Ewing sarcoma (ES) rarely derives from the sacrum or mobile spine. The discovery of primary ES with multimetastatic involvements is exceedingly less frequent in clinical practice. A 23-year-old man with initial primary sacral ES developed metastases of rib, lung, and multifocal skull after receiving surgical intervention and series of adjuvant therapies. We provide this very rare case consisting of its clinical features, imaging findings, treatments, and outcomes. Therapeutic modalities of ES are also reviewed in previous published articles. The prognosis of metastatic ES remains dismal; effective therapeutic modalities for ES require multidisciplinary collaboration, with more high-quality clinical trials to promote the optimal protocols. EWSR1) gene and friend of leukemia virus integration site 1 gene (FLI1) (Ewing sarcoma (ES) is a rare sarcoma with high aggressiveness and peak occurrence during 10–20 years old . ES genee (FLI1) . ES in te (FLI1) . To the e (FLI1) –16. Howee (FLI1) . Optimal9/L , with neutrophil–granulocyte ratio of 75.8%.A 23-year-old man developed initial back pain and progressively worsened in the following 6 months. It started to radiate to the hip with additional plantar numbness for 2 weeks; he came to the local hospital for medication and suggested to our department without regular treatments. However, he complained that his sleeping quality was extremely poor due to the night-increasing back pain, with weight loss of approximately 5 kg in the last half year. Physical examinations showed claudication, tenderness of the spinous process and perispinous process at L5–S1 level, paresthesia of the left lower extremity, abnormal Achilles tendon reflex, and positive Lasègue sign of the left lower limb. Magnetic resonance imaging (MRI) revealed a space-occupying lesion with abnormal signal of the sacrum at the S1 level Figure 1via an en bloc method, then bilateral vertebral pedicles at L4–L5 level and posterior superior iliac spine were used to accomplish spinal reconstruction. Emphasis was put on exposing the tumor margin to ensure a radical surgical procedure with a negative tumor margin. Oxaliplatin was used intraoperatively  for local chemotherapy on the basis of unbroken dura. The whole procedure lasted 3.5 h, with blood loss of about 1,200 ml. The postoperative physical examinations showed certain improvements of the motor and sensory functions 10 days after surgery. Subsequently, the hematoxylin–eosin (HE) and immunohistochemical staining indicated small round tumor cells with CD99(+), and histopathology confirmed the diagnosis of ES with molecular translocation t  and four cycles of systemic chemotherapy. He received EBRT at a total dosage of 60 Gy with daily doses of 600 cGy (10 fractions in a month) and 30 Gy with daily doses of 200 cGy (15 times in a month). The chemotherapeutic protocol was cyclophosphamide, dactinomycin, vincristine, and doxorubicin (CAVD), and the blood test showed the quantity of leukocytes ranging from 2.32 to 2.55 * 109/L. Good local control, satisfactory spinal reconstruction in the sacrum, and general condition of the lung without detecting metastasis were gained through physical and radiological examinations at 1, 6, and 12 months after surgery, respectively.Full evaluation and written informed consent informing about the operation, as well as risks, were obtained after conducting necessary preoperative examinations. Intraoperative biopsy aiming at rapid diagnosis suggested the typical oncologic histology of uniform small round cells, so we removed the whole mass cation t However, the patient had been experiencing increasing headache 13 months after sacral ES excision. Although X-ray and computed tomography (CT) images did not indicate any change of the operative region Figure 2ES is the second most common primary malignancy of bone and soft tissue in adolescents and young adults after osteosarcoma, with an annual incidence of 1–3 persons per million and the highest morbidity during 10–20 years old , 19. TheCD99 (surface antigen MIC2)  . Moreoveof cases , produciEWS-FLI1 .The spinal column as the primary site of ES is rare; data derived from the Japanese Orthopaedic Association indicated that 23 of 326 ESs (7%) between 2006 and 2011 arose from the spine  reportedvia reverse transcriptase polymerase chain reaction (RT-PCR), 20% of patients with a diagnosis of localized ES were detected to have widespread malignant tumor cells in the bone marrow and blood , ifosfamide (I), dactinomycin (A), etoposide (E), cyclophosphamide (C), and doxorubicin (D), with the recommended combination of VIDE/VAI in Europe and VDC/IE in the United States , 36, 56.However, outcomes of systemic chemotherapy toward metastatic ES and recurrent and primary refractory Ewing sarcoma (rEECur) remained extremely poor, where 5-year OS rates are less than 30%  and 15% via shrinking the tumor volume.Currently, chemotherapy was administered not only for metastatic control or prevention but also for local control as a neoadjuvant and/or postoperative modality . The curSince the prognosis of patients with metastatic EFSTs remains dismal, molecular targets have been applied in the preclinical and clinical treatment protocols. Because of the difficulty of targeting fusion oncoproteins mediated by chimeric transcription factors, attention was shifted to alternative mechanisms regulated by oncogenic fusion transcription factors.IGF-1R) is one of the most important targets because tumor growth, metastasis, and angiogenesis are achieved through the activated IGF-1R pathway , has the capacity to interfere with the binding between EWS-FLT1 and RHA to induce apoptosis in in vitro and in vivo experiments (PARP) inhibitors are capable of interfering with the DNA repair process of ES in preclinical models, but they do not yield any positive results in clinical trials  was observed after receiving TK216 alone or with vincristine . Insulin pathway , 64. Howl trials –67. EWS-n levels . YK-4-27eriments –70. Polyl trials , 72. In l trials . NonetheIn conclusion, effective treatment modalities for localized and metastatic ES require multidisciplinary collaboration, with more high-quality clinical trials to promote optimal therapeutic protocols.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SH and BX contributed to the implement of the treatment. WW, FL, and QC contributed to the collection and preparation of clinical data and graphic presentation, CY drafted the manuscript. JX and SH supervised and reviewed the writing. All authors approved the submitted version.This work was supported by a grant form the National Natural Science Foundation of China . The funding source had no role in the study design, data gathering analysis, and interpretation, writing of the report, or the decision to submit the report for publication.The authors thank all the colleagues for great supports to this study and conscientious guidance.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Inflammatory pseudotumors may be defined as lesions that clinically and radiologically simulate neoplasms. These tumor are not a single clinical-pathological entity, but rather a generic term applied to any nonspecific, chronic, inflammatory expanding lesion. There are few reports of inflammatory pseudotumors in the nasal cavity and paranasal sinuses.We report three cases of inflammatory pseudotumors of the nose and paranasal sinuses seen at the Division of Otolaryngology of the Medical School University Hospital, Sao Paulo University.Inflammatory pseudotumors of the paranasal sinuses present a variety of symptoms according to the site. The patient developed progressive nasal obstruction during the past four months in the left nasal fossa, hyposmia, pain in the left maxillary region and repeated episodes of nasal bleeding. Fever, headaches or other complaints were absent. The patient had no underlying diseases, no previous surgery, and no allergies; she used no medication, was a non-smoker and did not drink alcoholic beverages. The physical examination revealed good general health; the patient had a normal-colored mucosa and was hydrated and eupneic. Anterior rhinoscopy showed a yellowish tumor filling the left nasal fossa, and a small amount of secretion; the right nasal fossa was unaltered. Oroscopy, otoscopy and palpation of the neck were normal. The complete blood count was within normal limits. Rigid nasal endoscopy revealed a solid yellowish tumor originating from the left middle meatus. Computed tomography of the paranasal sinuses  revealedA tumor biopsy through the nasal fossa revealed coagulation necrosis with vascular thrombi within a polypoid structure that was partially covered with respiratory epithelium. Following this inconclusive result, a deeper sublabial biopsy was done; the procedure coursed uneventfully. This biopsy revealed necrotic tissue, and a small fragment of respiratory mucosa with fibroplasia of the chorion and a mononuclear inflammatory infiltrate; there were no signs of malignancy. Surgical treatment was undertaken, with removal of the tumor sublabially  under general anesthesia. There was erosion of the anterior wall of the left maxillary sinus and a friable, well-defined tumor that filled the sinus; the tumor was completely removed. Pathology revealed an inflammatory polyp with extensive necrosis, confirming a diagnosis of inflammatory pseudotumor.Symptoms regressed, and the patient developed a small oroantral fistula in the gingivo-labial sulcus. Telescopy revealed wide opening of the medial wall of the maxillary sinus, with no lesions in the posterior area or secretion. A control tomography six months postoperatively  showed aMIHS, female, age 62 years, white, born in the state of Bahia, and living in Sao Paulo. The patient presented bilateral, progressive nasal obstruction, worse to the right, developing over four years. She complained of frontal, pressure-like, moderately intense headaches, hyposmia, clear rhinorrhea, nasal pruritus and bleeding episodes through the right nasal fossa. The patient reported a history of systemic high blood pressure and no other disease. The patient had not been operated previously, had no allergies and did not drink alcoholic beverages. She had stopped smoking five years ago. The physical examination revealed good general health; the patient had normal colored mucosa, and was hydrated and eupneic. The arterial pressure was 130×100mmHg and the heart rate was 80bpm. Anterior rhinoscopy showed left nasal septum deviation, a hypertrophic left lower turbinate and a reddish tumor filling the entire right nasal fossa to the nasal vestibule; there was a small amount of hyaline secretion. Oroscopy, otoscopy and neck palpation were normal. Nasal telescopy brought no further information, as the tumor did not allow progression of the endoscope. The complete blood count was within normal limits; there was mild hypergammaglobulinemia . Computed tomography of the paranasal sinuses revealed a large, heterogeneous expanding solid tumor in the right maxillary sinus, extending to the right nasal fossa; the tumor widened the right nasal fossa and displaced the septum towards the left. The lesion also extended to the choana, the rhinopharynx, the sphenoidal sinus and the ethmoidal cells, bulging the papyraceous lamina.Three biopsies were done of the nasal fossa tumor. The first biopsy demonstrated inflammatory polyps. The second biopsy showed a chronic, non-specific inflammatory process of the respiratory mucosa, with fibrosis of the chorion. The third biopsy revealed a chronic eosinophilic inflammatory process in the nasal mucosa, areas of squamous metaplasia of the respiratory epithelium, and fibrosis of the chorion. A sublabial approach for excisional biopsy was done to remove the entire tumor. Pathology revealed an inflammatory mucosal polyp with non-specific chronic inflammation and ample hemorrhagic, necrotic and hyalinized areas, suggesting an inflammatory pseudotumor.Nasal obstruction and bleeding regressed; there was hypoestesia in the right maxillary area. Telescopy showed an ample cavity with no signs of recurrence to the present (one year and three months postoperatively).MSM, male, age 26 years, white, born in the state of Pernambuco, single, an IBGE survey worker. The patient presented a history of nasal bulging to the left since age 12 years, together with bilateral nasal bleeding and obstruction. At that time there was facial asymmetry and left proptosis. A first surgery was done in 1991 at another unit; pathology revealed an inflammatory pseudotumor. A new surgical procedure was done in 1993 due to recurrence of the lesion. A further biopsy was done in 1996; pathology suggested paracoccidioidomycosis. The patient was treated with amphotericin B, with no improvement. In 1998, the patient was seen at the HC/FMUSP. At this time the patient reported that nasal obstruction and bleeding had regressed, but there was still proptosis to the left. There was no diplopia or altered visual acuity.The physical examination showed facial asymmetry and left proptosis. Nasal telescopy revealed an ample nasal cavity with signs of previous surgery and no tumors within. The complete blood count was within normal limits.Computed tomography of the paranasal sinuses revealed an expanding solid lesion in the left anterior and posterior ethmoidal sinuses, extending to the left orbital area. Four biopsies were done of the ethmoidal lesion, revealing a chronic, non-specific inflammatory process with an intense lymphoplasmocytic infiltrate in all samples. On September 1999, an excisional biopsy was done through an external approach, accessing the ethomoidal sinus from the left. Pathology demonstrated a non-specific chronic inflammatory process with no granulomas . InvestiFollowing this result, the diagnosis was defined as inflammatory pseudotumor of the ethmoidal sinus.The patient is clinically stable, nasal obstruction has regressed and there have been no further episodes of nasal bleeding.,,,Inflammatory pseudotumors are chronic inflammatory lesions of unknown origin. They have no common identifiable cause, although some authors have assumed that any inflammatory stimulus may originate these pseudotumors.Inflammatory pseudotumors occur in various anatomical sites; the lung is the most commonly affected organ.There appears to be no sex or age preference. In a review of the literature that included 28 cases of mouth and maxillary sinus inflammatory pseudotumors, Vigneswaran found a 1.5:1 male to female ratio and a mean presentation age of 33 years (ranging from 2 to 67 years).,,Inflammatory pseudotumors of the paranasal sinuses present a variety of symptoms depending on the site of origin. The most frequent clinical picture is a non-specific nasosinusal tumor that grows to a stable state over months or years; it may be painful and may be associated with nasal obstruction, nose bleeding, proptosis, increased lymph nodes, dysphagia or cranial nerve dysfunction.Although these tumors usually follow a benign course, such clinical behavior may not be generalized to all cases. There have been reports of local recurrence in about 37% of cases in some abdominal and mediastinal inflammatory pseudotumor series, and also cases of metastases at a distance.Computed tomographic findings that indicate inflammatory pseudotumors of the maxilla suggest a more aggressive appearance compared to findings in such tumors located in the orbit.Although there are suggestive clinical features, multiple biopsies are frequently required to establish a diagnosis of an inflammatory pseudotumor. It is an exclusion diagnosis, after eliminating the possibility of benign and malignant neoplasias, collagen diseases, vasculitis, infection and other inflammatory diseases.Laboratory exams may be altered, such as thrombocytosis, hypochromic microcytic anemia, hypergammaglobulinemia and an increased hemosedimentation rate, which resolve following tumor resection.2 The three patients had normal complete blood counts. Protein electrophoresis was done only in case 2, revealing mild elevation of gammaglobulins.,Corticosteroids, surgery and radiotherapy have been used in the treatment of inflammatory pseudotumors. Some authors have preferred corticosteroid therapy, while others have chosen surgery as the treatment of choice.Radiotherapy is used in selected cases, as its success rate is low; furthermore, it may induce a malignancy in a previously benign lesion.The aggressive aspect of paranasal sinus inflammatory pseudotumors is a diagnosticr challenge. The first concern should be to exclude neoplasia; multiple biopsies may be required. Rhinologists should raise the possibility of an inflammatory pseudotumor in the differential diagnosis of sinusal tumors, given the possibility of treating this condition medically, avoiding unnecessary ample resection.


Inflammatory myofibroblastic tumors have a wide spectrum of biological behaviour and are composed of inflammatory cells and myofibroblastic spindle cells. Tumors may infrequently involve the liver. Imaging findings are non-specific.Teaching Point: Radiologists should be familiar with inflammatory myofibroblastic tumors as a diagnostic consideration to avoid unnecessary surgery. Inflammatory myofibroblastic tumor (IMT) of the liver is a rare and benign lesion with an unknown pathogenesis and etiology, but in some cases IMT is thought to result from an inflammation response to an underlying infection . ActinomIt is difficult to obtain a diagnosis only by imaging, and radiological features may suggest malignant neoplasms. So histological examination is mandatory for a definitive diagnosis.A 3-year-old girl presented at the urgency department with persistent fever. The medical and surgical history was unremarkable. C-reactive protein levels and white cell count were elevated. Alpha fetoprotein was within the normal ranges. At initial evaluation, an abdominal ultrasound showed a hypoechogenic tumor and a peripheral cystic complex lesion in the right liver lobe . The hypFor further evaluation, abdominal magnetic resonance imaging (MRI) of the liver was performed 14 days later, which demonstrated an enhancing mass on segment VIII and a wall enhancing complex cystic lesion with extra-hepatic extension .A CT-guided drainage of the cystic component and a histologic biopsy of the solid component were performed. The microbiological study of aspirated liquid from the cystic component revealed a methicillin-susceptible Staphylococcus Aureus. The histopathological and immunohistochemical findings were compatible with inflammatory myofibroblastic tumor with expression of caldesmon and actin. This patient was diagnosed with a liver abscess complicated by the presence of an inflammatory myofibroblastic tumor. The antibiotherapy were optimized and it was decided at the multidisciplinary group consultation to re-evaluate with MRI after the cessation of antibiotic therapy. Five months after the initial diagnosis, MRI revealed a significant dimensional regression of both intra and extra-hepatic components of the lesion , with a Inflammatory myofibroblastic tumors are uncommon in liver and occur more frequently in children and young adults and affect males more than females . It is d3IMTs may be associated with fever, abdominal pain or a palpable mass . The ima2If the biopsy proves the diagnosis of IMTs and it excludes malignancy, observation, and medical treatment with no steroidal anti-inflammatory drugs and antibiotics may be prescribed in patients with peripheral liver IMTs .The knowledge of this entity is fundamental because it can affect treatment. If radiological and histologic findings are compatible with IMT, the patients can be treated with observation in an initial phase. Surgical resection is indicated if the lesion persists or progresses after a conservative therapy or manifest malignant transformation. Complete resection is curative in most patients .


Nodular histiocytic/mesothelial hyperplasia (NHMH) is a pathologic entity that has not been well characterized in the cytopathology literature. This is unfortunate because if unrecognized, NHMH may be misdiagnosed when encountered in cytology specimens. The aim of this communication is to accordingly alert cytologists about NHMH by means of an illustrative case report. A 51‐year‐old male patient, who never smoked and had no significant past medical history, presented with left sided chest pain. A computerized tomography (CT) scan of his chest revealed a large 13.4 × 11.5 × 16.0 cm heterogeneous pleural‐based mass with an associated small left pleural effusion. There was no metabolic imaging evidence of distant metastatic malignant disease on a positron emission tomography (PET)/CT scan. Excision of the mediastinal mass revealed a completely excised paraganglioma. The pleural fluid (30 ml) was sent for cytological examination. A direct smear preparation, ThinPrep slide and cell block material were prepared from his sample and displayed moderate cellularity. There were large cohesive aggregates of mononuclear cells observed within a background of dyshesive vacuolated histiocytic cells and reactive epithelioid mesothelial cells Figure . A separNHMH is a benign proliferative process that was first described in 1975 by Rosai and Dehner as a “benign reactive condition simulating a neoplastic process” in hernia sacs.In the present case, given the CT finding of a large pleural‐based mass and cytologic appearance of NHMH in pleural fluid the differential diagnosis included malignant mesothelioma, metastatic adenocarcinoma, and less likely a soft tissue pleural lesion . It is believed that NHMH results from chronic irritation of the mesothelial surface from tumor, inflammation and/or mechanical irritation. In the present case, NHMH was most likely induced by the large mediastinal paraganglioma abutting the pleural mesothelium. In accordance with a previous report of NHMH,In conclusion, we report a rare case of pleural fluid NHMH in which the cytomorphology and immunoprofile are described. NHMH in body fluid cytology specimens may mimic malignant cell clusters. Awareness of this entity will help prevent diagnostic errors and unnecessary therapy.All authors were equally involved in the conceptualization, review, writing, and editing of the manuscript.The authors declare no conflict of interest.


Relapsed rhabdomyosarcoma (RMS) has several therapeutic challenges. The novel treatment for relapsed RMS was surgical management, chemotherapy, and radiotherapy. Reoccurrence significantly occurs in children and adolescents. RMS occurs anywhere in the body but mostly occurs in the legs, head, neck, urinary, and reproductive systems. Here, we present the case of a 19-year-old female who came to the emergency department with complaints of swelling in the left side of the neck that extended toward the face and left eye, breathlessness, and vomiting for one month. She has a history of peripheral nerve sheath tumor and type 1 diabetes mellitus. Surgical management was done through excision of the mesenchymal tumor surgery, and the patient's prognosis was good. Rhabdomyosarcoma (RMS) is a mesenchymal malignancy that is correlated with pediatric malignant soft tissue sarcoma of skeletal muscle that arises from the primitive mesenchymal cell . It is aWe present a case of a 19-year-old female who came to the emergency department with complaints of swelling on the left side of the neck extending toward the face and left eye, breathlessness, and vomiting for one month. She has the comorbidity of uncontrolled type 1 diabetes mellitus and was taking insulin (Mixtard) daily. She had a history of peripheral nerve sheath tumor in the left posterior triangle of the neck one year back and underwent a diagnostic test, namely, fine needle aspiration cytology (FNAC), which revealed a cytological feature consistent with a benign adnexal tumor. Subsequently, she was operated on for excision of the malignant vascular mesenchymal tumor. Postoperatively, chemotherapy was advised for her, but she refused the therapy due to her personal financial crisis; she was then discharged from the hospital.After three months of discharge, she revisited with the same complaints, but due to COVID, she was unwilling to be admitted to the hospital. After six months, her swelling started to increase. Contrast-enhanced computerized tomography (CECT) of the neck revealed a large heterogeneously enhancing lobulated ill-defined infiltrative soft tissue mass lesion with an area of necrosis in the region of the left sternocleidomastoid muscle with a highly malignant tumor Figure . After uOn physical examination of the neck, a cystic swelling of 20 cm x 10 cm on the left side of the neck was noted, which was extended over the face involving the area up to the left eye. Shiny skin was present over the swelling; the swelling was non-tender, and there was no discharge from the swelling. The tumor excision from the left posterior neck was done, and after that, she took chemotherapy. Her prognosis was good and was advised for continuous follow-up.RMS is a malignant soft tissue tumor of the skeletal muscle that was described by Weber in 1854. RMS is most significantly found in the head, neck, genitourinary tract, retroperitoneum, and extremities. Head and neck cancer (HNC) is one of the causes of cancer-related deaths due to conventional therapy resistance .RMS begins at mesenchymal and immature cells and develops into skeletal voluntary muscle, which is also known as striated muscle . RMS comMost commonly, RMS has five types. (1) Embryonal RMS is the most common type, which usually affects the head and neck or reproductive organs. (2) In botryoid RMS, hollow organs are involved (bladder and vagina) . (3) SpiRMS occurs anywhere in the body, and the symptoms may differ from victim to victim. The symptoms also depend on the size and site of the tumor. The primary symptoms of RMS are a lump or swelling over the affected areas like the neck, chest, leg, back, armpit, or groin area (testicles) . In someRMS is a highly aggressive malignancy in childhood, which needs early detection. Patients with suggestive symptoms should undergo complete evaluation, including blood tests, FNAC, biopsy, immunocytochemistry test, a genetic test of the tumor, etc. . There aIn this case, the patient faced a therapeutical challenge for the treatment modalities because of her financial condition. For patients with a first-time relapse, chemotherapy is the most effective treatment. There is a need to do a clinical trial among patients with relapsed RMS to identify the ideal treatment. In this case, the patient was treated with surgical and chemotherapy intervention, which proved to be a novel treatment for the relapse of RMS with a good prognosis.


Transvaginal evisceration is a rare life-threatening condition that is usually seen in postmenopausal women with past history of gynaecological surgery.A 54-year-old woman presented with sudden-onset abdominal pain and protrusion of a mass through the vagina after her grandson jumped on her abdomen while at play. She had undergone laparoscopic total hysterectomy and bilateral salpingo-oophorectomy 9 months earlier. Physical examination revealed an intestinal loop in the vagina. She was immediately taken to the operating room. Laparotomy was performed and the prolapsed intestine was reduced. The bowel from the duodenojejunal junction to the ileocecal valve looked healthy, with no areas of ischemia. The rupture in the vaginal vault was repaired with Vicryl. The postoperative course was uneventful, and the patient was discharged on day 5 after the surgery.Less than 100 cases of transvaginal evisceration have been reported. The condition, which is more common in postmenopausal women, usually presents with sudden-onset abdominal pain. Some patients may be asymptomatic and only complain of swelling at the introitus. Diagnosis can usually be made by visual examination. Immediate surgery is necessary to reduce the risk of intestinal ischemia and necrosis.Transvaginal evisceration must be suspected in any woman presenting with sudden-onset abdominal/pelvic pain. Awareness of this rare condition is necessary to minimize mortality. •Transvaginal evisceration is a rare life-threatening condition.•It most commonly affects postmenopausal women with past history of hysterectomy.•Diagnosis can usually be made by physical examination alone.•Immediate surgical intervention is necessary to reduce risk of intestinal ischemia. Prompt recognition and surgical management are crucial. We report a postmenopausal woman who presented with transvaginal evisceration and was successfully treated with abdominal surgery. This work has been reported in line with the SCARE criteria 2In March 2022, a 54-year-old woman presented to the emergency department complaining of lower abdominal pain that had started suddenly about 10 h earlier after her grandchild playfully jumped on her abdomen. The pain was localised to the lower abdomen, and had slowly increased in severity over time. There were no relieving or aggravating factors. While passing stools before her presentation she had noticed an intestinal loop protruding through the vagina and so came immediately to the emergency room. On examination, she was conscious, alert, oriented, and comfortable lying on the examination couch. Her vital signs were stable. The abdomen was soft and lax, with only mild lower abdominal tenderness. The bowel sounds were normal. Vaginal examination revealed a bowel loop protruding through vagina. The bowel was pink in color, with no areas of discoloration or signs of ischemia. There was no blood or vaginal discharge. The patient's past history was significant for laparoscopic total hysterectomy and bilateral salpingo-oophorectomy performed 9 months earlier for uterine fibroid.9/L; hemoglobin, 13 g/dL; platelet count, 240 × 109/L; and blood lactate1.1 mmol/L. Due to the obvious findings on physical examination, imaging was not considered necessary, and the patient was taken directly to the operating room, where we were joined by doctors from obstetrics and gynaecology. Laparotomy was performed with a lower abdominal transverse incision. The bowel, from the duodenojejunal junction to the ileocecal valve, looked healthy, with no signs of ischemia or any other injury  may occur in 0.032 % of patients after abdominal or vaginal hysterectomy; the risk is reported to be three-fold higher after laparoscopic hysterectomy The patient usually presents with sudden-onset abdominal or pelvic pain, with or without vaginal bleeding and protrusion of a mass through the vagina; however, some patients may only complain of an undefined swelling at the vaginal introitus Most commonly, it is the terminal ileum that prolapses; this is because of its long mesentery and mobility and its location. The omentum, fallopian tubes, appendix, colon, and appendices epiploicae may also be involved The mortality rate in patients with transvaginal evisceration can be as high as 10 %, the risk being especially high in those with strangulated bowel Surgery is usually performed using a wide laparotomy; this allows the surgeon to perform a thorough intra-abdominal inspection and meticulous peritoneal lavage. However, transvaginal, combined vaginal–abdominal, and laparoscopic–vaginal approaches have all been successfully used Kowalski et al. have proposed some surgical steps for prevention of this serious complication; 1) restoration of normal vaginal axis; 2) anastomosis of the stumps of the supporting ligaments of the pelvis to the angles of the vagina; 3) preservation of vaginal length, and 4) maintenance of vaginal integrity with application of oestrogen if necessary 4Complaints of pelvic/abdominal pain or watery discharge in a patient with history of previous gynaecological surgery should arouse suspicion of transvaginal evisceration. It is a serious life-threatening condition requiring immediate surgical intervention.Patient was satisfied with her treatment and she was given regular follow up.Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.In our institute, ethical approval is exempted, depend on acquired patient consent.The Guarantor is DR. Ashwag Alharbi.We don't need to register this work.All authors contributed to manuscript preparation, manuscript editing, manuscript review.The authors have no conflict of interest.


Non-Hodgkin lymphoma is made from the B-cell lineage and includes extra-nodal marginal lymphomas, follicular lymphomas, mantle cell lymphoma, diffuse large B-cell lymphoma, and Burkitt lymphoma. Burkitt lymphoma is associated with Epstein Barr Virus and Human Immunodeficiency Virus. Although it is common for other B-cell lymphomas to develop in the stomach, it is less common for Burkitt lymphoma tumors to manifest there. Additionally, primary and/or secondary involvement of the duodenum, pancreas, and intestines is very rare in Burkitt lymphoma. Herein, we present a male diagnosed with extensive Burkitt lymphoma of the bone, lymph nodes, pancreas, small intestine, duodenum, and stomach.  B-cel cancers .BL was first described in the mid-1900s in tropical Africa as a sarcoma in children . By 1961The translocation t8:14) from the c-MYC gene is observed in approximately 80% of cases and is considered the hallmark of the disease, although the presence of MYC rearrangement is not specific for BL [ from theHelicobacter pylori is another important cause of gastric lymphoma that needs to be excluded at the time of diagnosis [Although diffuse large B-cell lymphoma commonly affects the gastrointestinal tract and colon, it is less common for Burkitt lymphoma to manifest there . Endemiciagnosis . Ann Arbiagnosis . Althougiagnosis ,5. Poor iagnosis .A 52-year-old African-American male with a past medical history of the human immunodeficiency virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), untreated Hepatitis C, and polysubstance use with intravenous drug abuse (IVDA) presented with left-sided back pain radiating to the stomach for two weeks before admission. The pain was sharp, exacerbated with movement, and improved with rest. He denied any inciting events or trauma to the area. Their blood pressure was 98/58 mmHg, heart rate was 81 beats per minute, respiratory rate was 18 breaths per minute, and he was saturating 100% on room air. On physical examination, the patient appeared cachectic with temporal wasting, track marks were present on the right arm, and he was lying on his right side in acute distress due to pain. The patient demonstrated severe abdominal pain to deep and superficial palpation throughout all quadrants and had focal tenderness upon palpation of his lumbar spine and left paraspinal muscles. Laboratory findings were most significant for relative leukocytosis, normocytic anemia, acute kidney injury (AKI), elevated alkaline phosphatase, elevated lactate dehydrogenase (LDH), and erythrocyte sedimentation rate (ESR), and urine toxicity positive for cocaine and opiates (Table An admission chest radiograph (CXR) was unremarkable. Computed Tomography (CT) of the abdomen and pelvis without contrast showed a fracture in the left ninth rib with soft tissue density extending to the left lateral epidural space, as well as a prominent gastric wall thickening with an asymmetric appearing stomach. A Magnetic Resonance Imaging (MRI) of the thoracic (T) spine without contrast showed abnormal marrow signals in multiple thoracic vertebrae highly suspicious for multifocal osteomyelitis (OM) with epidural abscess spanning from vertebrae T7-T9.The patient was taken the next day to the operating room for incision and debridement with laminectomy. Pathology samples obtained from the epidural abscess resulted in High-Grade Diffuse B-cell Lymphoma Figure .An esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) were performed for the abnormal findings on earlier CT imaging, as well as rising bilirubin and liver function enzymes. Endoscopic and endosonographic findings included esophageal candidiasis, multiple masses and nodules throughout the stomach and duodenum with abutment into the liver, dilation of the common bile duct (13 mm) with stricture at the lower third of the main bile duct due to large pancreatic mass 25 mm), and pancreatic duct dilation 4 mm) with another mass visualized in the pancreatic body (15 mm). A biliary sphincterotomy was performed. Additionally, there were numerous lymph nodes in the celiac and peri-gastric regions. All biopsies of the stomach, duodenum, lymph nodes, and pancreatic body were positive for Burkitt's lymphoma (BL) with Epstein-Barr virus-positive EBV+  flow cytometry, and MRI of the brain and spine were performed. Bone scan showed increased uptake in the distal shaft of the left humerus with a diffuse area of increased uptake in the midshaft of the left femur. The CT of the chest demonstrated a 4mm lung nodule, and CSF flow cytometry and MRI brain were negative for CNS involvement. The MRI of the spine, however, was positive for multifocal signal abnormalities in the thoracolumbar spine and paraspinal region suggestive of lymphoma. Oncology diagnosed him with Stage IV Burkitt Lymphoma, and further workup was obtained Table .On Hospital day eight, the patient became severely constipated, and an abdominal X-ray revealed multiple dilated small bowel loops suggestive of obstruction. Through a repeat CT scan, it was presumed that the obstruction was secondary to a lymphoma of the intestines, and thus chemotherapy was initiated with Cyclophosphamide, Doxorubicin, Vincristine, and Methotrexate/Rituximab, Ifosfamide, Etoposide, and Cytarabine regimen (R-CODOX/ R-IVAC). Granulocyte colony-stimulating factor (G-CSF) and Intrathecal Methotrexate were also administered. The obstruction was resolved, and the patient was sent home for further management of his Burkitt Lymphoma under the oncology team.Primary gastric lymphoma is more prevalent in men older than 50 years of age and is usually due to B-cell lymphomas; however, other primary gastric lymphomas can also include mantle cell and marginal zone B-cell lymphoma (MALT) . PrimaryIn summary, we present an HIV patient with low CD4 counts who presented with localized pain and intestinal obstruction and was diagnosed with Burkitt lymphoma of the bone, lymph nodes, duodenum, stomach, pancreas, and small intestine. The primary site of Burkitt lymphoma is ultimately unknown due to its complex presentation; however, primary and/or secondary involvement of the duodenum, pancreas, stomach and intestine is very rare in non-endemic Burkitt lymphoma.


Supportive medical treatment, including antibiotics and fecal softener, was administered, and the clinical signs resolved uneventfully. Mild chronic proctitis without apparent malignancy was confirmed histopathologically, and no recurrence was observed after more than 14 months, and thus a colonic intramural hematoma was presumptively diagnosed. The information provided by multimodal imaging of the mass was essential for the diagnosis and determination of the treatment in this case.Colonic intramural hematoma is a rare condition in humans and companion animals. Its clinical presentation in cats has not previously been reported. An 8-year-old male American shorthair cat presented with acute onset of constipation and anorexia for 3 days. Laboratory examination indicated mild elevation of alanine aminotransferase, globulin, and total protein levels. Complete blood count was normal. Radiographs revealed a soft tissue opacity mass located caudodorsally to the urinary bladder, causing narrowing of the descending colonic lumen. Sonography showed a heteroechogenic intraluminal mass containing liquefied content between the submucosal and muscular layers of the descending colon. On computed tomographic images, the mass contained two different attenuated contents with an interface. Colonoscopy was then performed for intestinal biopsy, and the contents observed in the intraluminal mass were drained  Colonic intramural hematoma is rare in humans and animals and occurs mostly secondary to blunt abdominal trauma, anticoagulant therapy, coagulopathies, or intestinal neoplasia in humans . In humaAn 8-year-old neutered male American shorthair cat was referred to the Unicore Animal Hospital because of decreased defecation for 1 week and acute onset of constipation with anorexia 3 days prior. Physical examination revealed no apparent colonic narrowing on rectal palpation.Laboratory examination was performed for preanesthetic evaluation and revealed mild elevated levels of alanine aminotransferase , globulin , and total protein . The complete blood count was normal.Abdominal radiography  of the right lateral, left lateral, and ventrodorsal projections was performed while the cat was awake, and a large, well-defined, ovoid-shaped, soft tissue opacity mass was observed caudodorsal to the urinary bladder at the sixth lumbar vertebra to the sacrum level, causing dorsal displacement, and narrowing of the descending colon . The masAbdominal ultrasonography was performed with an ultrasound device  equipped with a linear transducer , and the patient was positioned in dorsal recumbency under general anesthesia. The sagittal and transverse planes of ultrasonographic images revealed a focal heteroechogenic intramural mass located between the submucosal and muscular layers of the descending colon (~2.6 cm in width and 1.3 cm in height), causing extreme compression and occlusion of the colonic lumen. The intramural mass was liquefied and floating. Enlarged colonic lymph nodes were observed cranial to the intramural colonic mass, indicating hypoechogenicity (0.6 cm in thickness and 0.9 cm in length). Considering the location and echogenicity of the mass, colonic intramural neoplasia with regional colonic lymphadenopathy was mainly suspected, whereas abscess and hematoma could not be completely excluded .A triple-phase CT examination  was performed to obtain further information. On CT images, a large, fluid-to-soft tissue attenuating mass was noted between the submucosal and serosal layers, arising from the middle portion of the descending colon, extending caudally to the distal descending colon immediately cranial to the rectum, and spanning approximately 8 cm in length. The colonic intramural mass contained two different attenuating contents with an interface at all three phases: hyperattenuating materials  accumulating on the gravity-dependent side and lower attenuating contents (30–40 HU) on the upper side . UltrasoLactulose  was prescribed for 1 week to resolve constipation. The cat underwent colonoscopy  1 week later at the Tzuoo Ann Animal Hospital, and a mass with an intact mucosal surface and spotty oozing blood was observed . A specuTM Class C, LA435, 6–18 MHz, Esaote, Italy) performed 2 weeks later at the Tzuoo Ann Animal Hospital revealed that the affected colon appeared to display normal layering with thickened and corrugated mucosa. The colonic lymph nodes showed homogeneous echogenicity and smaller size than before , lysozyme , L-glutamine , tranexamic acid , and lactulose  were prescribed for 2 weeks. Constipation resolved after surgical evacuation, only scant blood was observed in the stool for 4 days. No apparent defecation difficulty, anorexia, or abdominal pain was noted. Follow-up ultrasonography ; however, inconsistent with the loss of layering, our case showed intact intestinal layering –25. FluiOn CT images, a large, well-capsuled, soft-tissue attenuating mass was noted in the submucosal and serosal layers of the distal descending colon, causing severe narrowing of the colonic lumen. The mass was nonenhancing and showed stratified contents with a clear interface, 30–40 and 40–60 HU in the upper and lower layers, respectively, similar to that seen in the human literature . This inThe relationship between the timing of hematoma and image characteristics is well known in the human literature; however, it is less well described in animals. In humans, hematomas present variable echogenicity and density at different times on ultrasonographic and CT images , 34. ImmIn humans, the treatment of intramural colonic hematoma includes conservative and surgical treatment, whereas descriptions in animals are limited. The optimal management of colonic intramural hematoma depends on the differences in etiologies and the patient's general condition in humans. Conservative treatment is typically used, especially when coagulopathy is the cause , 3. SurgThere are several limitations to our case report. First, no full-thickness biopsy was performed in our case to confirm the origin of the hematoma. Second, the cause of hematoma in this cat is still unknown, thus the incidence of recurrence cannot be estimated. Last, although the outcome of surgical evacuation was good in the current case, as an individual case study, the contraindication of surgical evacuation cannot be fully confirmed.In conclusion, our report describes the multimodality imaging findings and their clinical relevance in a rare case of feline colonic intramural hematoma. The mass appeared as a large mass affecting the descending colon on radiographs, an intraluminal mass between the submucosal and muscular layers with heteroechogenicity and liquified contents on ultrasonography, and showing almost non-enhancing and stratified contents on CT images. Ultrasonography provides a more precise layering location, whereas enhancement and density in CT images can offer more definitive information regarding the diagnosis and formation of the hematoma. The patient responded well to surgical evacuation of the hematoma using the anal approach. No recurrence was noted for more than 14 months. The multimodal imaging findings in this case were invaluable for differential diagnosis and determining the optimal course of treatment.The original contributions presented in the study are included in the article/Ethical review and approval were not required for the animal study because this was a retrospective case report. Written informed consent was obtained from the owners for the participation of their animals in this study.T-CH, L-SL, CC, H-CC, and P-HH contributed to image acquisition. T-CH, L-SL, and CC contributed to image interpretation. H-CC and P-HH performed the colonoscopy and surgical intervention. T-CH, L-SL, and C-SC contributed to manuscript editing. All authors reviewed and approved the final submitted manuscript.This publication was supported by the Southern Taiwan Science Park Bureau, Ministry of Science and Technology, Taiwan, ROC under contract 110CB-1-04.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Appendiceal diverticulitis (AD) is an overlooked pathology that carries a high risk of perforation and associated neoplasia, especially carcinoid tumours and mucinous adenoma. AD may be congenital, but more commonly acquired. It may cause diverticulitis, which causes clinical and radiological signs like those of acute appendicitis, and that may delay the diagnosis till it is confirmed on histopathological examination. Here we report a case of acute AD in a case initially diagnosed as acute appendicitis. Appendiceal diverticulitis (AD) is a rare pathology that was reported for the first time by Kelynack in 1893 . The docA 71-year-old male presented to the emergency department with right iliac fossa pain for less than 24 hours with no associated fever, vomiting, or diarrhoea. His past medical/surgical history includes bilateral inguinal hernias repair, umbilical hernia repair, radical prostatectomy for prostatic cancer, and tonsillectomy. On examination, the patient was hemodynamically stable, with a blood pressure of 131/78 mmHg and a heart rate of 76 beats per minute. His temperature was noted to be 36.5°C and he was saturating at 97% on room air. His abdominal examination showed right iliac fossa tenderness and rebound tenderness, but no clinical signs of peritonitis.He underwent a series of laboratory tests that have been detailed in Table The patient underwent a computed tomography (CT) scan, which revealed large bowel diverticulosis and acute tip appendicitis with no evidence of perforation or abscess formation Figure , which wLaparoscopic appendicectomy and a peritoneal examination were carried out. The specimen was sent for histopathological examination. The postoperative course was uneventful, and the patient was discharged home the next day in optimal condition with a follow-up plan in two weeks to check on the histopathology results. In the follow-up appointment, the patient was asymptomatic with no complications.3. On the serosal surface and mesoappendix, there were some fibrinous adhesions and fibrinopurulent exudate. Cut sections revealed the distal tip filled with faecal material with fibrinopurulent exudate. The microscopic histopathological findings included features of acute appendicitis and foci of ulceration and acute transmural inflammation arising from the wall at the site of the AD. There was no evidence of dysplasia or malignancy (Figure The histopathological examination showed macroscopic findings of a heavily inflamed appendix measuring 62 mm in length and up to 9 mm in diameter with an attached fibrosed mesoappendix measuring 39x16x19 mmAD is one of the rare causes of right iliac fossa pain/acute abdomen, which mimics acute appendicitis. The mean age of patients with AD is higher than that of acute appendicitis with more predominance in males than females . A retroClassification into congenital and acquired types is based on the defective layers of the appendiceal wall . AcquireAD can present as an incidental finding, diverticulitis, or acute appendicitis. There is a clinical overlap between AD and acute appendicitis, but right iliac fossa pain in older age for a longer period of time is suspicious for AD ,3. PerfoIdentification of AD on CT can be difficult because of the associated inflammatory changes . HistopaIn conclusion, AD is a rare and dangerous pathology that needs to be considered on assessing a patient with suspected appendicitis. It is impossible to differentiate between AD and appendiceal neoplasia based on clinical or radiological assessment. Because of this, we recommend appendicectomy and accurate histopathological examination, whenever it is difficult to differentiate between AD and other pathology, to avoid missing a sinister pathology.


In this surgical video, we present a 57-year-old man with neck pain, dizziness, and imbalance. MRI showed a heterogeneously enhancing mass lesion within the posterior medulla at the level of the foramen magnum. Because the patient was symptomatic from this cavernous malformation, the decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of the cavernous malformation in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials.The surgery and postoperative course were uneventful. The postoperative MRI showed gross-total resection of the mass with histopathology indicating a cavernous malformation. The patient continues to do well without recurrence at 7 years of follow-up. In this video, we demonstrate important microsurgical steps for the resection of this challenging and rare vascular malformation.https://youtu.be/gbGleLowzxo.The video can be found here:  Surgical resection of cavernous malformations involving the medulla oblongata can be more challenging than other brainstem locations. This is due to the presence of densely packed vital neural structures in the medulla oblongata.In this video we demonstrate important steps in the microsurgical resection of a large, challenging cavernous malformation in the medulla oblongata.(0:30). MRI showed a heterogeneous enhancing intra-axial mass lesion located within the posterior medulla at the level of the foramen magnum (0:34). Because the patient was symptomatic from this cavernous malformation, the decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy (0:43) for surgical resection of the cavernous malformation in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials.The patient is a 57-year-old man with neck pain, dizziness, and imbalance (1:01). A midline skin incision was marked. A midline suboccipital craniotomy was then performed by placing two burr holes on either side of the occipital keel (1:05). Since the lesion extended below the level of the posterior foramen magnum, the posterior arch of the C1 was also removed. We then opened the dura. At this time point, baseline neuromonitoring responses of both somatosensory and motor evoked potentials were obtained, which were then continuously monitored throughout the remainder of the case (1:18).The patient was placed in the prone position (1:29). Upon opening the thick arachnoid, a large vascular malformation with the typical appearance of cavernous malformation came to view at the lower aspect of the medulla oblongata (1:35). This lesion was large and expanded the medulla oblongata. The right posterior inferior cerebellar artery was observed. The loop of PICA was then dissected and freed from the cavernous malformation (1:40) and kept in place using a Telfa patty. An unusually large developmental venous malformation with multiple tributaries was also observed on the dorsal surface of the malformation (1:44). This DVA was dissected away with spreading motions of the bipolar forceps and untethered from arachnoid bands. During dissection, we encountered an orange color fluid coming from around the malformation, indicating hemosiderin from an old hemorrhage (2:23). We then used gentle bipolar coagulation to shrink the malformation.The arachnoid of the cisterna magna was opened sharply with the aid of microscope magnification and illumination (2:44), we created a plane. Another surgical maneuver which we found very useful was to apply gentle bipolar coagulation at the malformation’s surface, at a location away from the brainstem. Dissection was then carried out rostrally using gentle traction and contratraction.At this stage of the surgery we created a plane between the malformation and the brainstem tissue using a diamond knife. By initially using sharp dissection, followed by spreading motions of the bipolar forceps At this stage we divided the malformation with a microscissor and then removed part of the malformation. We then found a gliotic plane between the brainstem and the vascular lesion and used this to circumferentially dissect along the lesion. Here we again used traction and contratraction technique to develop the plane. It is important to note that coagulation of the normal brainstem tissue should be done to avoid thermal injury to the brainstem. We continued this dissection to develop a plane both caudally and laterally.We then resected the mass piecemeal and continued the circumferential dissection using microsurgical techniques. The vascular malformation was dissected away at the caudal aspect and a microcotton patty was placed on this aspect of the dissection plane.(3:54), which traversed the dorsal aspect of the malformation. This should be respected at all times. Only the small venous drainage tributaries should be coagulated and divided. At this stage, we then bisected the malformation to facilitate safer dissection. This prevents excessive traction on the brainstem.We emphasize the importance of preserving the developmental venous anomaly (4:25). The SSEP and MEP neuromonitoring responses remained unchanged throughout the case (4:31). We also obtained meticulous hemostasis in the resection cavity. The wound was then closed in layers.Careful dissection was patiently continued until every last piece of the malformation was removed. Here we see the final view after complete resection of the cavernous malformation (4:42). Histopathology indicated a cavernous malformation. The patient continued to do well without recurrence at 7 years’ follow-up.The surgery and postoperative course were uneventful. The postoperative MRI showed gross-total resection of the mass


Curvularia lunata seldom occurs with only five cases reported in the literature, all in middle-age patients with comorbidities undergoing dialysis.Peritonitis associated with fungal species cancer antigen 125 (CA 125) and suspected tubo-ovarian mass (TOM) on magnetic resonance imaging (MRI). A review of the MRI showed a pelvic collection with TOM, suggestive of infective pathology. Fungal culture and mass spectroscopy of the cystic collection identified the presence of Curvularia lunata. She was treated with oral itraconazole which showed symptomatic improvement and radiological response. In the follow-up period, the patient developed chest wall swelling, aspiration and geneXpert® revealed multidrug-resistant (MDR) tuberculosis, and treatment was started.A 21-year-old female who was referred to surgical oncology OPD with a diagnosis of ovarian malignancy, based on raised Unusual causes of TOM and raised CA 125 should be kept in mind when dealing with young patients, as the possibility of epithelial ovarian cancer in this age is very low.The online version contains supplementary material available at 10.1186/s12957-022-02651-w. Candida albicans, there are other rare fungal species that have also been identified [Curvularia lunata is one such organism which seldom causes infection in humans. It is a saprobic dematiaceous fungus that is primarily found in the soil [Fungal peritonitis is an uncommon entity, which is associated with significant morbidity and mortality. Although most of the fungal peritonitis cases that have been reported are caused by entified . Curvulathe soil .C. lunata was first described in 1898 by Wakker and Went, when they isolated it from dead sugar cane leaves. It was first suspected as a human pathogen in 1959, when Baylet isolated it from black grain mycetoma in Senegal [C. lunata in humans, which includes mycetoma, paranasal sinusitis, peritonitis, cerebral phaeohyphomycosis, and disseminated disease infecting the eye, skin, pleura, lung, spine, brain, etc. In this article, we report a rare case of fungal peritonitis associated with Curvularia lunata in a female followed by multidrug-resistant (MDR) tuberculosis. Senegal . A revieA 21-year-old sexually virgin female, from a middle-class family, was referred to Surgical Oncology outpatient in June 2020 with a provisional diagnosis of epithelial ovarian malignancy on the basis of magnetic resonance imaging (MRI) findings and raised cancer antigen 125 (CA125) level of 129.8 U/ml . On enquiring, she had irregular menstruation for the last 6 months, abdominal distension for 2 months, and pain in the lower abdomen for the last 1 month. There was no history of fever or night sweats. She had a past history of cervical lymph node tuberculosis in 2017, for which she completed antitubercular therapy for 18 months with a standard regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol. Other than this, there was no significant medical and surgical history. Personal and family history was noncontributory. On clinical examination, the general condition was fair and vitals were stable, neurological, respiratory, and cardiovascular systems, and were within normal limits. On per abdomen examination, the patient had mild tenderness in the lower abdomen with no signs of guarding, rigidity, or free fluid in the abdomen. No definite mass or lump was palpable.Her previous MRI scan was reviewed which showed extensive smooth peritoneal thickening with moderate ascites, multiloculated cystic lesion in bilateral adnexa, variably hyperintense on T2-weighted MRI, and variably hyperintense to hypointense on T1-weighted images, and the lesions were in close relation with ovaries but bilateral ovaries were normally visualized -guided aspiration of the fluid was done and sent for geneXpert®, cell cytology, cell block, and culture . GeneXpert® was negative for tuberculosis. The fluid cytology was negative for malignant cells and the cell block showed reactive mesothelial cells and neutrophils. The microbiological reports revealed a sterile bacterial culture. On fungal culture, fungal elements were seen, which were grown on Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) , which showed them to be She was started on oral standard itraconazole 200mg once daily and was followed up every week. During the second week of follow-up, an abdominal contrast-enhanced CECT was repeated that showed bilateral adnexal masses with dilated tubular structures with thickened enhancing walls, moderate fluid collection was still seen in the pelvis along with peritoneal thickening, and the lesion also showed calcifications and cystic components of various compositions suggesting a diagnosis of a tubo-ovarian abscess  and most commonly seen in sexually active women of reproductive age. Cho et al. reported a 4.1% incidence of virginal women PID among all cases of PID. Several hypotheses have been proposed for origin in virgin women through the lower genital tract, urinary tract, gastrointestinal tract, and skin wound but none of them was proven . Early dDifferentiating these masses on imaging from bacterial or tubercular infection is also important. In genitourinary infections, fungal infections on CT range from homogeneous hypoattenuating masses to heterogeneous masses with areas of hypoenhancement or calcifications. On MR images, the appearance varies according to the acuity of the infection, extent of necrosis, and degree of calcification. Most frequently, the masses are T1 hypointense and mildly T2 hyperintense . DiffereCurvularia lunata. The MALDI-TOF MS library used in the present study offers the most extended but comprehensive technique for the identification of filamentous fungi from clinical samples. Becker et al. compared it with the classical method (microscopy) based on morphological observations. MALDI-TOF correctly identified 95.4% of the total samples using the in-house database, while microscopy identified only 61.5% of the isolates, so MALDI-TOF MS provides reliable identifications and showed a higher accuracy than the traditional approach [The MRI findings in the present case which showed adnexal mass and the raised tumor marker (CA 125) level were initially suggestive of epithelial ovarian malignancy. However, increased level of CA 125 may also be seen in non-malignant conditions such as menstruation, pregnancy, liver disease, congestive heart failure, uterine fibroids, pelvic inflammatory disease, peritonitis, etc.  Malignanapproach .C. lunata peritonitis cases reported, this is the first case that presented with TOA with peritonitis in a virgin woman.In young women, most cases of TOA mimic as pelvic tumors even after imaging studies and they usually undergo a surgical procedure which can easily be avoided and treated by appropriate medical management as the first line of treatment. A radiologist experienced with pelvic imaging is necessary for making or excluding the diagnosis before deciding any plan of management. Of all the Additional file 1: Table S1. Cases of Curvularia peritonitis reported in literature.


Isolated torsion of a fallopian tube is a rare event and it is extremely difficult to be diagnosed in pregnancy. The aim of this study is to present a clinical case report that occurred in our department and to summarize the latest evidence about tubal torsion in pregnancy.We reported data, ultrasonographic features and an intra-operative image of a case report of tubal torsion in a term pregnancy. Then a review of the literature was performed following the PRISMA statement: we searched all the articles related to tubal torsion in pregnancy in the last 10 years from the international electronic bibliographic database PUBMED. We collected data regarding population characteristics, clinical features, treatment, and feto-maternal outcomes.According to our search strategy, 10 articles were included. The main clinical symptoms were abdominal pelvic pain (100%), nausea, and vomiting (30%). The mean gestational age at the diagnosis was 36 weeks after the last menstrual period in 50% of cases. Ultrasound images showed a cystic lesion in the adnexal area in 70% of cases. In most of the cases, a cesarean section with a contextual salpingectomy was performed. No cases of maternal and fetal death were respectively reported.Isolated torsion of the fallopian tube is a rare obstetric condition but it should be considered in case of acute lower abdominal pain presentation during pregnancy. Depending on gestational age, surgical treatment as soon as possible could prevent a salpingectomy. Isolated torsion of a fallopian tube in pregnancy is a rare event in women of reproductive age . It coul2 98%; temperature 36.8°C / 98°F.A 23-year-old primipara was admitted to our obstetric emergency unit at 38 weeks and 5 days of gestational age with acute abdominal pain. This pain was situated in the left lower abdomen, and it was constant and acute. She did not complain of nausea, vomiting, or diarrhea. There was no history of urinary symptoms, fever, or vaginal bleeding. The patient had a similar recurring pain for about 1 week, but she did not take any medication. Her anamnesis was uneventful, she had no medical pathology and she never had previous surgery. Until the occurrence of the pain, her pregnancy had been regular. The vital signs of the woman were stable: systolic blood pressure was 105 mmHg; diastolic blood pressure was 70 mmHg; heart rate was 103 bpm; SpOAbdominal examination revealed tenderness in the left lower abdomen and a soft abdomen. The uterine fundal height was correspondent to the period of gestation. Cardiotocography showed irregular uterine contractions, not perceived by the patient. The fetal heart rate was Category I (FIGO classification). The vaginal examination showed that the cervix was closed, Bishop index O, the fetal membranes were intact and there was not any evidence of bleeding or abnormal discharge.3 white blood cells (WBCs), 3.61 ×10,12/L red blood cells (RBCs), 12.0 g/dl hemoglobin (HGB), 1.56 reactive protein c (CRP), and 190.000 platelets (PLTs). The laboratory parameters for renal and hepatic function were normal.An ultrasonographic scan showed a single alive fetus in cephalic presentation with corresponding biometry and a normal amniotic fluid index (AFI = 11 cm); the position and thickness of the placenta were normal, without any sign of abruption. An anechoic mass (65 mm × 46 mm) was observed in the left lower abdomen, with evidence of good posterior enhancement. There was no abnormal vascular flow on Doppler examination. The ovaries were not well assessed due to the uterine expansion of term pregnancy. There was no fluid in the pouch of Douglas. The laboratory blood parameters were as follows: 8.500/mmThe pregnant woman was hospitalized and the pain was unchanged after treatment with paracetamol 1 g every 6 h and phloroglucinol 80 mg. The onset of the pain was sudden and paracetamol was ineffective as pain relief. After hospitalization abdomen became tense. Due to her pregnancy status and the insufficient basis for a definitive diagnosis, a suspicion of a left ovarian cyst was considered, and it was decided to perform a surgical treatment. The patient underwent a cesarean section and an emergency exploratory laparotomy under spinal anesthesia. The findings were as follows: triple isolated torsion of the left fallopian tube had occurred and the tube presented edematous and purple, completely necrotic. The left ovary, the uterus, and the right adnexa looked healthy . After dThe newborn was male, with a weight of 3,300 gr, an Apgar score of 10 at 1 min, and a normal score of 10 at 5 min. The patient was treated with intravenous antibiotics (cefazolin 1 g × 2/die) for 3 days and then it was continued for 2 days by intramuscular administration. The operation course and puerperium were uneventful, and the patient was discharged on the third postoperative day in good condition. The follow-up parameters of postpartum were all normal. The patient had no further complications. The histopathology report indicated that in the left fallopian tube there was hemorrhage and necrosis.The study protocol was approved by the Ethics Committee of the ARNAS Garibaldi Hospital and conformed to the ethical guidelines of the Helsinki Declaration. The woman signed informed consent before entering the study, and their anonymity was preserved.A review of the literature was performed following the PRISMA Statement . In the last 10 years, we searched all the articles related to our topic from the international electronic bibliographic databases PUBMED (from 01/01/2011 to 31/03/2021). The articles were found using comprehensive search criteria and a combination of MeSH terms. We used the following words for selection: . We selected the articles published between January 2011 and March 2021. The search was limited to studies reported in the English language. The references of the items chosen were also evaluated for related citations. Two independent researchers assessed the titles and abstracts retrieved to select the most relevant articles. The full text was obtained if the title and abstract did not provide enough information. Letters to editors, editorials, review articles, duplicates, meta-analysis were excluded. We only included items that followed our eligibility criteria, represented by pregnant women with a diagnosis of tubal torsion.We excluded those studies evaluating data from women with ovarian torsion, adnexal torsion, patients not in pregnancy, and finally postmenopausal patients.We also included articles concerning single case reports of tubal torsion where both treatment and the maternal prognosis were discussed. We collected data regarding population characteristics, clinical features, treatment, and feto-maternal outcomes.According to our search strategy, 10 articles were included –13 Tabl. We founThe mean gestational age at the diagnosis was 36 weeks after the last menstrual period in 50% of cases; in a term pregnancy in 20% of cases (in one case during labor); in an early preterm (30–33 weeks) pregnancy with a rate of 20%; finally, it occurred in the second trimester in 10% of cases. Ultrasound images showed a cystic lesion in the adnexal area in 70% of cases. This was not diagnostic but raised the suspicion of a gynecological cause of acute pain. Magnetic Resonance Imaging (MRI) was performed in two cases but its findings could characterize the cystic lesion and suggested the right diagnosis only in one case. In a single case, abdominopelvic computed tomography was carried out and it showed a homogenous cystic mass in the lower quadrant; therefore, it did not add anything to ultrasound findings .After 36 weeks of gestation tubal torsion was diagnosed during cesarean section with clinical suspicion (60%), in one case it was treated by laparoscopy. In early preterm pregnancies (30–33 weeks) it was diagnosed by diagnostic laparoscopy, in one case by a laparotomic exploration  and on the type of procedure (laparoscopy or laparotomy). Some authors have described previously a case of laparoscopic removal of a perforated intrauterine device (IUD) during the first trimester of pregnancy under regional anesthesia  as a feaIn our review of the last 10 years, we found 10 cases, and in most of them the main problem to solve was always the diagnosis; in most of these cases, the diagnosis was performed surgically, by laparoscopy, or, more frequently by laparotomy, in a contextual cesarean section procedure. We agree with Origoni et al.  that preIsolated torsion of the fallopian tube is very rare, is an infrequent obstetric condition but should consider in case of acute lower abdominal pain presentation during pregnancy. Considering that this sign is not specific, the cases are frequently misdiagnosed as having other causes of acute abdominal pain. Ultrasound images are not diagnostic but could help in the differential diagnosis.Cesarean section is performed in most of the cases with contextual salpingectomy, considering the gestational age at diagnosis. Depending on gestational age, surgical treatment as soon as possible could prevent a salpingectomy.FG and FC conceived the project of this work and designed the experiment. CE and GM made the clinical activity and following the patient in their appointments. SS made the review of literature. GE was the clinical and scientific coordinator of the study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Lymphoepithelioma-like carcinoma (LELC) is a rare lymphoproliferative malignancy that has been described in many organs over the years. LELC in the duodenum has rarely been described in literature. This article aims to present a rare cause of melena in a young man and the diagnostic challenge that ensued to throw more light on this rare disease. In this article, we describe a 43-year-old man who presented with melena and weight loss and was subsequently diagnosed with LELC after multiple endoscopic biopsies. The patient was also found to have celiac disease in association with his LELC. LELC has been described in organs such as the stomach, lung, bladder, esophagus, thymus, cervix, skin, and salivary glands.10 There have only been 2 documented cases in literature of LELC in the duodenum, and both were described in association with Epstein-Barr virus (EBV).12Lymphoepithelioma is a form of undifferentiated carcinoma initially described in nasopharyngeal carcinomas.A 43-year-old Eastern European man with no significant medical history presented with melena and unintentional 20-pound weight loss. Work-up revealed severe anemia which was managed with blood transfusions and an urgent esophagogastroduodenoscopy.Esophagogastroduodenoscopy revealed a dilated stomach with retained solid food and a dilated duodenal bulb with circumferential narrowing at the level of the duodenal sweep Figure . ProximaHistology of the biopsies from the distal duodenum revealed chronic active duodenitis with villous blunting, increased intraepithelial lymphocytes, and mild active inflammation. Tissue transglutaminase  immunoglobulin A was found to be elevated to 64.0 U/mL consistent with celiac disease (CD). The patient was started on a gluten-free diet and has remained asymptomatic during scheduled follow-ups.10 To the best of our knowledge, this is the first case of LELC in the duodenum being described in the United States. Two other cases have, however, been described in Italy and Spain.12 The first ever case of LELC in the duodenum was described in a 63-year-old patient with active Crohn's disease after presenting with severe anemia and intestinal subobstructive symptoms.11 The second case was described in a 77-year-old man who was undergoing work-up for chronic microcytic anemia in Spain.12 Immunohistochemical analysis was also positive for EBV in both patients. Many observational studies have suggested a causal relationship between LELC and EBV, but this is mostly true for upper aerodigestive tract LELC.10 Abnormalities involving p53 regulation and human papillomavirus have been described in association with LELC in the urinary tract and cervix, respectively.14 Immunohistochemical analysis, polymerase chain reaction, and in situ hybridization have confirmed the presence of EBV DNA and RNA in malignant epithelial cells of LELC.16 Of particular interest is the Epstein-Barr–encoded RNA, which has been shown to be abundantly expressed in malignant epithelial cells of LELC.10 In addition to the 2 other cases described of LELC in the duodenum, our report further supports the oncogenic role of EBV in LELC arising in the duodenum.LELC is a rare type of malignancy that is characterized by proliferation of poorly differentiated malignant cells within a prominent lymphoid infiltrate.17 The association between CD and small bowel adenocarcinoma (SBA) was first described more than 40 years ago.18 The link between SBA and CD has been explored in a few case reports, implying that a variety of mechanisms may contribute to the pathogenesis of SBA arising in the setting of CD.20 These mechanisms include chronic inflammation, increased permeability of carcinogenic factors, malabsorption of anticarcinogenic substances, as well as impaired immune surveillance.20 Having established the oncogenic properties of both EBV and CD, it is entirely plausible to suggest that the combined presence of EBV and CD in this patient likely played a huge role in his cancer diagnosis.Interestingly, the cancer reported here occurred in a patient with CD. CD has never been described in association with LELC but has been shown to increase the risk of developing adenocarcinoma and lymphoproliferative malignancies.23 The improved survival has been suggested to be due to reduced tumor spread from the intense lymphocytic proliferation associated with LELC.10Treatment of LELC is mainly surgical with or without adjuvant chemotherapy. Our patient was T2N0M0 at diagnosis and required no adjuvant chemotherapy after pancreaticoduodenectomy. He remains cancer-free at 18 months similar to the 2 other patients. Because of our very limited sample size, it is inherently difficult to make any conclusion regarding prognosis; however, gastric LELC which is more common compared with duodenal LELC has been shown to have a better overall prognosis compared with the other gastric tumor subtypes.Author contributions: All authors participated in the writing and review of the manuscript. R. Kwei-Nsoro is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.


Morgagni hernia is an uncommon type of diaphragmatic hernia and commonly presents as a congenital disease. Acquired Morgagni hernias following open cardiac surgery are exceedingly rare and only reported in the pediatric population.The patient is a 70-year-old female who presented with complaints of shortness of breath and cough one year following a coronary artery bypass graft (CABG). A chest CT scan showed a large Morgagni type diaphragmatic hernia with herniated transverse colon occupying the anterior mediastinum as well as the right hemi-thorax. This hernia was successfully repaired using transabdominal robotic approach with complete resolution of patient's symptoms.This is the first reported case of acquired Morgagni type diaphragmatic hernia in an adult following open cardiac surgery. The potential etiologies for this hernia include distal extension of the median sternotomy and involvement of the anterior diaphragm, iatrogenic injury to the attenuated anterior diaphragm during pericardial window creation, or pericardial drain placement. Operative repair is the mainstay of treatment and is usually performed with a transabdominal approach since it is thought to be less challenging and allows for evaluation of the entire abdominal cavity. If primary repair cannot be achieved, then synthetic mesh may be needed to obtain a tension free and durable repair.We present a case of acquired Morgagni type diaphragmatic hernia in an adult following open cardiac surgery that was successfully repaired using a transabdominal robotic approach. •Morgagni hernia is an uncommon type of diaphragmatic hernia and commonly presents as a congenital disease.•Acquired Morgagni hernias following open cardiac surgery are exceedingly rare and only reported in pediatric population.•Most Morgagni hernias can be approached thoracoscopically, laparoscopically, or robotically with reduction of hernia contents and diaphragmatic repair.•If primary repair cannot be achieved, then synthetic mesh may be needed to obtain a tension free and durable repair. She underwent an urgent coronary artery bypass graft via median sternotomy one year prior to presentation. About 6 weeks after the procedure the patient started to develop progressively worsening shortness of breath with exertion and at rest. Her shortness of breath was so severe that she was not able to walk across a room without experiencing symptoms. This was associated with non-productive cough, and chest pain and pressure. She presented to her primary care physician and a CT scan of the chest was obtained. This imaging study showed a large anterior Morgagni type diaphragmatic hernia with herniated transverse colon occupying the anterior mediastinum as well as the right hemi-thorax . The pat3Upon entering the abdomen with a 5 mm 30-degree laparoscope there was note of a large anterior diaphragmatic hernia containing the transverse colon and omentum -A. The v4Diaphragmatic hernias can be classified as congenital or acquired. Of the congenital diaphragmatic hernias, the Bochdalek hernia accounts for nearly 80%, while the Morgagni hernia is far less common accounting for only 2–6% Presenting symptoms in the adult population are variable. A comprehensive literature review performed by Horton and colleagues showed that most patients present with chest and abdominal pain or pressure (37%) as well as pulmonary symptoms which consist of dyspnea, cough, and shortness of breath (36%). The remaining symptoms consist of obstruction (20%), dysphagia (3%), bleeding (1%) and GERD (1%) Diagnosis can be made with radiologic evaluation using chest x-ray, upper gastrointestinal contrast study, magnetic resonance imaging (MRI), and CT scan which can confirm the diagnosis in nearly all patients. Studies such as an upper endoscopy or endoluminal functional lumen imaging probe (EndoFLIP) technology in our patient provided additional information to support the diagnosis.There are some reported cases of acquired Morgagni hernia following open cardiac surgery in children. Carballo et al. discuss the case of a 4-year-old female with a history of trisomy 21, ventricular septal defect (VSA), patent foramen ovale (PFO) and patent ductus arteriosus (PDA) who presented with acquired Morgagni hernia and pericardial hernia after open cardiac surgery. The patient presented with acutely incarcerated colon and small bowel into the right hemithorax, which was successfully reduced, and repaired using laparoscopic approach In our report, the patient is a 70-year-old female with no history of congenital Morgagni hernia, no history of penetrating or blunt thoracoabdominal trauma, and without risk factors for the development of acquired Morgagni hernia aside from obesity. Furthermore, the imaging prior to her CABG did not show any evidence of diaphragmatic hernia. To the best of our knowledge, this is the first report of Morgagni type of diaphragmatic hernia in an adult following cardiac surgery.There are two plausible explanations for the development of an acquired Morgagni hernia following cardiac surgery. The first is distal extension of the median sternotomy and involvement of the anterior diaphragm resulting in a direct communication between the thoracic and abdominal cavities. Panda et al. discuss that this occurs due inferior extension of the median sternotomy to facilitate exposure of the heart and that inadvertent breach of the peritoneum results in late herniation of the visceral contents into the pericardial cavity. This can be avoided by limiting the inferior extent of the sternotomy and extending this preferentially in a T-shaped fashion above the diaphragm if more exposure is required Operative repair of acquired Morgagni hernia can be approached through the abdomen or the chest. The abdominal approach is commonly preferred; it is thought to be less challenging and provides ability to examine the entire abdominal cavity and the viscera, in addition allows evaluation of the contralateral diaphragm for additional defects Excision of the hernia sac is also a matter of debate. Excision of the hernia sac is considered a surgical principle which is thought to decrease the risk of hernia recurrence 2Once the hernia contents are reduced and the defect is well-defined, the diaphragmatic repair can be achieved primarily, with mesh interposition, or with mesh reinforcement. The choice to use mesh or to repair the defect primarily depends largely on the size of the defect with Thoman et al. recommending prosthetic repair for defects with surface area greater than 20–30 cm5We reported the first case of acquired Morgagni type diaphragmatic hernia in an adult following an open cardiac surgery. These hernias are most likely caused by iatrogenic injury to the attenuated anterior diaphragm during pericardial window creation, pericardial drain, chest tube placement, and distal extension of median sternotomy. Surgical repair remains the mainstay of treatment for Morgagni hernia due to the high risk of strangulation of herniated contents. There is no standardized technique for repair, however, most Morgagni hernias can be approached thoracoscopically, laparoscopically, or robotically with reduction of hernia contents and diaphragmatic repair. If primary repair cannot be achieved, then synthetic mesh may be needed to obtain a tension free and durable repair.Yes.Not commissioned, externally peer-reviewed.Yes.N/A.Shahin Ayazi, MD.None.Equal contribution by all authors.None.


Kaposi sarcoma is a malignancy common in patients with acquired immune deficiency syndrome (AIDS). It is a proliferative soft-tissue tumor commonly manifesting as pigmented papules and nodules on the skin. Lesions can also appear on the mucosal lining of the oropharynx and other parts of the body such as the lymph nodes. Head and neck involvement in Kaposi sarcoma is not unusual; however, laryngeal involvement is not commonly seen. We report the case of a 31-year-old gentleman, a former smoker with AIDS, who developed a mass in the throat with progressive hoarseness of voice without stridor. An elective tracheostomy was done to protect his airway before performing a direct laryngoscopy with biopsy. Histopathology examination showed neoplastic spindle cells positive for CD31, erythroblast transformation specific-related gene, and human herpesvirus 8, consistent with Kaposi sarcoma. The diagnosis of laryngeal Kaposi sarcoma in immunodeficient patients requires a high index of suspicion, especially when it occurs without classical dermatological manifestation, an interesting feature in this report. Kaposi sarcoma was first described in 1872 as a pigmented cutaneous sarcoma that presents most commonly on the lower extremities. Four epidemiologic-clinical subtypes of Kaposi sarcoma are African-endemic, epidemic acquired immune deficiency syndrome (AIDS)-related, classic, and iatrogenic Kaposi sarcoma. Although AIDS-related Kaposi sarcoma involves the head and neck, the primary laryngeal disease is uncommon [Kaposi sarcoma is causally associated with infection of vascular endothelial cells by human herpesvirus 8 (HHV8) or Kaposi sarcoma herpesvirus (KSHV) infection, characterized by inhibition of apoptosis, angiogenesis, inflammation, and cellular proliferation. The interaction between the host immune dysfunction and the local inflammatory response to herpesvirus creates a conducive environment for the growth and progression of the disease . KSHV inDiagnosing Kaposi sarcoma in the larynx can be challenging, especially without any cutaneous manifestations. Clinical presentation may include hoarseness, throat discomfort, urge to cough, aphonia, dysphagia, stridor, or complete airway obstruction. Radiographic evaluation with computed tomography (CT) scan of the neck helps to locate the laryngeal mass, as was done in this case. Biopsy of such vascular laryngeal mass is required for a definitive diagnosis but is associated with risks and severe bleeding .Highly active antiretroviral therapy (HAART) is an indispensable component of the treatment for AIDS-associated Kaposi sarcoma and has resulted in a substantial decline in the incidence of Kaposi sarcoma . Close cA 31-year-old African American man, newly diagnosed with HIV, presented to the hospital with a five-month history of throat mass associated with hoarseness of voice without stridor or dysphagia. He also reported a 30-pound weight loss over a six-month period, lethargy, and anorexia. He had never sought medical attention in the past. Physical examination showed temporal wasting, a muffled voice, and a mass protruding from the posterior pharynx. Submandibular lymphadenopathy was palpable. No skin lesions were found on examination.Routine blood tests showed a CD4 count of 28 cells/µL and an HIV viral load of 221,000 copies/mL. CT scan of the neck showed a large lobulated, heterogeneous, enhancing, mass-like lesion, likely arising from the epiglottis measuring approximately 4.2 × 3.7 × 6.7 cm, extending to the hypopharynx and supraglottic/glottic larynx, and effacing the bilateral vallecula and left pyriform sinus. The lesion was causing near-complete obstruction of the upper airway at the level of the supraglottic larynx, posterior to the epiglottis  tube placement due to the dysphagia resulting from the mass effect of the lesion on the esophagus. The patient was later referred to an oncology center where he is currently receiving systemic chemotherapy consisting of liposomal anthracycline (doxorubicin) in addition to HAART. His CD4 count improved from 28 cells/µL at the time of admission to 115 cells/µL at the time of transfer.Visceral involvement of AIDS-related Kaposi sarcoma is uncommon, and laryngeal involvement without cutaneous lesions rarely occurs. To our knowledge, a recent systematic review found only 77 published case reports of Kaposi sarcoma of the larynx, predominantly in males and mostly arising in the supraglottic region . The preGiven the highly vascularized nature of the tumor, a biopsy of suspected laryngeal Kaposi sarcoma is usually associated with a high risk of airway compromise from significant bleeding and edema . In thisThe AIDS Clinical Trials Group (ACTG) guidelines allow for better staging of AIDS-associated Kaposi sarcoma based on the extent of the disease (T), the severity of immunodeficiency (I), and the presence of systemic symptoms (S). Based on these criteria, patients are classified as good or poor risk . TreatinThe widespread use of HAART as an essential component of the treatment regimen for AIDS-associated Kaposi sarcoma has yielded excellent results. It helps in shrinking existing cancer lesions and prevents dissemination. Since its introduction, HAART has significantly reduced disease incidence and improved the survival rate of individuals with AIDS-associated Kaposi sarcoma . Our patIndividuals classified as poor risk according to the ACTG criteria, an example being this index case, generally benefit from a combination of antiretroviral drugs and an additional therapy such as chemotherapy . Drugs sStudies have shown that patients undergoing chemotherapy or radiotherapy with head and neck cancers are at an increased risk of significant weight loss and malnutrition due to impaired swallowing and concomitant odynophagia from mucosal injury during treatment. They lead to frequent hospitalizations, poor compliance with treatment, and reduced quality of life. The early use of PEG tubes for enteral feeding reduces the impact of systemic therapy on weight loss and nutritional status ,15. ConsKaposi sarcoma, a highly vascular tumor, is commonly seen in patients with AIDS as cutaneous lesions. Laryngeal involvement is uncommon but often associated with AIDS or a history of immune suppression. Diagnosis requires a high index of suspicion in the absence of cutaneous lesions. Biopsy must be cautiously performed due to the risk of bleeding and airway obstruction. HAART is fundamental in the treatment in addition to systemic therapy and good nutritional support.


PTT most commonly affects the scalps of women above 60 years old and is frequently misdiagnosed due to its rarity. Herein, we present a case of a 68-year-old man with a malignant proliferating trichilemmal tumor on his right thumb. X-ray image showed a soft tissue mass on his thumb accompanied by bone destruction, while  Proliferating trichilemmal tumor (PTT) is a benign neoplasia originating from the outer root sheath of hair follicles. PTT generally affects older women in the head and neck region and is often misdiagnosed , 2. PrevA 68-year-old man was diagnosed with a soft tissue mass at the distal end of his right thumb that had been present for 6 months but was overlooked due to the mild symptoms. Two months prior to admission, the lesion showed rapid growth accompanied by persistent dull pain. Physical examination revealed swelling at the distal segment of the thumb, local skin flushing, and slight tenderness.18F-FDG PET/CT examination revealed a significantly high metabolic activity in the thumb and right axillary lymph nodes  for the publication of any potentially identifiable images or data included in this article.GW, XZ, and JZ: manuscript writing. XZ: pathological review. GW, XZ, JL, QH, and JZ: manuscript revision. All authors contributed to the article and approved the submitted version.This work was supported by the Science and Technology Program of Zhuhai (2220004000244) and the Medical Scientific Research Foundation of Guangdong Province(A2021449).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.