndrome is a rare condition accounting for only 0.25%–0.28% of all abdominal imaging worldwide. To rule out Chilaiditi‘s syndrome from other acute abdominal emergencies is very important to avoid unnecessary treatment or surgical procedure.A 25-year-old female presented in the emergency room with 1 week history of abdominal discomfort. At time of examination, she had a mild shortness of breath that was not related with rigorous activities. A plain abdominal x-ray was suggested the presence of an air-filled bowel tract within the right subphrenic space . Abdominal computed tomography suggested colonic loop present between the right hemi-diaphragm and liver. The absence of abdominal free air confirmed an isolated pseudo-pneumoperitoneum due to colonic interposition between the liver and diaphragm.Chilaiditi sign is radiolucency in the subdiaphragmatic space as a result of bowel interposition between a diaphragm and the liver. If gastrointestinal symptoms present, the condition is known as Chilaiditi's syndrome. The abdominal symptoms including severe pain, anorexia, diarrhea, nausea, vomiting, bloating and constipation might mislead physicians or surgeons with diaphragmatic hernia, subdiaphragmatic abscess, bowel perforation, infected hydatid cyst and liver tumor. Thorough physical examination, imaging, and timely follow up is very important to avoid unnecessary exploratory laparotomies.Chilaiditi’s Syndrome is often misdiagnosed with bowel perforation because the presence of pseudopneumoperitoneum in the plain X-Rays. It is important to understand the unique characteristics of the sign, symptoms and findings of Chilaiditi’s Syndrome to prevent unnecessary surgical procedures. Most patients with Chilaiditi sign of intestinal anomaly are without symptom. However, a small proportion of patients present with intermittent profuse vomiting, abdominal pain or distention, anorexia, diarrhea, and constipation that on very rare conditions need surgery .In physiological condition, suspensory ligament of the liver and colon fixation can prevent the bowel interposition with the liver and diaphragm. Anatomical variations including absence, elongation, or laxity of the falciform liver ligament and the suspensory ligament of the transverse colon can predispose the interposition. Congenital malposition and functional disorders including chronic constipation, distension, and elevated intra abdominal pressure can predispose the development of symptoms in the Chilaiditi sign.Surgical intervention is usually not recommended inpatients with Chilaiditi’s syndrome. However, serious conditions of acute abdomen have to be first ruled out. Intravenous fluid rehydration, abdominal decompression with nasogastric tube, bed rest, and enema or stool softeners are initial management for patients with Chilaiditi’s syndrome. Surgery procedure is only performed if the patient does not respond to the conservative treatment or there is evidence of bowel ischemia or mechanical bowel obstruction. Therefore, differentiating Chilaiditi's syndrome with other acute abdomen as well as careful monitoring during conservative treatment are very important in the management. We reported a case of Chilaiditi's syndrome with severe abdominal pain and responded with conservative treatment following SCARE guidelines .2A 25-year-old presented to the emergency department in our hospital with 1 week history of abdominal discomfort. His symptoms present with a mild shortness of breath that doesn’t exacerbated with activities. He denied history of fever, nausea & vomiting, melena, constipation or diarrhea. He denied having diabetes mellitus, hypertension, or any history of heart disease. He denied any tobacco use, alcohol, or any illicit drug use.1 week before, this patient came to the small hospital that only have plain X-ray facilities. Patient came with abdominal pain and mild shortness of breath. Then the patient undergo chest X-Ray imaging which the result suggested Cardiomegaly and pneumoperitoneum in the upper right abdominal quadrant. This patient diagnosed with gastric perforation and then the patient referred to our hospital to get further treatment.In our emergency room patient was afebrile with body temperature 36,5 °C, blood pressure 122/58 mmHg, pulse of 83 beats/minute regular, respiratory rate of 20 time/minute, and oxygen saturation level 99% on room air. His physical examination showed that he was cooperative, alert, and oriented to person, place, and time. His chest examination revealed that his lungs were clear to auscultation bilaterally, with no wheezing, no rhonchi, and no rales. His cardiovascular examination showed regular rate and rhythm, no murmurs, rubs, or gallops. His abdomen was soft, nontender, nondistended, no hepatosplenomegaly, normal bowel sounds, no muscle guarding with tympanic percussion tones.From the Cardiology team, electrocardiography performed to confirm any cardiac problem from this patient and showed there was no abnormality on the ECG.Laboratory investigations was obtained and showing normal results. A plain abdominal x-ray was obtained . It suggIn this case, the patient was treated conservatively with bed rest, analgesia and intravenous fluids. Decompression with nasogastric tube was already performed by the previous hospital because there was suspicious hollow viscus perforation although the patient was not showing any sign of gastrointestinal obstruction or peritonitis. We conclude that no surgical intervention necessary in this case. This patient discharged home 3 days after observation from the surgery and cardiology teamOn outpatient follow-up 1 week post discharge, this patient showing no sign of abdominal discomfort or any sign of obstruction.3Greek radiologist in 1910 Demetrius Chilaiditi, first described a radiographic finding of radiolucency in the subdiaphragmatic space as a result of colonic interposition is termed Chilaiditi's sign [Symptoms that cause by Chilaidi’s sign is called Chilaiditi's syndrome, which primarily located in abdominal area, such as abdominal pain, anorexia, diarrhea, nausea, vomiting, bloating and constipation. Patients that have significant weightloss, redundant colon, high diaphragm, small liver, or absence of suspensory ligaments, all of which can be congenital or acquired are more likely to experienced Chilaiditi’s syndrome ,4,5.The differential diagnosis should consider primarily every potential cause of perforation of the abdominal hollow viscus. It can mislead physicians or surgeons to diagnosed it with diaphragmatic hernia, subdiaphragmatic abscess, bowel perforation, infected hydatid cyst and liver tumour possibly leading to unnecessary exploratory laparotomies ,7.The diagnosis is made primarily through imaging, such as plain chest or abdominal X-rays which may result in air filled bowel tract can suggest colonic interposition. But chest and abdominal X-rays are not as sensitive for the diagnosis as CT scans for the modality of choice ,6,8.In most cases nearly all patients are successfully managed by conservative treatment with bed rest, intravenous fluids and bowel decompression playing a significant role in alleviating the symptoms. Only occasionally, patients with recurrent presentation or evidence of vascular sufferance of the interposed bowel tract are offered surgical management ,6.Surgical treatment is reserved for patients whose symptoms do not resolve with conservative management or for suspicion of a complication such as ischemia or perforation. Surgical options may be performed using open, laparoscopic or robotic surgery with a variety of procedures possible to correct the interposition range from resection of the involved part of the colon (right hemicolectomy) or fixation of the liver to the abdominal wall to obliterate the potential space and prevent colonic displacement ,5.4Until nowadays Chilaiditi’s Syndrome often misdiagnosed with hollow viscus perforation because the pseudopneumoperitoneum present in the plain X-Rays examination which can lead to unnecessary surgical procedure. Its important to understand the unique characteristic of the sign, symptomps and findings of Chilaiditi’s Syndrome. We suggest that conservative treatment is the best option of treatment for Chilaiditi’s Syndrome without any complication.The authors report no declarations of interest.The authors declare that this study had no funding source.The informed consent form was declared that patient data or samples will be used for educational or research purposes. Our institutional review board also do not provide an ethical approval in the form of case report.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.Imam Sofii conceived the study. Imam Sofii, Sumadi Lukman Anwar, and Zakariya Aji Parminto drafted the manuscript. Imam Sofii and Sumadi Lukman Anwar revised the manuscript for intellectual contents. Imam Sofii, Sumadi Lukman Anwar, and Zakariya Aji Parminto facilitated all important tasks in the study.Not applicable.Imam Sofii.Not commissioned, externally peer-reviewed.


Peptic ulcer perforation in the early post-cesarean period is rare but may result in maternal mortality.Four cases of post-cesarean peptic ulcer perforation are presented. In all four patients, presentations include peritoneal signs such as acute abdominal pain and progressive distention, hemodynamic instability and intraperitoneal free fluid by ultrasound. Laparotomy and repair were done in all 4 cases. There were 2 maternal deaths. We also have reviewed English literature for the similar cases reported from 1940 to March 2019.New onset tachycardia, abdominal pain and progressive distension after cesarean section without congruent changes in hemoglobin should raise concerns for intra-abdominal emergencies including perforated peptic ulcer. Early use of ultrasound should be considered to assist in diagnosis. Coordinated care by an obstetrician and a general surgeon is necessary in presence of any unusual postoperative abdominal pain. Early recognition of the disease is imperative to limit the surgical delay and to improve the outcomes. Caesarean section is the most common obstetrical procedure worldwide. Post-cesarean section surgical emergencies are rare . Re-operData were extracted from local maternal mortality and morbidity committee in the city of Tehran from March 2015 to April 2018 among 608.000 deliveries. There was no vaginal delivery complicated by peptic ulcer meanwhile. The clinical manifestations, the diagnostic and therapeutic approaches, and the outcomes are detailed. We have also performed a PubMed, Ovid Medline, and google scholar literature search of English language articles from 1940 to March 2019 using keywords: “peptic ulcer perforation” “gastric ulcer” “duodenal ulcer” and “cesarean section” or” abdominal delivery”. Approval from our institution’s review board and local ethics committee was obtained. Written consent was signed upon admission by all patients included in this study to use their information in research studies.A 35 year old G2P1 (Gravida 2 Para 1) pregnant woman was admitted to a university hospital in 38 weeks of gestational age due to labor pain. An uneventful cesarean section was performed due to the previous cesarean section and there were no extensive adhesions. Due to patient’s request, she was discharged 24 h post operation after physician examination, in normal general condition and oral NSAID pain killers were prescribed. She was readmitted on the 3rd day postpartum for the left upper quadrant abdominal pain, abdominal distension, and tachycardia with pulse rate of 108 per minute. Additionally, she endorsed nausea, vomiting, and constipation. An emergent abdominal ultrasonography was performed which revealed multiple gas-filled bowel loops and large amount of free fluid in the abdominal cavity. Re-laparotomy via Pfannenstiel incision was performed after 7 h of admission and a 2 × 2 cm perforation in anterior stomach wall was demonstrated  pregnant woman had a scheduled cesarean section at term due to the previous cesarean section. In the morning of the second day postpartum, she experienced a sudden onset severe abdominal pain, chest pain and dyspnea. Her vital signs were recorded as 105/min for pulse rate, 110/70 mmHg for blood pressure and 18/min for the respiratory rate. O2 saturation was normal with the Hb level of 10.5 g/dl. The patient’s hemodynamics worsened  in the afternoon and abdominal pain and dyspnea was reduced. Bedside abdominal ultrasound was requested and revealed massive intra peritoneal fluid. Re-laparotomy after 3 h of admission via Pfannenstiel incision was performed by the obstetrician with the probable diagnosis of hemoperitoneum. A general surgeon was attended after detectinggastric fluid and he explored the abdomen via midline incision. Five liters of gastric fluid was collected in abdominal cavity along with a duodenal perforation that completely repaired by general. The patient was transferred to the intensive care unit (ICU) and ultimately discharged 1 week later in stable condition.E. coli. The patient subsequently developed acute respiratory distress syndrome complicated by pneumothoraces requiring bilateral tube thoracostomy. She died on post-operative day 8. Based on autopsy results, the cause of death was reported as disseminated abdominal infection.A 34 year old G1 (gravida1) pregnant woman was admitted with complaints of a headache, vertigo, and vomiting in 36 weeks of gestational age. The blood pressure was 140/90 mmHg upon admission, and the urinalysis showed 2+ proteinuria. However, on hospital day 1, the patient was taken for the emergent cesarean section due to preterm labor pain and fetal distress. Her blood pressure rose to 150/95 mmHg postoperatively and the loading dose of magnesium sulfate was prophylactically administered. On postoperative night 2, she developed worsening abdominal pain and distension, obstipation and new onset hypotension (100/60 mmHg). An upright abdominal x-ray was performed and demonstrated air-fluid levels. A bedside ultrasound was performed and showed massive intraperitoneal fluid. Re-laparotomy was performed by obstetrician within 6 hours from the onset of pain, with the probable diagnosis of hemoperitoneum. General surgeon was consulted who explored the abdomen via midline incision and found a pre-pyloric ulcer and repaired the perforation. The patient was transferred to ICU but required mechanical ventilation due to decreased level of consciousness. Postoperatively, the patient developed high fever despite broad-spectrum antibiotics. Blood cultures were positive for A 32 year old G2P1 (gravida 2 para1) pregnant woman was admitted for a scheduled cesarean section at term due to the previous cesarean section. An uneventful cesarean section was performed. In ten hours post-operation, patient developed sudden abdominal pain, distension and tachycardia. She had bowel function but worsening abdominal distension prompted further clinical evaluation. Within two hours, the patient became cyanotic and clinical presentations of the cold phase of septic shock appeared. A bedside ultrasound was performed, demonstrating a large amount of intra-peritoneal free fluid. Re-laparotomy was performed rapidly by the obstetrician via Pfannenstiel incision when gastric fluid and food particles were encountered within the abdomen. A general surgeon was consulted, and explored the abdomen via midline incision, found a perforated duodenal ulcer and repaired the perforation. The patient developed cardiac arrest during the operation and subsequently died.Perforated peptic ulcer (PPU) is a surgical emergency associated with short-term mortality in up to 30% of patients . It accoIn one study 69.0% of patients diagnosed with PPU had no previous history of treatment for peptic ulcer disease and 87.5% had reported medication history of non-steroidal anti-inflammatory drug (NSAID) usage [There is a classic triad of acute onset abdominal pain, tachycardia, and abdominal rigidity which is the hallmark of PPU. Tachycardia occurs due to the compensatory reflex regarding to severe pain, systemic inflammatory response from chemical peritonitis, and fluid deficit either due to the poor intake, vomiting or pyrexia .In postpartum setting, acute abdominal pain of PPU may be confused with usual post-operative discomfort and may be subsided in patients who receive post cesarean narcotic analgesics, and any tenderness may be confused with local pain at the incision site . HoweverHere, we reported 4 patients who developed abdominal pain in the early postpartum period between 10 hours to 3 days postpartum. All of them had acute abdominal pain and progressive abdominal distension, which was misdiagnosed as paralytic ileus in two. All four patients experienced tachycardia without primary changes in hemoglobin or blood pressure to prompt concern for hemorrhage. Dyspnea prompted an erroneous diagnosis of the pulmonary embolism (PE) in second case. Chest pain and dyspnea has been also reported in a 54 year old man as an unusual presentation of the perforated peptic ulcer .It is believed that demonstration of free air on a plain abdominal upright X-ray is highly indicative of a perforated viscus organ and there is no other imaging modality necessary to use , but pneWhile laboratory data are not diagnostic for PPU, they are helpful for ruling out differential diagnoses such as acute pancreatitis . Acute pThere are strong evidences for an association of comorbidity and use of NSAIDs with mortality following PPU . cesareaIn case of post-cesarean acute abdominal pain, a high index of suspicion by the obstetrician coupled with coordinated care by a general surgeon is necessary. Early diagnosis and prompt resuscitation and antibiotic therapy improve the outcomes of patients diagnosed with peptic ulcers perforation .In our search in English literature, we identified and reviewed 8 reported cases of peptic ulcer perforation after the cesarean section, summarized in Table Peritoneocentesis was performed in three cases –21 and wComputed tomography was performed following an abrupt upper abdominal pain, coffee ground vomiting, and epigastric tenderness in one case, which revealed massive PP . After aAcross the review, 3 patients died in the first week after laparotomy , 20 and In conclusion, post cesarean PPU is a rare condition which may result in catastrophic maternal death. New onset tachycardia, abdominal pain and distension without congruent changes in hemoglobin should raise concerns for intra-abdominal emergency including PPU. A high index of suspicion by the obstetrician coupled with coordinated care by a general surgeon is necessary. Adjunct tools such as ultrasound and CT scan may contribute to a timely diagnosis and reduce maternal mortality rate.


Peroneal neuropathy is the most common type of peripheral neuropathy in the lower extremities. The peroneal nerve is usually compressed at the lateral aspect of the fibular head. Compression by ganglion cysts are one of the numerous underlying etiologies for peroneal nerve neuropathy and are most frequently located around the fibular neck and proximal tibiofibular joint. To the best of our knowledge, this is the first report of an extraneural ganglion cyst located at the level of the distal thigh that resulted in compressive peroneal neuropathy.We report a case of a 56-year-old man with sudden onset of left foot drop and gait disturbance caused by an extraneural ganglion cyst located in the popliteal fossa.Electrodiagnosis (EDX) suggested a peroneal nerve lesion. Subsequently, diagnostic ultrasonography (USG) revealed a cystic mass located within the left side of the supracondylar area of femur. Further magnetic resonance imaging confirmed that the mass was located at the proximal of popliteal fossa.Surgical excision was performed using a direct posterior approach. The cystic mass was compressing the common peroneal nerve, and was carefully and completely removed ensuring that all nerve branches were protected.A histopathologic evaluation confirmed the diagnosis of a ganglion cyst. There were no postoperative complications. Two months after the surgery, follow-up USG revealed no evidence of cyst recurrence or residual lesions. Six months after the surgery, the ankle dorsiflexor motor power improved and he experienced less pain and hypoesthesia.Physicians should bear in mind that the peroneal neuropathy can occur because of the ganglion cyst in the distal thigh. The thorough evaluation of EDX and USG is crucial for the early diagnosis and surgical intervention, although there is no abnormal finding around the fibular neck. Globally, the lifetime prevalence of lumbar radiculopathies ranges from 1.2% to 43%, with L5 being the most frequently affected nerve root.,4 Moreover, L5 radiculopathy-induced foot drop may indicate the presence of a progressive neurological deficit, which usually requires surgical evaluation.Foot drop can be ascribed to peripheral lesions in the L5 nerve root, sciatic, or peroneal nerves. However, in rare cases, it can also be caused by compressive mass lesion around the knee joint, such as cyst or nerve sheath tumors.,7Peroneal neuropathy has numerous underlying etiologies and is commonly caused by compression at the level of fibular neck, which can result from prolonged immobilization during deep sleep and anesthesia, in addition to trauma and stretch injury. Ganglion cysts are benign tumors that usually develop in underlying joint capsules or tendon sheaths and peripheral nerves, and characteristically contain mucinous fluid. They differ from other types of cyst in that they are not lined by synovial cells and are not associated with meniscal tears.Cystic lesions around the knee joint can be categorized into ganglion, synovial, and meniscal cysts.–15 Across previous reports, the most frequent location for cystic mass development was around the fibular neck and proximal tibiofibular joint. Moreover, a few studies have reported the development of peroneal neuropathy caused by intraneural-type cysts formed in the popliteal fossa.,17 To the best of our knowledge, no reports have described a case of common peroneal neuropathy caused by an extraneural ganglion cyst located at the proximal site of popliteal fossa.Since the first case report by Sultan in 1921 of a compression peroneal neuropathy caused by an intraneural ganglion cyst, limited reports have described similar cases.In this report, we describe a patient with common peroneal nerve palsy who presented with foot drop caused by compression by an extraneural ganglion cyst at the supracondylar area of femur.2A 56-year-old male welder presented to a hospital with sudden onset of left foot drop. He underwent lumbar magnetic resonance imaging (MRI) and mild disc protrusions of L3-4 and L4-5 were observed Fig. . The ini Consequently, the surgery was cancelled.The patient had been experiencing foot drop for 9 days and initial EDX results revealed abnormal spontaneous activity (ASA) in the left tibialis anterior (TA), peroneus longus (PL), and extensor hallucis longus (EHL). These findings suggested that the patient's foot drop was more likely due to peroneal nerve injury than lumbar radiculopathy. ASA, such as fibrillation, usually appears within 5 to 6 weeks after the onset of the lesion in radiculopathy.The next day, the patient was referred to our outpatient clinic for peroneal neuropathy. He complained of numbness in the area below the knee and especially in the dorsal aspect of his foot. These symptoms began 10 days prior and he did not recall any history of trauma. On physical examination, muscle manual testing (MMT) of the TA and EHL revealed a trace grade, while the peroneus muscle showed poor plus grade. There were no signs of TA or peroneal muscle atrophy. Soft tissue swelling was not palpable around the fibular head and popliteal fossa. The palpation of the lateral aspect of the knee showed no degree of tenderness. The Tinel sign over the fibular head was negative. The patient's ankle and knee jerks were normal.EDX, performed on the day of the patient's visit to our outpatient clinic, showed common peroneal neuropathy around the left knee with significant axonal denervation in the TA and PL. Compared with the contralateral limb, the compound muscle action potential (CMAP) amplitude was reduced by greater than 70% in the left lower limb distal muscles, which are innervated by the common peroneal nerve. However, because a conduction block across fibular head was not observed, we considered that the lesion was proximal to the stimulation site. Consequently, a diagnostic ultrasonography (USG) was performed to identify the lesion, which was compressing the peroneal nerve. However, we did not find any lesion around the fibular neck and proximal tibiofibular joint, where compression of peroneal nerve is most commonly found.At the 1-week follow-up, the patient's symptoms did not improve. As compression of the peroneal nerve can occur anywhere along its axonal tract, we investigated whether the compression site was located proximally to the knee. A follow-up USG revealed an approximately 19 × 16 × 40 mm sized cystic mass located in the upper lateral component of the popliteal fossa Fig. . SurgicaSurgical excision was performed using a direct posterior approach of popliteal fossa using curvelinear incision under general anesthesia. We found the cystic mass after traction of hamstring muscle. The cystic mass was compressing the common peroneal nerve from the medial side of the supracondylar region on the femur resulting the swelling of the nerve. The mass was carefully and completely removed ensuring that all nerve branches were protected with neurolysis Fig. . The masTwo months after the surgery, follow-up USG revealed no evidence of cyst recurrence or residual lesions Fig. . Moreove3 knee cysts can be classified into ganglion, synovial, and meniscal cysts (Table ,16,19–23 To our knowledge, our case is the first report of compressive peroneal neuropathy caused by extraneural type of ganglion cyst in the supracondylar area of femur. Ganglion cyst compressions of the peroneal nerve can be classified as intraneural or extraneural lesions. Most ganglion cysts, which cause peroneal nerve compression, are of an intraneural type. This type of cyst is often related to a history of traumatic knee injury. Interestingly, our patient did not sustain any direct traumatic injury to his knee. However, considering that he had worked as a welder for decades and had sustained a hyperflexion of his knee, his extraneural cyst may have resulted from repeated microtraumas.According to Malghem et al,ts Table . Table 2 EDX can be helpful for locating the compressive lesion and can provide information regarding the severity of the neuropathy, which can determine the neurological and functional prognosis. In addition, EDX can discriminate other peripheral nerve lesions including plexopathy or radiculopathy. Both USG and MRI can be used as diagnostic methods. USG can be easily performed to rule out space occupying lesions in outpatient clinics due to its portability and cost benefit. It is particularly useful for showing the cystic nature of mass and distinguishing it from solid tumors. MRI can be used to reveal the characteristics of the lesions and to identify the relationship between the compressive lesion with the joint and surrounding anatomic structures.In this case, EDX, USG, and MRI were used for diagnosis and treatment. Standard plain radiographs are of little value to detect of soft tissue lesions such as ganglion cyst despite of being useful in excluding bony abnormalities or fracture of fibular neck.,29 but it has been accepted as a less favorable method because of the high recurrence rate and the risk of nerve damage. In many previous studies, surgical excision is a standard treatment for ganglion cyst. In general, it has been recommended to perform early surgical excision in case of symptoms, but Fansa et al recommended surgical intervention to prevent delayed damage even if there are no neurological symptoms. Therefore, even minor symptoms in early phase should be considered as an indication of surgical excision following correct diagnosis.There have been some studies where cyst aspiration with corticosteroid injection was used as a treatment for cyst around the knee,,17,31 Careful examination for diagnosing the ganglion cyst and providing early surgical intervention can lead to a satisfactory recovery.In conclusion, peroneal neuropathy caused by an extraneural ganglion cyst is a rare and often misleading condition. When determining the etiology of peroneal neuropathy, a ganglion cyst around the knee should also be considered among the differential diagnoses. Using a combination of EDX, USG, and MRI can help in the formulation of an accurate differential diagnosis in difficult-to-diagnose cases. Although the optimal timing of surgical removal has not been described in the literature, early intervention, before axonal damage, is recommended.Conceptualization: Kyunghoon Min.Data curation: Jaehoon Sim, Hyunseok Kwak.Supervision: Soonchul Lee, Kyunghoon Min.Writing – original draft: Jaehoon Sim.Writing – review & editing: Soonchul Lee, Kyunghoon Min.


Conjunctival neoplasia is one of the most frequent tumors in the eye. Actinic keratosis (AK) or solar keratosis is a precancerous lesion that is included with other epithelial tumors. This alteration does not break the basal membrane. There is enough evidence of successful outcomes to consider interferon alfa-2b  as the first choice of treatment for this type of tumors. In addition, side effects are mild and uncommon. We report a case in an 83-year-old woman who was referred to evaluate a leukoplakia in the tarsal conjunctiva of the lower left eyelid that measured 1 cm in diameter. Pathological study revealed AK. After the INF alfa-2b treatment, we observed conjunctival hyperemia, noninfiltrated upper nasal de-epithelization, and inferior nasal bulla. AK with presentation in conjunctiva is rarely described and in tarsal conjunctiva is exceptional. It is the first case published with only tarsal conjunctiva affectation. Actinic keratosis (AK) or solar keratosis is a hyperkeratotic plaque-like lesion (leukoplakia) with defined borders and squamous surface . It is frequent in the elderly population and in the light skin since its main risk factor is sun exposure . Due to Individuals with Fitzpatrick type I or II (I-VI) skin characteristics, such as fair skin, freckles, light-colored eyes (blue or green), and blonde or red hair, are more likely to developed AKs, as they are more sensitive to damage from chronic sun exposure .Interferons are a set of glycoproteins identified in 1957 and produced naturally by the body for their antiviral, antiproliferative, and immunomodulatory properties . HoweverIn addition, the surgical procedure involves a higher cost and causes greater stress and trauma to the patient . TopicalThe use of topical INF alfa-2b is considered safe, effective, and generally well tolerated. However, side effects due to its systemic absorption have been found. These include flu-like symptoms, migraine or fatigue, and others due to its topical use such as follicular conjunctivitis, conjunctival injection, or superficial punctate keratitis –8. All oAn 83-year-old female referred from the outpatient clinic for a leukoplakia measuring 1 cm in its wide diameter on the tarsal conjunctiva of the lower eyelid of the left eye . The patAK  is described as neoplastic transformation and proliferation of keratinocytes within the epidermis that does no breach the basal membrane . The hisTo achieve tumor remission, surgical treatment with wide free margins has been performed classically, followed by cryotherapy at the base of the lesion . HoweverThe use of topical INF alfa-2b is considered safe, effective and generally well-tolerated. However, side effects due to its systemic absorption have been found; these include flu-like symptoms, migraine and fatigue; other side effects are due to its topical use, and include follicular conjunctivitis, conjunctival injection or superficial punctate keratitis –8. All oThe use of topical interferon achieves a higher resolution rate than the use of surgery plus cryotherapy of the base of the lesions, due to the difficulty of completely resecting the lesion without leaving infiltrated borders. In addition, the convenience of topical versus surgical treatment has led to its becoming a widely used treatment nowadays . Not rebAdverse effects due to systemic absorption in the case of the topical administration of the drug are rare, although flu-like and fever conditions are described .Alternatively, topical chemotherapeutic agents, 5-fluoracil, mitomycin C, imiquimod, photodynamic therapy, igenol mebutate, and diclofenac, have been effective .It should be noted that there are no reported cases in the literature of the side effects such as those found in our patient, upper infiltrated upper nasal circular epithelialization and lower nasal congestion, and that these signs decreased drastically within 5 days of cessation of interferon exposure, and the patient was fully recovered from the previously described lesions within one month.Few cases affecting the conjunctiva have been published , only onConjunctival AK lesions are scarcely reported in the literature. They are premalignant lesions with the presence of dysplastic keratinocytes. The etiology is due to UV radiation in elderly patients. The treatment of choice is excision with clearance of margins to avoid possible transformation in SCC. Other treatments have been described in the conjunctiva, such as INF alfa-2b, as in this case report. The form of presentation in the tarsal conjunctiva is not described to this day.


Cutaneous tender tumors manifest as painful dermal or subcutaneous masses. Acronyms, a memory aid created from the initial letters of other words, can be used to assist in recalling a list of conditions. We report the case of a man who presented with a painful lesion on his leg; 15 years earlier, hot solder had embedded beneath his skin at that location. The subcutaneous mass was removed, and his symptoms resolved. Microscopic evaluation of the specimen showed a foreign body reaction to metal. Therefore, after correlating his medical history, clinical presentation, and pathology findings, the diagnosis of a foreign body (solder) and a foreign body reaction to solder, as a cause of the patient’s painful skin lesion, was established. Including our patient’s diagnosis for his painful skin lesion, the list of conditions that have been described as presenting as a cutaneous tender tumor include calcinosis cutis, angioendotheliomatosis, leiomyoma, metastases, hidradenoma, osteoma cutis, glomus tumor, scar, fibromyxoma, leiomyosarcoma, eccrine angiomatous hamartoma, Dercum’s disease, piezogenic pedal papule, eccrine spiradenoma, neurilemmoma, something else (such as foreign body (solder) and a reaction to the foreign body), angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis, thrombus, blue rubber bleb nevus, angioma, chondrodermatitis nodularis helicis, and keloid. We introduce a novel acronym for painful lesions of the skin that was inspired by the book Charlotte’s Web in which a barn spider (Charlotte), by weaving praises of a pig (Wilbur) into her web, is responsible for the pig’s life being spared. Wilbur is a calm pig; however, there was an episode when he temporarily fled his pen and was subsequently induced, with a pail of slop, to get back into the pen. The new acronym for cutaneous tender tumors uses the initial letter of each of the 26 currently established painful skin lesions: CALM HOGS FLED PENS AND GET BACK. Dermal and subcutaneous lesions can present as tender masses. Although the diagnosis may be suspected based on the clinical history or the location or the morphology of the tumor, a biopsy for pathologic evaluation is often required to establish the diagnosis. However, the presence of pain is a unique feature that aids in allowing the clinician to formulate an appropriate differential diagnosis prior to tissue confirmation .Acronyms have been used as memory aids to assist in listing the potential possibilities for a painful skin lesion; specifically, the first letter of each tumor is used to create either a word or a phrase or a sentence. Glomus tumor, leiomyoma, eccrine spiradenoma, neuroma/neurilemmoma, dermatofibroma, and angiolipoma (GLENDA) and eccrine spiradenoma, neuroma, glomus tumor, leiomyoma, angiolipoma, neurilemmoma, and dermatofibroma (ENGLAND) were early acronyms for cutaneous tender tumors -3. In 19We recently performed a comprehensive review of the literature and discovered 25 cutaneous tender tumors; in addition to describing the unique painful dermal lesions of two patients caused by osteoma cutis or an organizing thrombus, we created a new acronym for these lesions, which include calcinosis cutis, angioendotheliomatosis, leiomyoma, metastases, hidradenoma, osteoma cutis, glomus tumor, fibromyxoma, leiomyosarcoma, eccrine angiomatous hamartoma, Dercum’s disease, piezogenic pedal papule, eccrine spiradenoma, neurilemmoma, angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis, thrombus, scar, blue rubber bleb nevus, angioma, chondrodermatitis nodularis helicis, and keloid: CALM HOG FLED PEN AND GETS BACK . HoweverA 74-year-old man presented for the evaluation and treatment of a painful lesion on his right leg of several years’ duration. His medical history is significant for prostate cancer (treated with radiotherapy and leuprolide acetate injections every three months) and hand dermatitis . Fifteen years earlier, his occupation involved soldering; he recalls hot solder dripping onto his right leg and embedding beneath the skin of his right thigh at the same location that corresponds to his pain.Cutaneous examination of his posterior medial right thigh showed a dark brown 5 x 5 millimeter patch. This dark area was surrounded by a lighter tan brown patch. A tender subcutaneous nodule beneath the colored skin was palpable Figure .A three-millimeter punch biopsy was performed. The 3 x 3 x 5 millimeter cylinder of tissue consisting of epidermis, dermis, and underlying fat was removed. Inspection of the wound demonstrated a solid material in the subcutaneous fat; this was firmly grasped with forceps detached from the adjacent tissue with scissors and removed through the opening created by the biopsy Figure . The bioMicroscopic examination of the tissue  showed fibroplasia and a mixed inflammatory infiltrate consisting of histiocytes and lymphocytes in the dermis. Foreign material (which polarized), recognizable as metal, was visible within not only the histiocytes but also the dermis. After hematoxylin and eosin staining, the metal appeared as brown amorphous masses Figure .Correlation of the medical history, the clinical presentation, and the pathology findings established the diagnosis of a foreign body (solder) and a foreign body reaction to solder as the etiology of the patient’s painful skin lesion. The biopsy site healed within two weeks, and the sutures were removed. The patient has had no further episodes of pain at that location.Painful skin lesions can be categorized by their tissue of origin. They can be adipose , cartilage (chondrodermatitis nodularis helicis), deposition , eccrine , fibrous , infiltration (cutaneous metastases and endometriosis), muscle , neural , or vascular  . In addiSolder refers to the low-melting fusible metal alloy used in soldering to create a permanent bond between less fusible metals. Solder usually consists of two or more metals that are combined into an alloy. Lead or cadmium used to be components of solder; more recently, combinations of different metals such as antimony, copper, silver, tin, and zinc are used.Our earlier acronym was inspired by the book Charlotte’s Web . CharlotThe current acronym (CALM HOGS FLED PENS AND GET BACK) is only a minor modification of our prior acronym (CALM HOG FLED PEN AND GETS BACK) Table  1]. It . It 1]. Cutaneous tender tumors present as painful dermal or subcutaneous masses; a biopsy is necessary to establish the diagnosis. Acronyms are a memory aid formed from the initial letters of other words; they are words, phrases, or sentences that can be used to assist in recalling a list of terms or conditions. Several conditions can be associated with tender cutaneous tumors; we respectfully propose a novel acronym that includes not only the currently established tender cutaneous tumors but also potential future painful skin lesions: CALM HOGS FLED PENS AND GET BACK.


Tension pneumoperitoneum, a form of abdominal compartment syndrome, is an important clinical condition. Increased pressure in the intraperitoneal cavity leads to respiratory and circulatory instability. Most of the reported cases include complications due to active air infusion into the peritoneal cavity or trauma; however, few reports are available on tension pneumoperitoneum caused by perforation from colon cancer. We present a case of a patient with tension pneumoperitoneum caused by gastrointestinal perforation owing to colon cancer.A 63-year-old Japanese man with altered mental state was brought to our emergency department. He was in shock, and an abdominal radiograph suggested gastrointestinal perforation. Despite rapid fluid infusion and inotropic support, his condition deteriorated. His abdomen was tensely distended; abdominal computed tomography showed significant intra-abdominal gas. Following immediate needle decompression, his circulatory status improved. Emergent laparotomy revealed an approximately 10-cm tumor (adenocarcinoma) in the colon, which caused the perforation.A perforated wall or the surrounding omental fat that acts as a one-way valve could lead to tension pneumoperitoneum without active air infusion. Although tension pneumoperitoneum is a life-threatening condition, it is reversible if prompt diagnosis and immediate decompression are performed. Physicians should always consider this condition as one of the causes of shock or cardiopulmonary arrest, even without an apparent medical history of active air infusion or trauma. Pneumoperitoneum is the presence of free air within the peritoneal cavity , 2. It uThe pathophysiology of TP and its treatment strategy should be widely recognized because it can be life-threatening, and adequate management is important to save patients. In this report, we present a case of a patient with TP caused by gastrointestinal perforation owing to colon cancer.A 63-year-old Japanese man with an altered mental state was brought to our emergency department. He had no major previous illness and was not taking any medication. His family history was unremarkable. His social history included chronic alcohol abuse, but he had no history of smoking. Two weeks prior to admission, he started developing anorexia and drank only alcohol. Although he could go out of the house until then, he gradually developed weakness. On the day of admission, his common-law wife found him unconscious, and he was not responsive; hence, he was brought to the hospital via ambulance. He had no apparent history of abdominal pain, shoulder pain, or dyspnea. His initial examination in the emergency department revealed an altered level of consciousness . His vital signs were the following: body temperature, 33.1 °C; blood pressure, 51/21 mmHg; and heart rate, 86 beats/minute. His pulse oximetry waveform was initially undetectable. His physical examination revealed the following: pale face; round and isocoric pupils (both 4 mm) that were responsive to light reflex prompt; cold extremities; and dirty appearance, especially in the intraoral cavity. His abdomen was tensely distended and tympanic. Bedside ultrasonography showed a poor image because of the large volume of abdominal air, and thus we were unable to obtain remarkable findings. Laboratory tests revealed the following: white blood cell count, 22,100/μl; hemoglobin, 15.8 g/dl; and C-reactive protein, 32.9 mg/dl . Arterial blood gas analysis showed respiratory and metabolic acidosis . Immediate resuscitation was provided using intravenous fluids, endotracheal intubation, a high dose of noradrenaline, and empiric antibiotics (meropenem and vancomycin). Chest and abdominal radiographs showed intraperitoneal gas . The patient underwent intensive care postoperatively and was extubated on day 4. He was discharged from the intensive care unit on day 10. He developed an intra-abdominal abscess, surgical site infection, and drug-induced acute kidney injury, which were treated for several weeks. Finally, he was transferred to another hospital for rehabilitation on day 41. He was able to walk and eat independently after rehabilitation; however, he subsequently developed peritoneal metastasis. He declined additional cancer treatment, and thus only palliative care was performed.TP is an extreme form of pneumoperitoneum, and the pathophysiology is similar to that of ACS. The abdomen is a closed anatomic space surrounded by the diaphragm and abdominal musculature; therefore, IAP increases as the intra-abdominal volume increases . AccordiMost reported causes of TP are complications of upper or lower gastrointestinal endoscopy , 7 and cIn our patient’s case, a relatively common condition of gastrointestinal tract perforation due to colon cancer resulted in TP. It is unclear why TP occurred without active air infusion. A perforated wall or the surrounding omental fat might act as a one-way valve as well as in the cases of TP caused by obstipation or unhealed abdominal mesh , 13. AddPhysical examination and investigation of medical history are crucial for diagnosing TP. Physical examination in TP usually shows tachypnea with accessory muscle use, abdominal tenderness, and abdominal distension with tympanitic sound on percussion. Patients with severe circulatory failure may have tachycardia, decreased blood pressure, and loss of peripheral pulses. Laboratory tests may show hypercapnia, hypoxemia, and lactic acidosis. Medical history in TP typically includes a history of endoscopic procedure, trauma, or mechanical ventilation. However, even without such apparent medical history, it is important to consider this condition as one of the differential diagnoses of shock, respiratory distress, and cardiac arrest, because it might lead to death if intervention is delayed.We were able to perform needle decompression using abdominal CT imaging safely. However, CT evaluation in an emergency is not mandatory, because it may lead to delayed intervention. Lateral radiographic views might help in the diagnosis and safer puncture .This case suggests that perforation by colon cancer without active air infusion can lead to TP. However, not all gastrointestinal perforations lead to TP. Further studies are needed to investigate the incidence and mechanism of gastrointestinal perforations leading to TP.


An adenocarcinoma of the appendix invading the urinary bladder, which is difficult to be diagnosed before the operation, is an extremely rare disease. Only a few cases have been reported. Here we reported a case of patient diagnosed with the mucinous adenocarcinoma of the appendix invading the urinary bladder. The case reported in this study was a 54-years old man who was admitted due to a 6-month history of intermittent episodes of irritative voiding symptoms of the bladder, and weight loss. The patient did not have any gastrointestinal symptoms. The physical examination, laboratory examination, cytology of the urine, computed tomography and cystoscopy were inconclusive. The partial cystectomy, subsequent exploratory laparotomy and intraoperative frozen analysis revealed the appendiceal mucinous adenocarcinoma with a fistula to the urinary bladder. The appendectomy and the right hemicolectomy with a ileocolic anastomosis, the lymphadenectomy and the partial cystectomy limited to the anterior wall was performed. Six months after operation, the patient was in a good health with no obvious discomfort, no recurrence or distant metastases. The recommended treatment for the adenocarcinoma of the appendix invading the bladder with a fistula formation is as follows: appendectomy, right hemicolectomy with ileocolic anastomosis, lymphadenectomy, partial cystectomy and intraperitoneal hyperthermic chemoperfusion. It has an age-adjusted incidence of 0.12 cases per 1,000,000 people per year , and 4%-The international Classification of Diseases for Oncology group divides the adenocarcinoma of the appendix into three categories: colonic, mucinous and signet ring cell adenocarcinoma ,6. AmongIt is well known that tumors of the pelvic organs, such as the ovary, the rectum and the sigmoid colon, can invade the urinary bladder due to spatial contiguity. However, the appendiceal mucinous adenocarcinoma infiltrating the bladder is extremely rare and less than 20 cases have been reported . The ade2A 54-years old man with a 6-month history of intermittent episodes of irritative voiding symptoms of the bladder and weight loss was admitted. The patient did not have any gastrointestinal symptoms such as pain, obstruction or melena, and he presented a negative medical history for gastrointestinal diseases. The physical examination was negative. An urine analysis revealed 30 white blood cells and 12 red blood cells per high power field. No malignant cells were observed in the urine. The carcinoembryonic antigen level was normal. The enhanced pelvic computed tomography (CT) scan revealed an irregular and slightly higher density , with thThe partial cystectomy was therefore performed, and the right posterior wall of the bladder was adherent to the peritonea. It was found, during the subsequent exploratory laparotomy, that the tumor was located between the ileocecum and the bladder. The appendix was not observed. The ileocecum firmly adhered to the bladder posterior wall with a fistula, which was full of mucus. The intraoperative frozen analysis revealed appendiceal mucinous adenocarcinoma. Thus, the mucinous adenocarcinoma of the appendix with a fistula to the urinary bladder was diagnosed. The following procedures: appendectomy, right hemicolectomy with ileocolic anastomosis, lymphadenectomy, and partial cystectomy limited to the anterior wall, were performed.On a gross examination, accumulation of mucus within in the lumen and thickening of the wall were observed. A pathological examination confirmed a mucinous adenocarcinoma of the appendix with a transmural growth to the right posterior wall of the bladder . The lymInformed consent: Informed consent has been obtained from all individuals included in this study.Ethical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee3The adenocarcinoma of the appendix invading the urinary bladder is an extremely rare disease. To our best knowledge, only a few cases have been reported in the world ,3, and tAn appendicovesical fistula accounts for 5% of intestinal vesical fistula , and theAn appendiceal neoplasm most often presents as an acute appendicitis or as a palpable abdominal mass. The mucinous adenocarcinoma invading the bladder does not have classical symptoms of gastrointestinal tracts and vesicoenteric fistula, such as abdominal pain and pneumaturia. Only irritative symptoms of the bladder or the gross hematuria are manifested. Therefore, it is difficult to make an early and accurate preoperative diagnosis of the appendicovesical fistula.in situ and localized cases [The key to diagnosis is the awareness and the vigilance for this disease. When the thickened appendix full of mucus was found during surgery, the mucinous adenocarcinoma invading the bladder should be considered, and the intraoperative frozen biopsy should be immediately performed. If the diagnosis is clear, the formal right hemicolectomy is considered as the traditional treatment for the patients with the non-metastatic adenocarcinoma of the appendix. The use of the appendectomy is limited to a small area of the appendix, especially for ed cases . The 5-yed cases ,14. The ed cases ,15.4The adenocarcinoma of the appendix invading the urinary bladder is an extremely rare disease. Surgeons should be familiar with the necessary knowledge to make an appropriate and accurate diagnosis, which will lead to a prompt and correct treatment. The recommended treatment for the adenocarcinoma of the appendix invading the bladder with a fistula formation is as follows: appendectomy, right hemicolectomy with ileocolic anastomosis, lymphadenectomy, partial cystectomy and intraperitoneal hyperthermic chemoperfusion.


Comparisons of hepatic epithelioid hemangioendothelioma (HEHE), hepatic hemangioma, and hepatic angiosarcoma (HAS) have rarely been reported. The purpose of our study was to analyze the clinical and magnetic resonance imaging (MRI) findings of these conditions.A total of 57 patients  provided hepatic vascular endothelial cell data between June 2006 and May 2017.P < 0.001). HAS lesions were less likely to have circumscribed margins. The proportions of lesions with hemorrhaging were 4% (1/25), 30.8% (4/13), and 36.8% (7/19) for hemangioma, HEHE, and HAS, respectively (P = 0.014). HEHE and HAS cases were more likely to show heterogeneous signals on T1-weighted (T1WI) MRI. HEHE and HAS cases were more likely to show heterogeneous signals on T2-weighted (T2WI) MRI. Centripetal enhancement was the most common pattern in vascular tumors, with proportions of 100, 46.2% (6/13), and 68.4% (13/19) for hemangioma, HEHE, and HAS, respectively. The difference in enhancement pattern between HEHE and HAS was not significant, but rim enhancement was more common for HEHE .The proportions of cases with circumscribed margins were 88% (22/25), 84.6% (11/13), and 31.6% (6/19) for hemangioma, HEHE, and HAS, respectively  and coagulation function of the HAS group decreased, whereas the alpha-fetoprotein (AFP) level increased. The 5-year survival rate for HAS was significantly lower than that of HEHE. A higher malignancy degree indicated a more blurred lesion margin, easier occurrence of hemorrhaging, and more heterogeneous T1WI and T2WI signals. Liver-derived vascular endothelial cells can cause angiogenic lesions, including those that are benign (hepatic hemangioma), low-grade , or malignant . The clinical treatment and prognosis of these conditions vary greatly –4. HEHE This retrospective study was conducted with the approval of our hospital’s institutional review board, and all cases were obtained from a picture archiving and communication system (PACS). Cases of hepatic hemangioma, HEHE, and HAS between June 2006 and May 2017 were collected. All patient diagnoses were confirmed by biopsy or surgical resection, and all patients underwent preoperative contrast enhanced MRI. This study included 57 patients with tumors derived from hepatic vascular endothelial cells: 25 with hemangioma, 13 with HEHE, and 19 with HAS. The male-to-female ratio of the sample was 24:33, and the median age was 48 years (17–80 years). None of the patients had a history of exposure to cesium dioxide, arsenic, or other toxins. Additional disease history and laboratory test results are shown in Table A GE Optima MR360 was used with a field strength of 1.5 T and an eight-channel abdominal surface coil. Before scanning, the patients fasted for 4 h and were trained to breathe. The patients were positioned supine on the examination bed, feet first. A sagittal T2-weighted image (T2WI) was acquired using a fat-suppressed fast spin-echo sequence . An axial T1-weighted image (T1WI) was also acquired .Gadopentetate dimeglumine  was intravenously injected before obtaining the fat-suppressed transverse T1WIs. The dose was 0.1 mmol/kg per patient, and the injection rate was 2.0 ml/s . The scanning delay times were 22 s, 60 s, and 180 s for the arterial, portal, and delay phases, respectively.Two radiologists who had performed liver imaging diagnoses for more than 10 years analyzed all MR signs and determined whether the lesion margins were circumscribed and whether hemorrhage had occurred as well as observed the signal intensity and MRI enhancement pattern . The types of margin included circumscribed and not circumscribed, where the latter refers to peritumoral buds on enhanced scans. Concentric enhancement means that the peripheral nodular irregular post-contrast enhancement on the early phase, which progresses centripetally on delayed phase. Rim enhancement means that the enhancement is more pronounced at the periphery of the lesion. Septal enhancement represents a linear or reticular enhancement within the lesion. The radiologists were blind to clinical and pathologic data.Specimens were fixed in 10% formaldehyde solution for 24 h, dehydrated, paraffin-embedded, sectioned, conventionally stained with hematoxylin and eosin (H&E), and immunohistochemically stained using the streptavidin-peroxidase (S-P)-linked method via DAB staining. A senior pathologist specializing (21 years of working experience) in the diagnosis of liver tumors read the specimens.P < 0.05 were considered significant.All clinical and imaging characteristics of the three lesion types were categorized and are listed in Tables P = 0.148) or sex (P = 0.950) among the three patient groups. The cases of HAS were associated with liver cirrhosis(P = 0.001). The liver lesions manifested mostly as masses, with proportions of 84, 92.31, and 78.95% for hemangiomas, HEHE, and HAS, respectively. The differences among these groups were significant (P < 0.001). The average tumor diameter was significantly higher  in the hepatic hemangiosarcoma group than those in the hepatic hemangiomas and hepatic epithelioid hemangioendothelioma . The surgical resection rates were 100% (25/25), 92.31% (12/13), and 57.89% (11/19) for hemangioma, HEHE, and HAS, respectively. The HAS resection rate was the lowest, with a significant difference of P < 0.001. The proportions of patients with hepatitis in the three groups were 8% (2/25), 38.46% (5/13), and 15.79% (3/19) for hemangioma, HEHE, and HAS, respectively (P = 0.063). The survival time was tracked for 8–39 months. The 13 cases of HEHE in this study showed no lung and bone metastases during the follow up after hepatectomy. Eleven patients in the HAS group died, but no deaths occurred in the hemangioma or HEHE groups.As Table P < 0.001). The differences among these groups were significant, and HAS lesions were more likely to not have circumscribed margins. The proportions of lesions with hemorrhaging were 4% (1/25), 30.8% (4/13), and 36.8% (7/19) for hemangioma, HEHE, and HAS, respectively, (P = 0.014). The proportions of cases with homogeneously low T1WI signals were 72% (18/25), 46.1% (6/13), and 21% (4/19) for hemangioma, HEHE, and HAS, respectively (P = 0.004). HEHE and HAS were more likely to show heterogeneous signals on T1WI . HEHE and HAS were more likely to show heterogeneous signals on T2WI. Centripetal enhancement was the common pattern in vascular tumors, with proportions of 100, 46.2% (6/13), and 68.4% (13/19) for hemangioma, HEHE, and HAS, respectively , and rim enhancement was common in cases of HEHE  and small vascular lumens rich in red blood cells (RBCs). In the tumor tissue, a few residual hepatocyte cords and small bile ducts were observed, with no capsule in the periphery area. The hepatic sinusoids in the neighboring liver tissues showed tumor cell growth, and the hepatic lobule structure was normal. Capsules were observed on the edges of a few HEHE cases . The immunohistochemistry results were as follows: HeP-1(−), CK18(+), CK19(−), CD24(−), β-Catenin(+), CA199(−), P53(+), CD31(+), and CD34(+).In the HAS group, tumor cells were solid and arranged in a fissure-like structure, forming a local vascular cavity-like structure. The lumens were irregular and anastomosing. Some vascular lumens were broken and invaded the liver tissue with large hemorrhages. Tumor cells were obviously atypical, showing pathological nuclear mitotic figures. The immunohistochemistry results were as follows: CD31(+), CD34(+), Vimentin(+), CK(−), CK8(−), CK7(−), hepatocyte(−), AFP(−), Actin(−), Desmin(−), and S-100(−).Hemangioma is common in vascular endothelial cell-derived benign and malignant tumors. Malignant tumors, including HEHE and HAS, are extremely rare. The incidence of HEHE is approximately 1 in 1 million , and 57%HAS is the most common interstitial liver malignancy, accounting for < 1% of primary liver tumors , 5. The The proportion of cases without circumscribed lesion margins on MRI in the HAS group was significantly higher than those in the hemangioma and HEHE groups because of the aggressiveness and rapid peripheral invasion of HAS. A significant difference was also noted in the hemorrhage rate among the three groups. Higher malignancy degrees were associated with complicated intratumoral hemorrhaging, because the higher the degree of malignancy, the more discontinuous the blood vessels, the more prone to bleeding. The HEHE lesions contained numerous collagen connective and fibrous tissue, and hemorrhaging with necrosis can easily occur in patients with HAS, thereby resulting in heterogeneous signals on MRI plain scans. Hemangiomas exhibited typical centripetal enhancement, regardless of size or number of lesions. The contrast agent can fill the entire lesion, which corresponds to the rich and complete vascular network in the microscopic tumor tissue without significant necrosis or hemorrhaging. Because HEHE is associated with a large amount of collagen and fibrous connective tissue, patients’ epithelium-like tumor cells and tumor lumens were dense at the edges of some lesions, whereas others were associated with staggered connective tissues and tumor blood vessel lumens with hemorrhaging and necrosis in areas. Thus, the 13 HEHE cases in this study included six cases of edge enhancement and six cases of centripetal heterogeneity. HAS is not associated with connective tissue. Because of its high degree of tumor cell malignancy, poor differentiation, discontinuous vascular networks, and many hemorrhage sites, most cases (13/19) showed heterogeneous centripetal enhancement. Of the three HAS lesions with the worst tumor cell differentiation, only the scattered vascular endothelial cells were observed to float on the blood pool under a microscope, without MRI enhancement.Differential diagnosis. HEHE and HAS with rim enhancement and heterogeneous centripetal enhancement should be differentiated from cholangiocarcinoma of the liver. Intrahepatic masses of cholangiocarcinoma are rich in fibrous tissue at the lesion center, with fewer peripheral fibers, and they often manifest with progressive and centripetal enhancement. Three typical enhancements have been reported : 1) edgeThis study has limitations. Because it is a retrospective and multicenter study, specific scanning parameter settings of the vascular tumors do not exist, and no DWI sequence data could be collected. In the future, we hope to cooperate with more hospitals to collect more vascular tumor clinical and imaging data for comparative analyses, especially for preliminary apparent diffusion coefficient (ADC) value comparisons of these tumors.In conclusion, we found many differences in the MRI signs of the three types of vascular tumors. Higher degrees of malignancy were associated with more blurred lesion boundaries, greater likelihoods of combined bleeding, and more uneven signals. However, little difference was found regarding the enhancement mode of the enhanced scan. However, HAS and HEHE did not significantly differ from benign hemangiomas in terms of age of onset, sex, lesion size, lesion number, PLT, coagulation function, AFP, or CEA. The 5-year survival rate for HAS was significantly lower than that of HEHE.


Major surgical trauma along with discontinuation of antiangiogenic treatment can exacerbate primary tumor growth even in the immediate postoperative period. Major surgical trauma along with discontinuation of antiangiogenic treatment can exacerbate primary tumor growth even in the immediate postoperative period. CT revealed progressive disease with massive primary tumor growth measuring 20 × 14 × 15cm with 2.5‐fold volume increase  left retroperitoneal malignant fibrous histiocytoma under pazopanib was admitted with signs of peritonitis. CT showed a 16 × 10 × 12cm left retroperitoneal mass with descending colon infiltration and perforation (Figure 1Surgical trauma can influence pathophysiological processes, such as wound healing response, local and systemic immunosuppression, that promote postoperative metastatic spread and recurrence.2The present article does not contain any studies with human or animal subjects performed by any of the authors.The authors declare that they have no conflict of interests.All authors equally accessed the data and contributed to the preparation of the manuscript. BKA and HA: were equally responsible for making and performing treatment decisions. HA: reviewed the manuscript for critical intellectual content and had the final approval.Informed consent was obtained from the patient.


A 70‐year‐old male was diagnosed with tiny capillary hemangioma of the ileum using double‐balloon endoscopy. Capillary hemangiomas should be included in the differential diagnoses of OGIB. For two consecutive years, a 70‐year‐old male patient presented with persistent iron deficiency anemia. Laboratory investigations showed a hemoglobin level of 9.9 g/dL, hematocrit of 35.8%, and mean corpuscular volume of 73.2 fL. Physical examination showed no signs of vascular changes in the skin. Investigations such as contrast‐enhanced computed tomography, esophagogastroduodenoscopy, and colonoscopy could not determine the source of the patient's bleeding. Transoral double‐balloon endoscopy revealed no lesions; however, transanal double‐balloon endoscopy revealed a submucosal‐like lesion with ulceration in the ileum Fig. . As the Hemangioma of the small intestine is a rare benign vascular tumor, which causes obscure gastrointestinal bleeding (OGIB).


Background: Actinomycosis of the tongue is an uncommon, suppurative infection of lingual mucosa, caused by actinomyces. The clinical diagnosis may present serious difficulties because of its ability to mimic other lesions, including both benign and malignant neoplasms. Methods: Here, we describe the case of a 52-years-old patient affected by an asymptomatic, tumor-like tongue swelling, then diagnosed as actinomycosis. A review of tongue localization of actinomycosis is also reported, with emphasis on clinical findings and therapy. Results and Conclusion: Early diagnosis and treatment, with pus drainage and systemic antibiotic therapy, are pivotal to avoid severe and life-threatening complications. Actinomyces israelii. It was recognized for the first time in humans in about 1845 by Von Langenbeck [Actinomycosis is an uncommon, chronic, suppurative bacterial infection affecting soft-tissues caused by an anaerobic, filamentous Gram-positive bacterium, Actinomycosis is classified by location as cervicofacial (50–60%), abdominal 25%), or pulmonary (15%) lesions. Cervicofacial actinomycosis is the most frequent clinical form, and the “lumpy jaw syndrome”, associated with odontogenic infection, is the most common clinical manifestation 5%, or pu,4, folloIn 1885, Von Hacker described the first case of actinomycosis of the tongue ,7. AlthoActinomycosis especially affects male patients aged 20 to 60 years . The maiThe diagnosis of actinomycosis of soft tissues is based on clinical findings and on histological examination and staining of the lesion. The presence of sulphur granules in tissue sample or the pus drainage help during diagnosis, although nocardiosis may also present with sulphur granules ,16,17. THere, we describe the case of a patient who presented with a tumor-like lingual swelling, then diagnosed as actinomycosis of the tongue. A review of lingual actinomycosis cases is also reported.A 52-year-old man was presented at our clinical unit  because of an asymptomatic, not-ulcerated swelling of the anterior part of the tongue. The patient reported a recent occurrence of the lesion. In his clinical history, the patient declared that, about 5 years before, a biopsy was performed approximately at the same location of the current lesion, with a diagnosis of benign squamous papilloma. He did not report any previous history of local trauma or abdominal, thoracic, or cervical abscesses.Intraoral examination revealed a solid, fixed, bilobed submucosal nodule, located slightly on the right to the midline of the anterior part of the tongue a,b.The lingual mucosa appeared normal in color, with two flat whitish spots and a small rounded erosion (about 2 mm in diameter). There was no restriction in tongue movement. Extraoral examination showed no evidence of cervical lymphadenopathy.Hematological examination revealed neutrophilia, monocytosis, and a raised value of c-reactive protein (CRP), with a concentration of 3.5 mg/dL .The clinical diagnosis was of a benign neoplasm, with a differential diagnosis including traumatic lesion, infective lesion or malignant neoplasm.Under local anesthesia, two incisional biopsies of the lesion were taken for achieving the histopathological diagnosis—the first one of the epithelial layer and the other of the submucosa—in order to obtain a representative section. During the biopsy, a yellowish purulent drainage coming from the lesion was observed.Three weeks after the biopsy, the patients received systemic antibiotic therapy because of a dental extraction. He was treated with oral intake of clarithromycin for one week (500 mg every 12 h), due to penicillin allergy.Post-surgical healing was excellent, with the complete resolution of swelling at six weeks follow-up, when the histological result was given to the patient .Histopathological examination of the biopsy specimen, indeed, showed a nodular mass deep into the muscularis propria of the tongue, showing colonies of actinomyces and a chronic and acute inflammatory process, including suppurative signs .Lingual actinomycosis is rare. In Actinomyces israelii, a filamentous Gram-positive bacilli, commensal of the flora of the oropharynx, gastrointestinal tract and urogenital tract. In the oropharynx, it is particularly present in gingival sulcus, tonsillar crypts, dental plaques, and periodontal pockets. Consequently, actinomycosis is considered an endogenous infection, where the trauma plays a catalytic role in starting the disease [In humans, the etiological agent of this disease is mainly  disease ,7,29.The microorganism is unable to penetrate healthy tissue, while, to become invasive, it requires the interruption of mucosal barrier to gain access to the submucosal tissue . ActinomLingual actinomycosis is generally localized on the anterior two-thirds of the tongue, lateral to the medline , as occuPain, dysphagia, speech impairment, difficulty in moving the tongue can be reported by the patient , althougThe gold standard for the final diagnosis is the histological examination including the histological staining to detect Actinomyces spp. colonies, whenever possible, also performed on purulent material. Bacterial culture is not recommended because it remains sterile in just about 50% of cases . TypicalThe differential diagnosis should include other infections , granulomatous lesions, infected cyst, pyogenic abscess, and benign and malignant neoplasms ,30,31.The preferred treatment remains administration of antibiotics with surgical excision or incision of the lesion. The drainage of abscess or surgical excision, when the lesion is small, largely enhance the efficacy of antibiotic therapy . The druAlthough lingual actinomycosis infections is a rare event, early diagnosis and treatment are pivotal to avoid severe and life-threatening cases. Because of its ability to mimic other diseases, especially neoplasms, actinomycosis can be a challenging problem for the clinician and always requires diagnostic investigations, including biopsy.This infection must be considered in the differential diagnosis of any cervicofacial mass. Treatment should always include pus drainage and systemic antibiotic therapy.


Intrasellar cavernous hemangiomas (ICHs) are rare vascular lesions that arise in the sellar region. ICHs are usually misdiagnosed and treated as pituitary adenomas. Therefore, a preoperative diagnosis is particularly important, especially when the goal is complete resection.A 55-year-old woman presented with a 1-month history of intermittent dizziness. Magnetic resonance imaging (MRI) revealed a well-demarcated abnormal ellipsoid signal in the sellar region (size: 2.7 cm × 1.7 cm), with a mulberry-like enhancement after gadolinium injection. Computed tomography revealed an intrasellar mass without calcification that extended into the left cavernous sinus and was faintly contrast-enhanced. Angiography revealed a tumor with mildly delayed staining fed by the C5 segment of the right internal carotid artery.An intrasellar cavernous hemangioma based on neuroradiological examinations.The patient underwent surgery with an endoscopic endonasal transsphenoidal approach to debulk the lesion and obtain tissue for the pathological diagnosis.Blood spurting was observed after puncture, and the capsule was stained blue. Lesion removal was stopped, and the patient underwent gamma knife surgery 1 week later. She remained in good condition during the follow-up.Sponge-like or mulberry-like lesions can be identified on MRI after gadolinium injection and can facilitate a preoperative diagnosis of ICH. Currently, surgical debulking with cranial nerve decompression during the acute stage and subsequent gamma knife radiosurgery are considered to be a safe and effective treatment. Successive cases of ICHs have been reported due to advances in imaging technology and particularly magnetic resonance (MR) applications.,6–13 ICH has a characteristic appearance on MR imaging (MRI), including isointensity on T1-weighted images, hyperintensity on T2-weighted images and diffuse homogeneous enhancement on gadolinium-enhanced T1-weighted images in the sellar region. Still, these lesions are frequently misdiagnosed and treated as pituitary adenomas.,15 To date, most studies of ICH involve case reports, which differ in terms of the imaging performance and typing of the disease . In this report, we present a case of ICH with a comprehensive imaging examination, including MRI, computed tomography (CT), and digital subtraction angiography (DSA), and summarize the findings of previous case reports to yield a reference that may facilitate preoperative diagnoses.Cavernous hemangiomas are benign vascular lesions that arise in both the intra- and extra-axial regions of the brain. The incidence of this tumor type is 0.4% to 0.8% in the general population.2A 55-year-old woman presented with a 1-month history of intermittent dizziness, which could be relieved by rest and was not accompanied by nausea, vomiting, and sight rotation. She was otherwise healthy and had no history of chronic diseases such as hypertension and diabetes. She was initially diagnosed at a neurology clinic and was referred for a whole-brain MR scan, which revealed an intrasellar mass  and DSA to determine whether the lesion was a thrombotic aneurysm. A CT scan revealed an intrasellar mass without calcification that extended into the left cavernous sinus and exhibited faint contrast enhancement Fig. a and b. The patient underwent surgery via the endoscopic endonasal transsphenoidal approach to debulk the lesion as much as possible and obtain tissue for a pathological diagnosis. Upon opening the sellar floor, tensioned meninges were encountered and the pulsation was visible Fig. a. We fir3 We have provided a table in which the characteristic clinical manifestations, imaging features, and treatment methods are described clearly with the aim of better understanding the characteristics of pituitary adenomas, ICHs, cavernous sinus hemangiomas and cerebral cavernous hemangiomas , the gadolinium-enhanced T1-weighted images can be classified into 2 completely different manifestations.,20 Specifically, Zhou reported 2 types of cavernous sinus hemangioma: sponge-like (bright homogeneous enhancement) and mulberry-like type (heterogeneous enhancement). The enhancement form in our case was the extremely rare mulberry-like type. Turan first reported this marked hyperintensity on T2-weighted images and the presence of signal void areas in an ICH patient. Third, CT and DSA are also important radiological examinations for the diagnosis of an extra-axial cavernous hemangiomas, although the manifestations are not specific and not widely reported. Only 2 cases have reported the DSA features of extra-axial cavernous hemangiomas in the literature.,22 In one case, angiography demonstrated an avascular mass with no feeding or draining vessels. In the other case, an angiogram revealed a highly vascular mass that was fed from both anterior cerebral arteries and drained through the cavernous sinus. CT is used more commonly in early cases, and most of them exhibit hyperdense lesions with homogeneous or mild enhancement. The case reported here involves the first comprehensive imaging examination of ICH with MRI, CT, and DSA findings.The preoperative radiological diagnosis of an ICH is a crucial determinant of the treatment program. Therefore, the imaging features must be understood, as these can distinguish ICHs from other common lesions in the sellar region. First, significant differences have been observed between the imaging features of extra-axial and intra-axial cavernous hemangiomas, the later are surrounded by a ring of hypointensity due to hemosiderin deposits from recurring microhemorrhages. The specific imaging features of cerebral cavernous hemangiomas are described in Table  According to this classification, many ICHs reported in the literature belong to the mixed type (Type III), while only a few cases belong to the true intrasellar type (Type I). Lombardi divided sellar and parasellar extra-axial cavernous hemangiomas into 3 types based on the patterns of growth, namely endophytic lateral growth, endophytic medial growth, and exophytic growth. However, tumor growth is a dynamic process, and it can be difficult to judge the growth pattern based on a certain MR performance, especially when the tumor is large and spans multiple anatomical regions. Therefore, we believe that a classification based on the tumor morphology and anatomical location may help to predict the clinical course of the tumor during development, as well as the response to treatment.Intrasellar and parasellar extra-axial cavernous hemangiomas can be classified into 3 types according to the relationships among the tumor origin, expansion, and ICA on coronal MRI. However, remarkable intraoperative bleeding and postoperative neurological dysfunction are common results of the surgical treatment of ICHs and cavernous sinus hemangiomas. Consequently, only a few cases in the literature describe total resection. Surgical debulking with acute cranial nerve decompression, followed by gamma knife radiosurgery, is considered a safe and effective treatment option for ICH.,4,17 Radiosurgery can also be performed directly  in some cases that can be diagnosed based on imaging findings.Cavernous hemangioma is a benign tumor, and total removal is the optimal treatment option. However, surgery requires balancing the benefits with the natural history of the lesion and functional impairment, even in a case of cerebral cavernous hemangioma in which 50% is located in the cerebral hemispheres. Technologies such as functional MRI and neuro-navigation have increasingly enabled the safe removal of cerebral cavernous hemangiomas, including brainstem cavernous hemangiomas.4ICHs and cavernous sinus hemangiomas are rare extra-axial cavernous hemangiomas that can be classified into 3 types according to the relationships between the tumor origin, expansion, and ICA features on coronal MRI. ICHs belong to type I, which is confined medially to the ICA, and these lesions do not expand beyond the so-called carotid line. Gadolinium injection reveals either a sponge-like or mulberry-like appearance on MRI. Therefore, MRI can facilitate a preoperative diagnosis of ICH. Surgical debulking with acute-stage cranial nerve decompression, followed by gamma knife radiosurgery, is considered a safe and effective treatment for ICH.Investigation: Yuxiang Weng.Supervision: Yuehui Ma, Haiyan Lou.Writing – original draft: Xinfa Pan, Jie Shen.Writing – review & editing: Renya Zhan.


Pleuroperitoneal communication (PPC) is rarely observed, accounting for 1.6% of all patients who undergo continuous ambulatory peritoneal dialysis (CAPD). Although there have been several reports concerning the management of this condition, we have encountered several cases in which control failed. We herein report a valuable case of PPC in which laparoscopic pneumoperitoneum with video-assisted thoracic surgery (VATS) was useful for supporting the diagnosis and treatment.2 gas into the abdominal cavity. On thoracoscopy, bubbles were observed emanating from a small pore at the central tendon of the diaphragm, which was considered to be the lesion responsible for the PPC. We closed it by suturing directly.The patient was a 58-year-old woman with chronic renal failure due to chronic renal inflammation who was referred to a nephrologist in our hospital to undergo an operation for the induction of CAPD. Post-operatively, she had respiratory failure, and chest X-ray and computed tomography (CT) showed right-sided hydrothorax that decreased when the injection of peritoneal dialysate was interrupted. Therefore, PPC was suspected, and she was referred to our department for surgical repair. We planned surgical treatment via video-assisted thoracic surgery. During the surgery, we failed to detect any lesions with thoracoscopy alone; we therefore added a laparoscopic port at her right-sided abdomen near the navel and infused COVATS with laparoscopic pneumoperitoneum should be considered as an effective method for inspecting tiny pores of the diaphragm, especially when the lesions responsible for PPC are difficult to detect. The occurrence of hydrothorax due to pleuroperitoneal communication (PPC) under continuous ambulatory peritoneal dialysis (CAPD) is relatively rare, with an incidence of about 1.6% . To our We herein report a case in which pneumoperitoneum with laparoscopy during surgery was useful for detecting pinhole PPC.The patient was a 58-year-old woman who was referred to a nephrologist in our hospital to undergo an operation for the introduction of CAPD. One week after starting CAPD, she developed hypoxemia and gained weight. Chest X-ray Fig.  and compWe planned to perform surgical repair of the diaphragm using video-assisted thoracic surgery (VATS). Dialysis solution (1000 ml) containing 20 mg of indigo carmine was injected into the abdominal cavity through the CAPD catheter just before starting the surgery. Under general anesthesia, the patient was intubated with a double-lumen endotracheal tube and positioned in a left-sided half-lateral decubitus position. Three 1.5-cm skin incisions were made at the seventh, sixth, and eighth intercostal spaces on the anterior, middle, posterior axillary lines, respectively. A 30°, 10-mm thoracoscope was inserted at the sixth intercostal space of the middle axillary line.2 gas into abdominal cavity at 8 cmH2O. By inspecting the diaphragm with a thoracoscope under pneumoperitoneum, bubbles were seen gushing out from a small pore at the right central tendon of the diaphragm, which was considered the responsible lesion  felt  using fibrin glue  Fig. e. The paPPC occurs in 1.6% of patients who undergo CAPD, and the average interval between the start of dialysis and the occurrence of hydrothorax ranges from 1 day to 8 years . ApproxiThe pathogenesis of hydrothorax in CAPD remains unclear. According to some studies, a PPC either through congenital or acquired diaphragmatic fenestrations and the leakage of fluids secondary to increased abdominal pressure is the most common explanation for the etiology of hydrothorax. The diagnosis is usually not difficult because of the close relationship between the increase in the pleural effusion and CAPD performance. Laboratory data can sometimes assist in its diagnosis as well. Chow et al.  reported2 gas and increasing the intra-abdominal pressure caused bubbles to gush out of a small pore, which confirmed that it was the lesion responsible for PPC. Although some previous studies have reported a similar approach using a CO2 pneumoperitoneum through a peritoneal dialysis (PD) catheter [VATS is the standard procedure for treating this condition. However, Saito et al. reviewed 29 cases of PPC and found that there were 8 cases in which fistulas were unconfirmed during the operations, and in these cases, the recurrence rate was relatively high [catheter , we opteNocardia rubra cell wall skeleton, OK-432, and autologous blood [Regarding the treatment of PPC, various approaches have been reported, such as mechanical rub pleurodesis and chemical pleurodesis using tetracycline, fibrin glue, steroid, us blood . RegardlWe herein report a case in which VATS combined with laparoscopic pneumoperitoneum was effective for the detection of the lesion responsible for PPC. For the accurate diagnosis and treatment, we recommend VATS combined with laparoscopy as the surgical method of first choice for PPC.


Discriminating them is crucial to avoid improper treatment or delayed correct treatment. We describe a 48‐year‐old woman presenting with a sudden onset of scintillating scotoma and left‐lower quadrantanopsia. Hyperacute cerebral infarction was suspected. However, brain magnetic resonance imaging (MRI) revealed a mass at the cortico‐medullary junction in the right occipital lobe. We diagnosed her as metastatic melanoma. We suspected that neurological deficits can be attributed to seizure, and therefore introduced levetiracetam. She showed neurological improvement immediately. Our case demonstrated the importance of considering brain tumor as a differential diagnosis in patients presenting with acute‐onset neurological deficits. In addition to appropriate treatment of tumor, the use of newer antiepileptic drugs resulted in good neurological prognosis in metastatic brain tumors. Brain MRI and CT showed a mass lesion 2 cm in diameter at the cortico‐medullary junction in right occipital lobe. The findings were typical characteristics of metastatic melanoma. Seizure, syncope, sepsis, migraine, and brain tumor are the most common. When they come within 4.5 hours from onset, neurologists consider thrombolytic therapy, which accompanies the risk of symptomatic hemorrhage. So, discriminating them from stroke is crucial to avoid improper treatment or delayed correct treatment of the disease. We herein report a case of central nervous system (CNS) metastasis of malignant melanoma which presented with stroke‐like onset. The patient was successfully treated with levetiracetam, a newer antiepileptic drug (AED).2A 48‐year‐old woman was referred to our hospital suspected of hyperacute cerebral infarction with a chief complaint of left‐lower quadrantanopsia. She exhibited a sudden onset of scintillating scotoma one and a half hours before arrival, followed by left‐lower quadrantanopsia. On arrival, she was alert and oriented. Her vital signs were within normal limit. Neurological examination revealed left‐lower quadrantanopsia, horizontal gaze palsy, and disturbance of attention. Her National Institute of Health Stroke Scale (NIHSS) was 4. We considered undergoing thrombolytic therapy with the use of tissue plasminogen activator.We performed brain MRI immediately. However, contrary to our expectation, it showed a hypointense lesion in the right occipital lobe on diffusion‐weighted images and fluid‐attenuated inversion recovery. T2*‐weighted images showed hypointense areas at the edge. This lesion was hyperintense on gadolinium contrast–enhanced T1‐weighted images. These findings were typical characteristics of metastatic melanoma  and D‐dimer (0.2 μL/mL). Cerebrospinal fluid findings revealed slightly elevated protein (53 mg/dL), but were otherwise normal. Cytology and bacterial cultures were negative. Electroencephalography (EEG) showed sharp waves in the occipital region, accompanied by reduced appearance of alpha waves. Truncal CT and abdominal ultrasonography revealed no metastatic lesion or swollen lymph node.We made the diagnosis of melanoma CNS metastases. Stroke‐like episode was speculated to be induced by a seizure‐like mechanism from metastatic lesion. The patient was treated with levetiracetam, concentrated glycerin, fructose, carbazochrome, and tranexam immediately after admission. Quadrantanopsia and gaze palsy gradually subsided, disappearing 2 days after admission. She was discharged from our hospital 7 days after admission. Subsequently, stereotactic radiation therapy was performed at another hospital for 3 days, and follow‐up MRI after 3 months from admission showed the reduction in the size of lesion. The lesion was surgically resected 6 months after admission. For the next 1 year, the patient still followed an uneventful course without any recurrence of metastasis, seizure recurrence, or neurological deficits. One and a half years later after admission, the patient experienced recurrence of melanoma with multiple brain metastases. On brain MRI, hydrocephalus and melanomatosis cerebri were not observed. The patient eventually died 2 years after discharge from our department because of multiple‐organ failure.3Stroke mimics account for 20%–25% of suspected stroke cases in the UKMisdiagnosis might lead to improper treatment of the disease, especially when they came within 4.5 hours from onset, and therefore, thrombolytic therapy was considered.With regard to brain tumor, most patients present with subacute or chronic time course. On average, symptoms developed approximately 3 weeks before the diagnosis of brain metastases (median 2 weeks).Seizure is a common manifestation of brain tumors. Patients with metastatic melanoma are most likely to develop seizures, with 67% of all cases.The good neurological prognosis of the patient and the absence of recurrence could be achieved by appropriate treatment of metastatic lesion and medication with newer AEDs.4This report highlights the importance of considering brain tumor as a differential diagnosis of patients with acute‐onset neurological deficits. Non‐negligible proportion of brain tumors present with stroke‐like episodes. Newer AEDs in addition to tumor‐oriented treatments could result in good neurological prognosis.Dr Narita has received an honorarium from Chugai Pharmaceutical Co., Ltd and conducted contract research with AbbVie GK, Ono Pharmaceutical Co., Ltd., Stella Pharma Co., Ltd., Sumitomo Heavy Industries, Ltd., and Nihon Medi‐Physics Co., Ltd. The other authors state that they have no conflict of interest. All the authors state they have no conflict of interest with Otsuka Pharmaceutical Co., Ltd. or UCB Japan Co. Ltd, the distributor of levetiracetam. Click here for additional data file. Click here for additional data file.