Although primary duodenal adenocarcinoma (DA) is a rare malignancy representing ~ 0.5% of all gastrointestinal cancers, the incidence of DA is more frequent in Lynch syndrome. Because of its rarity, treatment strategies or optimal chemotherapeutic regimens have not been clearly defined for advanced DA.A 72-year-old woman with Lynch syndrome visited our hospital with a right upper abdominal pain. Computed tomography (CT) showed wall thickness with enhancement in the second portion of the duodenum and adjacent abdominal wall, which suggested direct tumor invasion to the abdominal wall. Upper gastrointestinal endoscopy (UGE) showed a large ulcerative tumor in the second portion of the duodenum, and histological analysis revealed a poorly differentiated adenocarcinoma. A cT4N0M0, cStage IIB  DA was diagnosed. After three courses of chemotherapy with S-1 and oxaliplatin (SOX), follow-up CT and UGE showed shrinkage of the duodenal tumor. Therefore, the patient underwent pancreaticoduodenectomy with lymph node dissection with curative intent. Histological examination showed a pathological complete response to SOX therapy. The postoperative course was uneventful, and the patient was discharged on postoperative day 29. The patient received no adjuvant chemotherapy, and there has been no evidence of recurrence 6 months after the operation.SOX therapy provided a remarkable response and can be an optimal chemotherapeutic regimen for advanced DA in Lynch syndrome. Primary duodenal adenocarcinoma (DA) is a rare malignancy, representing ~ 0.5% of all gastrointestinal cancers, and is often diagnosed at an advanced stage –3. Surgi3 and a decreased hemoglobin level of 10.8 g/dL. Serum levels of the tumor markers carcinoembryonic antigen and carbohydrate antigen 19–9 were within normal limits. She had a history of four resections of different parts of the colon because of colon cancer associated with Lynch syndrome. At the age of 36, she was diagnosed with transverse colon cancer, and a partial resection of the transverse colon was performed. At the age of 44, she was diagnosed with cecal cancer for which ileocecal resection was performed. At the age of 45, she was diagnosed with sigmoid colon cancer, and a sigmoidectomy was performed. At the age of 72, she was diagnosed with descending colon cancer, and a partial resection of the descending colon was performed. Pathological evaluation revealed a pT2N0M0 pStage I tumor based on the seventh edition of the Union for International Cancer Control TNM staging. Her family history fulfilled the Amsterdam II and revised Bethesda criteria. Her father died of colon cancer in his 40s, one of her brothers had colon cancer at the age of 39 years, one of her cousins died of colon cancer in his 30s, and her son had ascending colon cancer at the age of 35 years; these observations suggested Lynch syndrome. After genetic counseling, a written informed consent was obtained from the patient, and we examined her for microsatellite instability (MSI). The five microsatellite markers BAT25, BAT26, NR21, NR24, and MONO27 exhibited replication errors in the descending colon cancer resected in 2017. Therefore, the patient’s colon cancer was considered to be a high-frequency MSI (MSI-high) tumor. Further genetic testing was performed using DNA from the patient’s peripheral blood. The analyses revealed one missense mutation [c.676C > T (p.Arg226)] in the MLH1 gene, thus confirming Lynch syndrome.A 72-year-old woman complained of right upper abdominal pain at the time of a routine check-up for colon cancer. A physical examination revealed a hard, palpable mass with pain in the middle part of the upper abdomen approximately 5 cm in diameter. Laboratory data showed an elevated leukocyte count of 10,100 cells/mmContrast-enhanced computed tomography (CT) showed wall thickness with enhancement in the second portion of the duodenum and adjacent abdominal wall, suggesting direct tumor invasion to the abdominal wall Fig. . There w2 S-1 orally on days 1–14 and 100 mg/m2 oxaliplatin intravenously on day 1 of a 21-day cycle. Grade 1 adverse effects based on the National Cancer Institute Common Toxicity Criteria  were neutropenia, fatigue, appetite loss, and stomatitis, all of which improved with conservative treatment.The patient was scheduled for combination chemotherapy with SOX: 80 mg/mAfter three courses of chemotherapy with SOX, follow-up abdominal contrast-enhanced CT revealed reduced wall thickness of the second portion of the duodenum and the adjacent abdominal wall Fig. . There wThe patient underwent pancreaticoduodenectomy with combined resection of the adjacent abdominal wall and regional lymph node dissection with curative intent 3 weeks after the last administration of chemotherapy. During the operation, no peritoneal dissemination or lymph node swelling was observed. Gross examination of the surgically resected specimen showed an ulcerative lesion measuring ~ 2.0 cm Fig. a. PatholThe postoperative course was uneventful, and the patient was discharged on postoperative day 29. The patient received no adjuvant chemotherapy, and there has been no evidence of recurrence 6 months after the operation. Postoperative surveillance is being planned according to the Japanese Society for Cancer of the Colon and Rectum Guidelines 2016 for the Clinical Practice of Hereditary Colorectal Cancer .Primary DA is one of the rare malignancies representing ~ 0.5% of all gastrointestinal cancers, although it accounts for > 50% of small bowel adenocarcinomas (SBAs) , 2, 8. BDA is included in SBAs, and the outcomes for all SBAs are grouped together in many studies. Owing to the rarity of SBAs, prospective clinical trials are limited, and treatment guidelines or optimal chemotherapeutic regimens have not been clearly defined. Initially, SBAs were treated with chemotherapy based on the regimen used for gastric cancer. In 1984, Jigyasu et al. reported in a retrospective study that a 5-fluorouracil (5-FU)-based regimen for advanced SBAs achieved a response rate (RR) of 7.1% and a median OS time of 9 months . In a prThe role of preoperative therapy for patients with locally advanced, clinically unresectable DAs has not been well documented. A retrospective study involving unresectable or recurrent DA who was treated with preoperative chemotherapy or chemoradiation found that 9 of 10 patients showed the conversion to resectable disease after the therapy, suggesting prolonged survival after conversion to resectable disease . AnotherLynch syndrome is a known risk factor for SBA, as are familial adenomatous polyposis, Crohn’s disease, Peutz–Jeghers syndrome, and celiac disease. In Lynch syndrome, the risk of developing SBA within a lifetime is reported to be ~ 4%, almost the same as the lifetime risk of CRC in the general population , althougWe report that chemotherapy for a locally advanced DA made the surgical procedure possible and achieved pCR in Lynch syndrome. To the best of our knowledge, this is the first case of a DA patient with Lynch syndrome achieving a pCR. This case indicates that SOX therapy can be a good regimen for advanced DA even in Lynch syndrome. Since DA is a rare malignancy but occurs relatively frequently in Lynch syndrome, further clinical reports will be needed to establish the most appropriate chemotherapy regimen.


Myositis ossificans of the hand is extremely rare and tumors do not usually infiltrate adjacent structures. We present a very unusual case with a tumor infiltrating adjacent structures.A 30-year-old female presented with a 5-week history of a painful rapidly-growing mass over the proximal phalanx of the right ring finger. The mass infiltrated the entire flexor sheath over the proximal phalanx as well as the checkrein ligament of the proximal interphalangeal joint. The common digital artery of the 3rd web space was obliterated by the tumor. The radial digital nerve of the ring finger was stretched and attenuated. Total excision was done and histology confirmed the diagnosis of myositis ossificans. No recurrence was seen at the one-year follow-up.Myositis ossificans of the hand is extremely rare. We report our case to document the unique feature of tumor infiltration of adjacent structures. We also document that excision is curative despite the infiltrative nature of the tumor.Our case is unique because of the infiltrative nature of tumor. There is no indication for amputation even for infiltrative tumors. We demonstrate that complete excision is curative with good regain of function even in infiltrative lesions. It usually arises from skeletal muscles and present as a painful soft tissue mass with overlying skin erythema. It is most frequently seen in the thighs of active athletes. The two commonly involved muscle groups are the quadriceps and adductor muscles of the thigh. Most cases resolve with conservative management  .Myositis ossificans of the hand is extremely rare, and hand tumors have a different presentation and prognosis from the classic thigh lesions. Pain is usually more severe in the hand and this may be related to space limitations within different hand compartments. Furthermore, the proximity of nerves may lead to nerve compression. Finally, most hand tumors require surgical excision despite the initial trial of conservative management either because of intractable pain or persistence of the mass . Simple We report for a very unusual case of myositis ossificans of the hand with infiltration of the flexor sheath, checkrein ligament of the proximal interphalangeal join, and the neurovascular bundle. The work has been reported in line with the SCARE criteria .2iso-intense (similar to intensity of muscle) lesion on T1-weighted images  and an outer zone of mature bone . The pato . Upon pa3Myositis ossificans of the hand is extremely rare. We report our case to document the unique feature of tumor infiltration of adjacent structures. We also document that excision is curative despite the infiltrative nature of the tumor.We reviewed all previously reported cases of myositis ossificans of the hand and wrist since 1982 . There wiso-intensity on T1 and homogeneous high intensity on T2 images. A high intensity in the center of the lesion with a low intensity at the periphery of the lesion is a feature of subacute (4–8 weeks) and mature (over 8 weeks) lesions [The MRI features of intra-muscular myositis ossificans is well described in the literature . Early l lesions . The MRIThe most important differential diagnosis of myositis ossificans of the fingers is fibro-osseous pseudo-tumor of the digit  ,20. This4Myositis ossificans of the hand is very rare. Although an initial trial of conservative treatment is usually tried, most cases end-up with surgical excision either because of intractable pain or persistent mass. The lesion does not usually infiltrate adjacent structures. Our case is unique because of the infiltrative nature of tumor. There is no indication for amputation even for infiltrative tumors. We demonstrate that complete excision is curative with good regain of function even in infiltrative lesions.None.None.The study was approved by the research committee, National Hospital (Care), Riyadh, Saudi Arabia.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by Editor-In-Chief of this journal on request.Both authors contributed significantly and in agreement with the content of the manuscript. Both authors participated in data collection and in writing of the manuscript.Not relevant here.M.M. Al-Qattan.Not commissioned, externally peer reviewed.


Furthermore, the diagnostic modalities’ invasiveness & the associated radiation exposure that might harm the fetus.•The best treatment modality for resectable tumors is in the form of surgery  that is possible during pregnancy. Yet challenging as its important to choose the appropriate time of surgery to insure the viability of the fetus without risking the progression of the disease.•Another challenge that might be encountered is intra-operatively, due to the bulkiness of the uterus which makes such a procedure even more difficult to preform safely & successfully. Ampullary adenocarcinoma is a rare entity during pregnancy. It accounts for 0.5% of all gastrointestinal malignancies. The best treatment modality for resectable tumors with the best reported outcome is surgical resection in the form of pancreaticoduodenectomy (Whipple procedure). In this case report, we discuss the challenges in the management of ampullary adenocarcinoma in a pregnant patient.We report a case of 22 years old pregnant women who presented with vague abdominal pain and jaundice at the 28th week of gestation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a stricture around the ampulla and distal common bile duct (CBD). The CBD was stented and a biopsy was taken. Histopathology revealed: an invasive adenocarcinoma. The patient was managed by elective pancreaticoduodenectomy after induction of vaginal delivery at the 34th week of gestation.Diagnosing and managing ampullary adenocarcinoma in pregnant patients in their 3rd trimester is challenging. Yet, a delayed viable delivery followed by a definitive surgery in the form of pancreaticoduodenectomy offers the best outcomes for both the mother & fetus in case of early stage disease. Ampulla2We report a case of a 22 years old pregnant female medically free, referred to us from her Obstetrician when she was complaining of abdominal pain and jaundice. Abdominal US confirmed a single intrauterine pregnancy at 28th week of gestation with appropriate growth for date and showed dilated intrahepatic ducts otherwise it was inconclusive due to the gravid uterus . Her bloTherefore, we proceeded with pancreaticoduodenectomy. A laparotomy incision was done, intraoperative examination of the abdomen revealed; a palpable mass at the ampulla of Vater and the stent was felt in the CBD and duodenum, a bulky uterus as the patient was still in the postpartum period. There was no vascular invasion, peritoneal deposits or any other distant metastasis. For the pancreatojejunostomy anastomosis, a two-layer end-to-side duct-to-mucosa approach was adopted. The pancreatic duct was stented to divert the pancreatic secretions away from the anastomosis. Then the hepaticojejunostomy was done in an end-to-side fashion followed by the gastrojejunostomy.The Patient had uneventful postoperative course and was discharged 1 week after her surgery. Histopathology came as poorly differentiated invasive adenocarcinoma of ampulla of Vater with negative resection margins. Three out of thirteen lymph nodes revealed metastatic involvement so she received six cycles of adjuvant chemotherapy which she tolerated well. Upon 6 years follow up, computed tomography (CT) and positron emission tomography (PET) scans were normal with no evidence of recurrence.3Patients with periampullary tumors can present with wide variety of gastrointestinal symptoms. The most commonly is obstructive jaundice 2ry to CBD obstruction. In other cases, they can present with biliary colic along with constitutional symptoms especially in adenocarcinoma compared to other types of GI malignancies .We reviewed published articles concerning periampullary & pancreatic malignant tumors that has been diagnosed during pregnancy & confirmed by histopathology in the English literature. To the best of our knowledge, only 41 cases have been reported  and our In case of pregnancy, diagnosing of ampullary adenocarcinoma can be challenging. The way it does that is by making alarming symptoms of malignancy through the physiological changes of pregnancy. As jaundice can develop frequently in the 3rd trimester due to benign intrahepatic cholestasis, which can be misleading initially as in our case. Furthermore, other symptoms that adenocarcinoma of ampulla of Vater cause like abdominal discomfort, nausea & vomiting also can happen in normal pregnancy. Another challenge is that the gravid uterus that decreases the sensitivity of non-invasive imaging modalities . The repThere are different radiological modalities that can aid in obtaining a confirmatory diagnosis and staging of ampullary carcinoma but not all of these can be used freely during pregnancy such as ERCP or CT scan, due to the risk of radiation exposure to the fetus . The maiIn our case, the MRCP revealed an ampullary mass measuring 2 cm with no vascular involvement. ERCP is used during pregnancy for diagnosis by obtaining a biopsy, stenting for biliary draining and to prepare the patient for surgery or if the tumor is not operable. To minimize the risk radiation exposure to the fetus the patient should have a lead shield in place as we did in our case. Biochemically, an elevated carbohydrate antigen 19-9 (CA 19-9) level may help to guide the diagnosis towards an ampullary adenocarcinoma . NeverthManagement wise, surgical resection is usually done by a Whipple procedure (Pancreaticoduodenectomy) followed by an adjuvant therapy is the standard of care for early stage disease. Such surgery carries a risk of many complications. One important complication to consider is pancreatic fistula or leak with a reported incidence ranging from 2 to 40% .To decrease the risk of such complication, intraoperatively a pancreatic duct stent can be used. Adaptation of this technique to protect the anastomotic site & decrease the chance of any leak have led good to outcome of such procedure in some centers .Surgical intervention is challenging in pregnant patients, the appropriate time to intervene depends on the gestational age at the time of diagnosis and the stage of the disease. The challenges that might be encountered in first trimester, is the risk of spontaneous abortion and the best strategy is to abort the pregnancy. While in the second trimester induced delivery can’t be applied as gestational age is not compatible with life and it is the most dangerous time to put the patient on chemotherapy. In the third trimester, the large size of the uterus is another challenge especially intraoperatively .In our patient, the obstetrician induced labor at week 34 of gestation & Whipple procedure was done afterwards and the major challenge was a presence of a bulky uterus during the surgery.4Obtaining a diagnosis of ampullary adenocarcinoma in pregnant patients in their third trimester & managing them can be challenging due to; 1) the overlapping symptoms between it & the physiological changes of pregnancy, 2) the limitation of using the appropriate diagnostic modalities in order to avoid radiation exposure to the fetus, 3) the intraoperative technical difficulties 2ry to the gravid uterus. Yet, a delayed viable delivery followed by a definitive surgery in the form of pancreaticoduodenectomy is still achievable with a multi-disciplinary approach & good perioperative preparation in early stage disease.None.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Case reports are exempted from ethical approval according to our institution policies.Written informed consent was obtained from the patient for publication of this case report.Abdullah Saleh AlQattan: study design, data collection, writing the paper, reviewing and editing the case report.Feras Ahmed Alkuwaiti: study design, data collection, writing the paper.Elham Saleh Alghusnah: study concept, reviewing article, correction and editing of the case report.Shoukat Ahmad Bojal: study concept, reviewing article, correction and editing of the case report.Mohammed Saad Alqahtani: study concept, reviewing the final manuscript of the case report, final approval.N/A.Dr. Mohammed Saad Alqahtani.Not commissioned, externally peer-reviewed.


Giant cell tumors (GCTs) of the bone are locally aggressive primary bone tumors with a benign character. Spinal involvement is rare and they are quite rare in the cervical spine.A 31-year-old male patient presented with neck pain. Cervical CT revealed a lytic lesion extending posteriorly and causing the collapse of the C4 vertebra corpus. The patient underwent excision of the tumor extending from the anterior to the posterior with a single-stage anterior intervention followed by the placement of an anterior cage and plate-screw system for fusion. The pathology was reported as GCT.The posteriorly located lesion was widely curetted through an anterior approach in a single session. Giant cell tumors (GCTs) of the bone are locally aggressive primary tumors with a benign character involving the metaphysis of long bones. The tumor develops after physeal closure and causes pathological fractures. The incidence in the spinal cord varies between 1.4% and 9.4% and the most common spinal location is the sacrum. The incidence in the cervical spine is quite low . PrimaryA 31-year-old male patient presented to our clinic with symptoms of neck pain, back pain , and numbness in both arms for the last 3 months. His physical examination revealed hypoesthesia at the C4 and C5 dermatomes in both arms with no loss of strength. Cervical computed tomography (CT) showed a destructive and compressive lesion in the C4 vertebra corpus Fig. . WeinsteGCTs are rare tumors and are quite rare in the cervical spine. Various treatment options such as surgery, radiotherapy, embolization, cryotherapy, and chemical adjuvants are used for spinal GCTs. Denosumab has been used in adjuvant therapy in recent years . The aimCurettage can be used for small lesions limited to the anterior cervical column, and anterior stabilization can be used for lesions limited to the vertebral corpus in cervical spine GCTs , 21, 22.It is difficult to predict the prognosis in GCT cases as the recurrence rate is 11–50% even with the best treatment method of en bloc resection –12, 24. In this case, the posteriorly located lesion was widely curetted through an anterior approach in a single session. The patient did not experience any recurrence during the 3 years of follow-up.


In the setting of altered anatomy, diagnosis of superior mesenteric artery syndrome requires high clinical and imaging suspicion as the defined imaging criteria cannot be applied. A 78‐year‐old male patient presented to our surgical department due to a recent history of abdominal distention, bilious vomiting, obstipation, and weight loss of 22 kg. Computed tomography (CT) depicted: (a) circumferential cecal wall thickening with fat infiltration and pericolic lymphadenopathy Figure A; and bB. Colono1Review of CT images enabled visualization of duodenal vascular compression. The 3rd part of duodenum was compressed by the close proximity of the superior mesenteric artery (SMA) to the renal cyst and isthmus, as the distance between SMA and renal cyst was 6 mm Figure .1 In the2The present article does not contain any studies with human or animal subjects performed by any of the authors.The authors declare that they have no conflict of interests.Informed consent: Informed consent was obtained from the patient.All authors equally accessed the data and contributed to the preparation of the manuscript. BK, BKA, and HA: were equally responsible for making and performing treatment decisions. HA: reviewed the manuscript for critical intellectual content and had the final approval.


Acupuncture, a component of traditional Chinese medicine, is also a well-known form of complementary and alternative medicine. Serious adverse events of acupuncture have been reported, including the acupuncture-related pneumothorax which is a rare but fatal condition sometimes. The pneumothorax was related to needle insertion in the upper back or paraspinal area and the reported victims suffered from either unilateral or bilateral pneumothorax. Postmortem computed tomography has advantages in the detection of pathologic gas and is being considered as a useful visualization tool for diagnosing the cause of death.A 52-year-old man underwent acupuncture and cupping treatment at an illegal Chinese medicine clinic for neck and back discomfort and was admitted to the hospital with severe gasp and dyspnea about 30 hours later. The patient suddenly became unconscious with heart rate and blood pressure lost and died after cardiopulmonary resuscitation. Diagnosis, interventions and outcomes: Whole-body postmortem computed tomography of the victim revealed collapse of the both lungs and mediastinal compression, which was also confirmed by autopsy. More than 20 pinprick injuries were found on the skin of the upper and lower back in which multiple pinpricks were located on the body surface projection of the lungs. The cause of death was concluded as acute respiratory and circulatory failure due to acupuncture-induced bilateral tension pneumothorax.Acupuncture-induced tension pneumothorax is rare and should be recognized by forensic pathologists. Postmortem computed tomography can be used to detect and accurately evaluate the severity of pneumothorax before autopsy and can play a supporting role in determining the cause of death. There is evidence for its efficacy in the treatment of chronic pain conditions such as neck and back pain, osteoarthritis, and chronic headache and shoulder pain. Other reports consider acupuncture as a form of integrative medicine that works solely through the placebo effect.,4 However, serious adverse events (AEs) of acupuncture have also been reported.–7 Since the occurrence of most cases of acupuncture-related pneumothorax is delayed, this complication is usually under recognized by acupuncturists and mainly addressed by hospital and emergency room physicians.Acupuncture, a component of traditional Chinese medicine, is also a well-known form of complementary and alternative medicine.,9 It has prominent advantages in the detection of both pathologic gas collections and fractures. At autopsy, the pneumothorax test may be ignored as a nonroutine dissection procedure. Furthermore, it is difficult to detect the presence of gas in the pleural space after exposing the chest cavity to the external environment. Bilateral pneumothorax will lead to the collapse of both lungs, while unilateral pneumothorax causes a shift in the mediastinum toward the intact side. In this case, critical information received from PMCT imaging helped forensic pathologist to easily determine the cause of death before the conventional autopsy.In recent years, postmortem computed tomography (PMCT) is being considered as a useful visualization tool for diagnosing the cause of death during forensic practices.2A 52-year-old man underwent acupuncture and cupping treatment at an illegal Chinese medicine clinic for neck and back discomfort. Multiple 0.25 mm × 75 mm needles were utilized and the acupuncture points were located in the middle and on both sides of the upper back and the middle of the lower back. The acupuncture and subsequent cupping treatment lasted 30 minutes, respectively. The patient presented to the hospital with severe gasp and dyspnea about 30 hours later. Physical examinations were as follows: blood pressure (BP) was 149/94 mm Hg, heart rate (HR) was 86 beats/min, and blood oxygen saturation level was 54%. The patient was lucid, was gasping, and had apnea and low respiratory murmur, accompanied by some wheeze in both sides of the lungs. Because of the respiratory difficulty, the patient could hardly speak. After primary physical examination, he was suspected of having foreign body airway obstruction. Around 30 minutes after admission, the patient suddenly became unconscious with HR and BP not being measured. The patient died after an hour of cardiopulmonary resuscitation.This study was approved by the Academic Committee of the Institute of Forensic Science, Ministry of Justice, People's Republic of China. Written informed consents were obtained from the victim's family to publish these case details.3The time interval between death and PMCT scanning was about 207 hours. The corpse was frozen after death and thawed before examination. The whole body was scanned using a 40-slice multislice CT system . Raw data were acquired using the following settings: voltage 120 kV, current 240 mAs, collimation 6.0 × 1.0 mm. Image reconstruction was achieved at slice thicknesses of 5.0 and 0.625 mm, each with an increment of half the slice thickness (soft tissue and bone-weighted reconstruction kernel). Image review and three-dimensional (3D) reconstructions were performed using Mimics 14.0 software .4Conventional autopsy was performed about one hour after the PMCT examination. During the autopsy, external and internal examinations of the body were performed. Histological samples of most of the organs within the cranial, thoracic, and abdominal cavities were subjected to hematoxylin & eosin (H&E) staining. Blood was sent for toxicological analyses.5PMCT results showed that both lungs had collapsed and the density of both lungs was significantly elevated Fig. . Mediast6External examination revealed that the deceased was of medium body shape and without developmental malformations. Multiple quasi-circular marks due to cupping were found on the both sides of the upper back and the middle of the lower back. In total, more than 20 pinprick injuries from the acupuncture were found on the skin of the upper and lower back. Five pinpricks were found above the scapulae, with 3 on the left, and 2 on the right side, respectively. Two pinpricks were located approximately lateral to the sixth thoracic vertebra on both sides, in the region between the scapular margin and thoracic spine. Two pinpricks were found on the left side, and one pinprick on the right side of the upper back, approximately lateral to the tenth thoracic vertebra, below the scapular margin. More than ten pinpricks were found on the lower back Fig. . Both luHistological examination revealed local atelectasis, blood congestion of alveolar capillaries, as well as pulmonary oedema and local emphysema. Dust-like black pigments were also discovered beneath the visceral pleura. Blood congestion of other organs was also found, however, no other abnormalities were found. Toxicological results were negative for alcohol and common drugs.The cause of death was concluded as acute respiratory and circulatory failure due to bilateral tension pneumothorax, which was caused by acupuncture in the paraspinal areas on both sides of the upper back.7 Pneumothorax could be spontaneous, traumatic, or iatrogenic. During acupuncture, especially when performed by untrained personnel, the needle may be inserted into the pleural space or even into the lungs themselves, leading to tension pneumothorax. In this case, the pathophysiology of the bilateral pneumothorax is most likely as follows: perforation of the lungs occurred when the acupuncture needles were inserted into the thoracic cavities from the paraspinal areas in both sides of the upper back. Five pinpricks in the back were located on the body surface projection of the lungs, without being obstructed by the scapulae. Considering that the length of the needle used in this case was 70 mm, such needles inserted too deeply into the body by untrained personnel during acupuncture treatment are likely to pierce the pleura and lungs. No obvious injury was found in lungs or pleural after careful examination in the present case. It is possible that the needles used in this case were too fine and the victim's lungs collapsed greatly such that the injuries were not visible. Furthermore, the acupuncture was performed more than 30 hours before death, and the corpse was frozen for several days and thawed before examination. Petechiae in the parietal and visceral pleura may feasibly be absorbed over time, or even vanish during body putrefaction, freezing and thawing of the corpse.Pneumothorax refers to gas accumulation in the pleural space and is considered a rare phenomenon compared to other severe AEs of acupuncture, such as central nervous system injury, infection, epidural hematoma, subarachnoid hemorrhage, cardiac tamponade, gallbladder perforation, and hepatitis.–7,12–14 The majority of the reported victims suffered from unilateral pneumothorax; however, there were also reports of bilateral pneumothorax;–14 the pneumothorax was related to needle insertion in the upper back or paraspinal area, similar to that in the present case. In these cases, the time interval between the acupuncture treatment and the appearance of symptoms of pneumothorax ranged from less than an hour, to 2 days. According to those reports, patients with existing respiratory disease, those receiving long-term acupuncture treatment, and those with multiple needle insertion were likely to have presented with rapid respiratory failure shortly after treatment. Moreover, the majority of the patients were not in a critical condition, and the cases of pneumothorax were diagnosed and cured clinically. In the present case, the cause of death was determined to be acute respiratory and circulatory failure due to cardiopulmonary compression and restricted respiration, caused by bilateral tension pneumothorax. No other possible lung diseases that may lead to bilateral spontaneous pneumothorax were found. The needles used in the case were too fine thus leaving tiny perforations in the victim's lungs. A small amount of air continued to slowly enter the chest cavities over a long period. The victim possibly tolerated the mild discomfort and did not pay attention when early symptoms appeared. It took 30 hours to develop into symptoms of severe pneumothorax, and then the victim was sent to the hospital.Cases concerning acupuncture-related pneumothorax have been reported.–18 Most of the reported victims suffered from gunshot, or stab wounds, or traffic accidents. Obvious chest injuries other than pneumothorax were detected by both PMCT and body examination. Reports on the use of PMCT to diagnose pneumothorax caused by acupuncture are rare. In this case, there was no obvious chest injury, and the victim could hardly speak when admitted, due to breathing difficulties. In fact, the important information that the victim had recently received acupuncture would have been omitted had there not been careful police investigation. Tension pneumothorax caused by acupuncture is rare and most likely not recognized by forensic pathologists. Total lung collapse and mediastinum shift to the intact side after exposure of the chest cavities may be detected during conventional autopsy, but not every pneumothorax has such significant lung collapse. In the scenario wherein gas cannot be observed in the pleural cavity, direct evidence of pneumothorax will be missed. PMCT is a sensitive tool in detecting gas and can be used to overcome the difficulty mentioned above. In this case, the information obtained from PMCT before the autopsy was used to detect and accurately evaluate the severity of pneumothorax; this information could be used by the forensic pathologists to relate the pinpricks on the back to pneumothorax and remind them of the possibility of acupuncture-related pneumothorax. It could also help to make an effective procedure for the following autopsy. PMCT also has some limitations. PMCT is unable to reveal the true color of the human tissues. And because the resolution of the CT images is closely related to the performance of the machine so minor injuries and lesions may be missed in some cases. In the present case, the information obtained by PMCT was sufficient for the diagnosis of pneumothorax. And the determination of the cause of death was not affected by such limitations. In conclusion, PMCT has shown diagnostic value in tension pneumothorax and played a supporting role in determining the cause of death.In recent years, PMCT has increasingly been applied to forensic examination, and pneumothorax was detected by postmortem imaging in some cases. During conventional autopsy, the pneumothorax test is a special examination process in which the examiner punctures the intercostal muscles under water and observes whether there are bubbles formed. Therefore, it is not part of the routine examination in each autopsy, and forensic pathologists may neglect the process and miss the findings. There also have been case reports regarding the use of PMCT to detect pneumothorax.Conceptualization: Jianhua Zhang.Data curation: Lei Wan, Min Zhang.Investigation: Ningguo Liu.Project administration: Yijiu Chen.Writing – original draft: Junqi Jian, Yu Shao.


Echinococcus granulosus, it most commonly affects the liver but every organ could be affected, musculoskeletal system involvement occurs in 0.5–4% of patients. Most patients present as soft tissue mass in the affected muscle.Hydatid disease is a zoonotic disease that is transmitted to the human by ingesting the eggs of the parasite Preoperative diagnosis usually done radiologically by ultrasound or MRI examination.We present a 60-year-old lady presented with painless mass in the right calf for 2 years.The mass was soft, non-tender, mobile from side to side. Ultrasound of the mass showed cystic lesion that contained multiple small cysts inside, and the diagnosis of hydatid disease was made before surgery.During surgery and after opening the mass the lesion appeared to be hydatid cyst containing innumerable daughter cysts. Complete evacuation of the all the daughter cysts done. The patient discharged next day with no postoperative complications.The patient received postoperative albendazole therapy for 2 months and follow up done 6 months after surgery with no complications.Hydatid disease should be thought when patients present with mass lesion in any part of the body especially in endemic areas. The most important step in the diagnosis is to exclude the presence of other cysts in other parts of the body. Involvement of the musculoskeletal system is very rare comprising about 0.5–4% [Hydatid disease is a zoonotic disease that is transmitted to the human by ingesting the eggs of the parasite t 0.5–4% .Hydatid cyst affecting the muscles present as soft tissue mass in the affected muscle, the mass may resemble a soft tissue tumor ,4.Preoperative diagnosis is very important and it is usually done radiologically by ultrasound, which may be the preferred diagnostic tool in some cases, or MRI examination which shows the characteristic radiological appearance of the cyst ,6.The radiological appearance of the disease varies from cystic lesion containing clear fluid, there may be rim calcifications of the edges, multi-cystic appearance, or calcified cyst ,8.The work in this article has been reported in line with the SCARE criteria .1.1We present a 60-year-old lady presented to the surgical consultation room complaining from painless mass in the right calf for the last 2 years.The mass accidentally discovered 2 years before presentation which was diagnosed that time clinically as lipoma, the patient didn’t receive any treatment at that time.In the last few months the mass increased gradually in size and the patient was aware about this change in the size.The patient has hypertension for 10 years controlled with antihypertensive drugs, the past surgical history of the patient included history of laparoscopic cholecystectomy before 10 years and hysterectomy for large uterine fibroid before 5 years. The patient didn’t receive anthelminthic medication before surgery.1.2During examination there was a 10 cm by 7 cm soft mass in the posterior aspect of the right calf region. The mass was soft, non-tender, mobile from side to side.1.3Ultrasound of the mass showed cystic lesion that contained multiple small cysts inside, and the diagnosis of hydatid disease was made before surgery. Chest X-ray was taken before surgery and pulmonary involvement was excluded. Abdominal ultrasound was done and showed no involvement of the intra-abdominal organs.1.4During surgery cyst opened and was containing innumerable daughter cysts , Fig. 2.Complete evacuation of the all the daughter cysts done, and the cavity of the cyst washed by chlorhexidine solution .Fig. 3In1.5The patient discharged next day with no postoperative complications. The patient received postoperative albendazole therapy for 2 months. Follow up ultrasounds done on 2 occasions after surgery, 3 months apart with normal ultrasound examination. The patient advised for medical consultation if any kind of symptoms developed.2Hydatid disease is endemic in certain parts of the world like certain parts of the middle east, some parts of India, south America, Australia, New Zealand .The presentation of hydatid disease depends of the organ involved, Hydatid cyst of the musculoskeletal system presents as mass lesion, however it is very important to exclude other organ involvement particularly the lungs and the liver before any operative intervention as primary involvement of the musculoskeletal system is very rare .Affection of the muscle is rare due to the high contents of lactic acid in the muscle which is not a suitable environment for parasite growth which needs high level of oxygen for its growth .Clinical examination usually shows a painless soft tissue mass of the affected muscle, there may be elevated eosinophil count in the blood film and the serological test is positive in the majority of patients with active disease .Many cases of hydatid cyst of the muscles have been reported worldwide. The treatment modalities depend on the anatomical site of the cyst and its relation to the major anatomical structures, the number, and the experience of the surgeon, this may include complete excision of the cyst without destroying the cyst wall. When the anatomical site of the cyst is difficult or in case of recurrent cyst, it can be managed using the PAIR method which is the abbreviation of the following, P: puncturing the cyst, A: aspiration of the fluid contents, I: injection of scolicidal agents such as hypertonic saline, chlorhexidine solution, povidone iodine solution, ethanol or formaldehyde solution in low concertation, the last 2 solution are not used in other locations like the liver because of the risk of biliary destruction an cirrhosis, and the R: re-aspiration of the fluid contents after the injection. In cases of recurrent cysts when complete excision is not possible, excision of the cyst alone may be the best option of treatment .Postoperative albendazole therapy was given for six weeks in the intend of decreasing recurrence. The anthelminthic medications are recommended by most of the authors after surgery in the intent of reducing the recurrence rates, the duration of medical therapy is variable but in most of the trials it ranges between 2–3 months. Long term follow up is required to exclude recurrence and to exclude other organ involvement ,8.The author has no conflicts of interest to declare.None.Ethical approval has been exempted by my institution for reporting this case.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Dr Ayad Ahmad Mohammed and Dr Sardar Hassan Arif. contributed to the concept of reporting the case and the patient data recording.Dr Sardar Hassan Arif and Dr Ayad Ahmad Mohammed are the surgeons who performed the surgery.Drafting the work, design, and revision done by Dr Ayad Ahmad Mohammed.Dr Ayad Ahmad Mohammed took the consent from the patient for publishing the case.Final approval of the work to be published was done by Dr Ayad Ahmad and Dr Sardar Hassan Arif.This work is case report and there is no need of registration.Dr Ayad Ahmad Mohammed is guarantor for the work.The patient was worried about the possibility of other cysts in other parts of the body but after clinical and imaging evaluation, we excluded this possibility. The surgery done with no complications and the patients informed for regular medical follow up.Not commissioned, externally peer-reviewed.


A 56-year-old female, known with a meningioma and history of histologically confirmed cerebellar hemangioblastoma, was referred to our department with complaints of equilibrium disturbances, stomach aches, nausea and vomiting. Brain MRI evaluation was performed and showed a status after surgical excision of the hemangioblastoma in addition to a known meningioma. Besides these expected findings, multiple foci of contrast-enhancing, nodular leptomeningeal thickening were present, dispersed through the posterior fossa and around the brain stem. Meningeal thickening was also prominently present in the internal auditory canal on the left. Axial postgadolinium T1-weighted image shows pathologic enhancement in the posterior fossa at the level of the pontocerebellar cistern and internal auditory canal on the left, expanding in the prepontine cistern and the internal auditory meatus Fig. .The lesion in the left pontocerebellar region was resected and pathologic report confirmed the diagnosis of hemangioblastomatosis. The patient was discharged with persistent left hearing impairment. Genetic testing for Von Hippel Lindau was requested, as no other associated lesions were clinically present.Haemangioblastomatosis is an exceptional, hypervascular, meningeal neoplasm of the central nervous system. This benign tumoral entity, which consists of multifocal, recurrent haemangioblastomas, usually involves the brain and spinal cord. The disease can be associated with Von Hippel-Lindau (VHL) syndrome (38%) but more often, it occurs sporadically (62%) . Up to 9Other known localizations of haemangioblastomas are the retina, brain stem and spinal cord. Supratentorial localisation is more common in VHL setting, besides the classically associated pheochromocytoma, renal cell carcinoma or cystic lesions of the pancreas or kidney. Spinal hemangioblastomas are mainly found posterior to the cord. They appear as well defined, contrast enhancing lesions, layering the leptomeninges.Haemangioblastomatosis, or scattered haemangioblastomas, is very rare. Presence of VHL-like pathology, and additional genetic and histopathologic confirmation, can facilitate the differential diagnosis with metastasis, pilocytic astrocytoma or schwannomas. Adequate measures should be considered during interventions to minimalize CSF spillage, as outcome after recurrence is usually poor.The authors declare that they have no competing interests.


Pagetic vertebral ankylosis is an uncommon presentation and occurs when Paget's disease is associated with diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis. In these cases, the pagetic trait extends from one vertebra to another by invasion of the intervertebral disc space. Such acquired vertebral ankylosis is extremely uncommon but possible when bony bridging syndesmophytes or osteophytes are present. We describe one such case, where a delayed diagnosis resulted in the most extensive pagetic vertebral ankylosis described in the literature and severe patient morbidity. First described in 1876 by James Paget,2 The classic radiological features of PD of the spine include generalized vertebral enlargement with marginal sclerosis, resulting in a “picture frame pattern,” as well as disruption of the normal trabecular architecture and increased density of the neural arch (ivory vertebra).The spine is a common site of development of PD, and vertebral involvement will be present in at least 50% of patients with polyostotic disease.4PD usually starts as a solitary focus within the bone and may spread until the entire bone is affected but does not typically progress to adjacent bones. The soft tissues act as natural barriers to the spread of PD, but when the vertebrae are bridged by syndesmophytes or osteophytes, the disease process can extend to involve the contiguous segments. Pagetic vertebral ankylosis (PVA) is an uncommon presentation and occurs when PD is associated with diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS).A 73-year-old male was referred to the spinal team with a presentation of becoming “off legs” with progressive difficulty in walking. He had a prior history of vertebral PD, diagnosed 11 years ago, but had reported no symptoms of back pain in the interim.In the recent months, he had started developing paraesthesia in both lower limbs, with progressive leg weakness and difficulty walking.There was no bowel or bladder involvement. His past medical history included chronic kidney disease, Type II diabetes mellitus and vitamin D deficiency. He was also noted to be human leukocyte antigen B27 positive.Clinical examination revealed a rigid thoracic kyphosis and spastic paraparesis. Lower limb power was globally reduced to Medical Research Council grade 4/5. Altered sensation to fine touch was demonstrated below the level of T7.Subsequent investigations included whole-spine MRI and CT. This demonstrated the features of AS with multilevel syndesmophytes and interspinous ligament calcification. There was cortical thickening, sclerosis and vertebral squaring of T10, consistent with the known history of PD. However, in addition, there was contiguous spread of the pagetic changes across the diffusely ankylosed thoracic segments . The comAn MRI confirmed the extent of canal stenosis and cord compromise, with intramedullary T2 hyperintensity extending from the cervicothoracic junction to T11 . There wFollowing discussion at our regional spinal multidisciplinary team, it was decided that surgical decompression would likely result in poor outcome, given the extent and severity of the disease. Multiple infusions of zoledronate were administered, in addition to three courses of calcitonin, in an attempt to delay the progression of the disease. Despite this medical therapy, the patient continued to suffer from progressive myelopathy.5 The condition is characterized by excessive abnormal bone remodelling. There are three stages classically described as part of a continuous spectrum. The lytic (incipient active) stage is predominated by osteoclastic activity, the mixed active stage is characterized by osteoblastic as well as osteoclastic activity and is followed by the sclerotic/blastic stage (late inactive phase).PD, also known as osteitis deformans, is a chronic bone disorder that is common in Western populations, with a prevalence of 5% over the age of 50 years.6PD affecting the spine may lead to cord or nerve root compression through a combination of factors. Myelopathy may be the result of direct compression by abnormal bone growth, ossification of epidural fat and/or sarcomatous change. There may also be ischaemic myelopathy that is related to the local increase in bone turnover, vascular steal phenomenon or compression of a nutrient artery.7 In cases of severe compressive myelopathy, decompression and stabilization are favoured.In cases of myelopathy due to PD, there is a role for both surgical and medical management. Both calcitonin and bisphosphonates have been used successfully for reversing myelopathic symptoms, presumably by reducing bone turnover.8 This usually presents with pain; however, it may be asymptomatic. In a study by Lander et al,8 67% of patients with disc involvement presented with pain; however, 22% were asymptomatic. They also report that PD transgressing the intervertebral disc occurs more often in the lumbar spine than in the thoracic and cervical spine. Aggressive pagetic invasion at the discovertebral junction may lead to pagetic tissue replacement of the cartilage endplate and subsequently of the intervertebral disc.8 It can then invade the adjoining vertebra across the disc space. This can also occur by direct extension of PD along large pre-existing bridging osteophytes or syndesmophytes9 as in this case.PD can involve the intervertebral disc, resulting in disc degeneration and transductal extension. The incidence of direct intradiscal transgression is about 10.7% and more commonly affects the lumbar spine than the cervical or thoracic segments.10 in 1932, having an incidence rate of 4.4%.8 PVA is more common in males and affects the thoracic spine in over 50% of cases.4Intervertebral disc involvement can eventually lead to PVA, an uncommon phenomenon first described by Schmorl4 found an incidence of 4.4% of PVA due to the coexistence of PD and DISH.4 In these cases, a maximum of three ankylosed levels were observed. To the best of our knowledge, no case of PVA involving more than three contiguous vertebra has been described.In a cohort of 245 patients, Marcelli et alAS  is a seronegative spondyloarthropathy, which results in fusion (ankylosis) of the spine and sacroiliac joints, although involvement is also seen in large and small joints. In our case, the patient had classical radiographic features of AS with bridging syndesmophytes acting as a path of transmission of the pagetic process into the adjacent bone.15 however, this is the most extensive case of pagetic vertebral pan-ankylosis described in the literature, with consequent long segment cord compromise. The extent of spinal fusion and deformity, in this case, made surgical intervention impossible. While medical management may reduce bone turnover and vascular demands of the pagetic process, thus reducing the vascular steal phenomenon, it was inadequate to halt the progression of symptoms in this patient. Our case highlights the need for early diagnosis and treatment of pagetic vertebral pan-ankylosis before disease progression limits management options.Coexisting PD and AS have been previously reported;PD with coexisting AS is an uncommon association in which the bridging syndesmophytes provide a path for extension of pagetic bony changes throughout the vertebral column. Pagetic vertebral pan-ankylosis may result in long segment spinal compromise and a poor patient outcome. This should therefore be considered in patients presenting with progressive spinal deformity and rigidity. If there is clinical or radiological suspicion of PD in association with conditions that may result in vertebral body fusion, including AS, DISH or advanced osteoarthritis, prompt investigation, monitoring and early treatment of the underlying PD is advocated.PD with coexisting AS is an uncommon association.In such cases, bridging syndesmophytes may provide a path for extension of the pagetic bony changes.Pagetic vertebral pan-ankylosis may result in long segment spinal compromise and a poor patient outcome.This differential must be considered in patients with known AS presenting with progressive spinal deformity and rigidity, as prompt investigation, monitoring and early treatment of the underlying PD may improve patient outcome.Informed consent has been obtained and is held on record.


Pneumocephalus is a rare presentation of sinusitis. The purpose of this case series and literature review is to highlight the critical importance of recognizing pneumocephalus on initial brain imaging, since it may serve as the first sign of acute sinusitis with intracranial complication. Although sinusitis is a treatable condition with appropriate and timely antibiotic therapy, failure to recognize intracranial extension and delays to prompt surgical drainage could lead to a dire clinical course. The purpose of this paper is to review the current imaging literature to characterize the clinical symptoms, neuroanatomical considerations, inciting pathogens, and clinical course of patients presenting with pneumocephalus in the setting of sinusitis. We reviewed the literature by searching MEDLINE through the United States National Library of Medicine’s PubMed online database, using the keywords: Pneumocephalus, sinusitis, meningitis, and infection. Relevant case reports, reviews, and their references were also examined for further sources. For each, we documented the clinical presentation, location of the sinusitis and pneumocephalus, whether imaging identified an osseous defect, and the subsequent clinical course. We further present in detail two additional cases of patients with bacterial sinusitis presenting with pneumocephalus. These cases and the accompanying review aim to highlight the critical importance of recognizing pneumocephalus as a rare presentation of sinusitis, since it may serve as the first sign of an intracranial complication. Although bacterial sinusitis is a treatable condition with appropriate and timely antibiotic therapy, failure to recognize intracranial extension and delays to prompt surgical drainage could lead to a dire clinical course.Pneumocephalus refers to the presence of air within the intracranial compartment, which occurs typically from trauma or surgery. Pneumocephalus is rare in the setting of infection without a breach in the calvarium, accounting for only 1% of cases in a historic case series,A 62-year-old woman presented with headache, nasal congestion, and vertigo. She presented to her primary care physician and was treated with antibiotics for presumed sinusitis. After days of having no improvement in her condition, she presented to the emergency department, where she was found to be mildly confused and agitated, not answering questions appropriately.A non-contrast computerized tomography (CT) scan of the head  showed cA magnetic resonance imaging (MRI) scan of the brain was then performed  which deUrgent surgical debridement was performed, with drainage of purulent material from the left sphenoid sinus. The previously reported mucocele in the left posterior ethmoid sinus was found to be a mucopyocele intraoperatively. The patient recovered well after a subsequent course of intravenous antibiotics.A 9-year-old boy presented with a 1-week history of frontal headaches, with intermittent cough and rhinorrhea. Medical history was unremarkable, including a normal birth history and developmental milestones. On the day of admission, he was found to have a fever of 104°F (40°C), and the family reported a possible seizure.Non-contrast CT of the head demonstrated opacification of the ethmoid and frontal sinuses. The remainder of the head CT was reported to be normal. The patient demonstrated no clinical improvement and was transferred to our institution for further management. Neuroradiological consultation identified a small focus of pneumocephalus in the right frontal extra-axial space, which was initially overlooked . Thin-slMRI of the brain was then performed and demonstrated a right frontal epidural fluid collection, most compatible with an epidural abscess . LeptomeStaphylococcus aureus and Escherichia coli. The patient was discharged home with intravenous antibiotics.Lumbar punctures revealed CSF with slightly elevated white blood cell count  with neutrophilic predominance (91%) indicating bacterial meningitis. The patient underwent emergent functional endoscopic sinus surgery and supraorbital craniotomy for epidural abscess drainage and debridement. The culture of the abscess grew coagulase-negative  On the other hand, infection is a rare cause of pneumocephalus and is typically otogenic when it occurs.Pneumocephalus as a presenting symptom of sinusitis is rare. In a historical review of 295 cases of pneumocephalus, before the widespread use of cross-sectional imaging, trauma was reported as the most common cause, accounting for 75% of cases. While uncomplicated sinusitis may be symptomatically managed or treated by oral antibiotics, surgical debridement must be initiated promptly when there is an intracranial extension. Missing subtle early signs of the intracranial extension, as in Case 2, could delay proper management and severe neurological damage may occur.Although sinusitis is often considered a common and benign entity due to the widespread and early use of antibiotics, there is still a reported 4% incidence of intracranial complication.-10 Two cases were reported before the era of antibiotics and imaging.,4 In both cases, chronic CSF rhinorrhea suggested significant osseous erosion by the time of presentation, and both patients died from their intracranial complications. Of the more recent 6 cases, the only two patients who died had fungal sinusitis as the inciting process.,6 Half of the cases reported a visible osseous defect on CT imaging.-8 However, as seen with our 2 cases, neither osseous erosion nor fungal infection is necessary for the development of pneumocephalus and intracranial extension. Several patients previously reported also had significant neurological deficits or meningeal signs that raised the clinical suspicion for an intracranial extension,,8,9 whereas our two patients reported only mild symptoms of headache and fever and had no concerning clinical signs on initial examination. As a result, the pneumocephalus on non-contrast CT of the head was the only indication of a potentially worrisome clinical course.In our review of the literature , we foun Coughing and sneezing could result in enough pressure to cause a “ball-valve” effect through small fistulae, introducing air, and pathogens into the intracranial compartment.In most cases, the location of the pneumocephalus corresponded to the diseased paranasal sinus in closest proximity. Our first patient was found to have pneumocephalus in the basilar cisterns, in close proximity to the patient’s sphenoid and posterior ethmoid sinusitis. The location of the pneumocephalus corresponded to purulent material associated with meningitis on subsequent MRI. Many have reported osseous defects in the skull base, which could precipitate the intracranial extension of a sinus infection. Although our patient did not have a detectable osseous defect on CT or during surgery, the lateral sphenoid region may harbor congenital fistulae that would predispose to an intracranial extension. Patients with frontal sinusitis may have subclinical presentations, which often lead to a delayed diagnosis. Complications such as subperiosteal abscess and osteomyelitis of the frontal calvarium are frequently identified weeks after the onset, when an abscess becomes more visible on CT or the patient reports severe clinical symptoms. In our case, the subtle focus of air on initial CT was the key to timely management.Small air collections can be difficult to identify. In our second case, the single focus of pneumocephalus in the right frontal epidural space was initially overlooked. On further review, the possibility of intracranial extension and epidural abscess formation from the frontal sinuses was considered. Besides well-established antibiotic treatment regimens, epidural abscess associated with frontal sinusitis is increasingly reported.We present these two cases and a literature review to highlight the importance of identifying pneumocephalus as the first sign of intracranial complication in the setting of bacterial sinusitis. Neither osseous erosion nor fungal infection is necessary to produce pneumocephalus, and, although rare, pneumocephalus may be the key to timely diagnosis and management of these patients.


Chordomas are malignant neoplasms derived from incomplete regression of notochordal tissue along the craniococcygeal axis.It is rare for Chordoma arising from the lumbar spine and the traditional long-term prognosis is typically poor.The persistent pain in the left side of the waist about 2 years.Chordoma.The patient was treated with surgical resection of the total tumor, followed by the spinal internal fixation of L1 to L2 with pedicle screws.After 5 month follow-up,we find the recurrence in the original lesion.At the 15 month follow-up,the patient was dead after a lot of times revisit by various doctor.So It is suggest that the diagnosis should be carried out accurately at the early stage, the lesions and source of lesions should be cut away as broadly as possible, also the radiation and chemotherapy should be carried out after the operation as necessary. The development of chordoma in men is more than in women (ratio 2: 1), and lesions typically arise in the sacrococcygeal area (29–57%), clivus area (27–35%), and vertebrae (10–33%). In the spinal columns, the tumor is located in the cervical spine (15–52%), lumbar spine (33–35%), and thoracic spine (14–17%). Histological examination described that these tumor cells often are separated by variable amounts of intercellular mucin and contain numerous intracytoplasmic vacuoles, accounting for 1% to 4% of all bone neoplasms.Chordoma is a rare, locally invasive, and slow-growing malignant tumor that occurs with an total incidence of less than 1 in 1,000,000 people.Here, we herein review the case of a 72-years-old patient with L1-2 vertebral huge chordoma who showed neurological symptoms because of tumor invasion into the neural foramen and canal, compressing the spinal cord and nerve root.2The patient was a 72-year-old man who was followed up for persistent pain in the left side of the waist for 2 years, radiating to the left hip. The history of schistosomiasis was 40 years, and with hypertension 1 year. On physical examination, he had pain on movement of the spine with bilateral Grade IV motor strength in both lower extremities. There was not numbness in both feet and ankles with normal ankle reflexes bilaterally. There was a normal knee reflex bilaterally. There was no obvious bulge in the bilateral kidney region, and the left lateral kidney region knocks out to be positive for pain. The neurological symptoms were ascribed to the compression of the spinal cord and nerve roots by an expanding mass partly protruding into the vertebral canal.Magnetic resonance imaging (MRI) was performed that the left side of the vertebral body and the left peritoneum showed an elliptical abnormal signal shadow, which showed a dumbbell growth. The MRI scan showed an area of increased signal intensity on T2-weighted images in the T12-L4 paravertebral region. At discovery, on the left side of the L1 vertebral body, there was a slightly longer T1/T2 signal, with a size of 8.6 × 8.4 × 12.4 cm . But in some studies, lumbar chordomas are more rare, accounting for approximately 6% in all spine chordomas. As seen in some reports, the patients diagnosed as chordoma were younger and younger, contrast to the age 60 years reported before.,24Chordoma is considered to be the tumor, which is derived from notochordal remnants.The clinical manifestations of paravertebral chordomas are mainly due to the compression of adjacent tissues caused by tumors, especially to the spinal cord and nerve roots, and even to the chest or abdominal organs. Low back pain is a common symptom of thoracolumbar spinal chordoma. Patients with saddle area chordoma are more prone to dizziness and other symptoms. The symptoms and imaging features of lumbar spine chordoma are not specific, and the pathological findings are required to establish the diagnosis. Therefore, it is easy to be confused with some rare tumors such as giant cell tumor and neurilemmoma before surgery. In this case, the patient's tumor crosses the intervertebral foramen. Therefore, the neurilemmoma are highly suspected before surgery.The case is reported in the position of L1, 2 segments, and as previously reported in literature, lumbar spinal cord tumors are very rare, what is more, we can observe that the volume of the chordoma is very huge, developing both directions to the posterior muscle and the left posterior peritoneal direction, the growth range from T12-L4, presenting a dumb-bell appearance and expanding through the enlarged intervertebral foramen. And bone destruction can be seen on left lateral transverse process of L2. On the basis of experience, the patient must have a very long tumor growth history. Because the preoperative diagnosis of chordomas is still challenging, delayed diagnosis occurs very frequently. CT and MRI are currently used in the diagnosis of chordomas. MRI signals of the mass are commonly isointense or hypointense on T1-weighted images and hyperintense on T2-weighted images. However, several other diagnoses including neurogenic tumors and lymphoma should also be considered. In our case, the initial diagnosis was a neurilemoma. Not just neurilemmoma, the patient's symptoms are also similar to the clinical manifestation of the lumbar disc herniation, so when the similar cases are appearing to us, we should have to give high vigilance in the chordoma, especially paying more attention on the imageological diagnosis and postoperative pathology.The rates of local recurrence and metastasis depend on the quality of the initial surgery, pathological features, and age of the patient. In the present case, gross total removal of the chordoma was achieved followed by the spinal internal fixation of L1 to L2 with pedicle screws. This resulted in successful spinal stabilization without neurological deficiency, and in the initial stage, the patient was able to obtain good performance in activities of daily living without lower and upper limb paralysis, that is, good functional prognosis. But after 5 months, the recurrence was found at the patient's back with a raised mass. And then the patient was dead at 15 months after the surgery. On the basis of available information, the lesions cannot be completely removed. In view of that requirement of the patient's neural function reserve in the early stage, extensive excision of the adjacent tissues, such as the intervertebral body, nerve root, etc, has not been carry out extensively, as the function of the patient can be restored, and the patient's old age is taken into account, thus the therapeutic means for subsequent radiation therapy is abandoned. So, it is suggested that the diagnosis should be carried out accurately at the early stage, the lesions and source of lesions should be cut away as broadly as possible, also the radiation and chemotherapy should be carried out after the operation as necessary. report that miR-155 expression will lead to the poor prognosis in the chordoma patients. This idea has been verified in their cell experiments. However, when the subject was changed to miR-1, Duan et al observed the opposite result. Zhang et al find that some miRNAs have a negative correlation with some molecules, such as miR-34a/MET and miR-608/EGFR in chordoma cells. Feng et al suggest that targeting PD-L1 may be a novel immunotherapeutic strategy for chordoma clinical trials. The findings of Hu et al,21 highlight that fibroblast growth factor receptor (FGFR)/ methyl ethyl ketone (MEK)/ extracellular signal regulated kinase (ERK)/brachyury pathway coordinately regulates chordoma cell growth and survival and may represent a novel chemotherapeutic target for chordoma. Jäger et al suggest that the differential expression of HOX genes in chordomas of the clivus and sacrum suggests an oncofetal mechanism in gene regulation linked to the anatomic site. In the study from Chen et al, human (hsa-) miR-185-5p was identified as a crucial miRNA in chordoma development via the Wnt signaling pathway. Wen et al indicate that Sam68 is an independent prognostic factor for the local recurrence-free survival of sacral chordomas . Thus, inhibition of certain molecules and their respective pathways could be a potential therapy for chordoma.More recent studies of chordomas have been based on molecular biology to increase the survival rate. Osaka et al4Chordomas are uncommon neoplasms that arise from the embryonic remnants of the notochord. It is very helpful for us to establish the diagnosis through CT and MRI, but histopathological examination still was the gold standard of accurate diagnosis on tumors, which can provide more useful characteristic indicators of chordoma. Surgical resection of the total mass remains the main method of treatment, and in many cases, postoperative adjuvant radiotherapy is also necessary. Nowadays, more and more molecular biological studies are being performed to explore the pathogenesis of chordoma, and therefore targeted therapy may be an option for related patients in the future. Furthermore, in order to change the status of the poor prognosis for chordomas, a postoperative follow-up protocol should be established and executed; more studies should be performed to fully expound the characteristic of chordoma.ZYB conceived and conducted the experiments and prepared the manuscript. HBL contributed to sort and analyze the data. WZW, CHX helped to perform the analysis with constructive discussions. ZB and DM contributed to the conception of the study and approved the final manuscript. All authors read and approved the final manuscript.Conceptualization: Bin Zhang, Min Dai.Data curation: Yibiao Zhou, Bolin Hu, Zhiwei Wu.Formal analysis: Yibiao Zhou, Bolin Hu, Bin Zhang.Funding acquisition: Yibiao Zhou, Min Dai.Investigation: Yibiao Zhou, Bolin Hu, Bin Zhang.Methodology: Bolin Hu, Zhiwei Wu, Hanxiong Cheng, Bin Zhang.Project administration: Hanxiong Cheng.Resources: Hanxiong Cheng.Software: Zhiwei Wu.Supervision: Hanxiong Cheng.Validation: Zhiwei Wu.Visualization: Hanxiong Cheng.Writing – original draft: Yibiao Zhou.Writing – review & editing: Bin Zhang, Min Dai.


Eccrine porocarcinoma (EPC) is an extremely rare, adnexal carcinoma that represents less than 0.01% of all cutaneous malignancies. An aggressive tumour with a high recurrence rate, it has a tendency to metastasise to regional lymph nodes. Once metastasis has occurred, mortality rate increases to 75%-80% and thus survival is dependent on adequate and timely resection of the lesion. EPCs are frequently missed as a differential diagnosis due to their rarity and non-specific appearance, which can lead to serious consequences for patients. Consequently, EPCs are an important diagnosis for clinicians to be aware of and consider when evaluating cutaneous lesions. We present a case of EPC of the knee, which was initially misdiagnosed as a benign lesion on magnetic resonance imaging (MRI). We discuss the use of MRI in aiding assessment of EPCs. Malignant cutaneous adnexal neoplasms are broadly divided into four groups of eccrine, apocrine, mixed, and un-classified tumours. Eccrine porocarcinoma (EPC), first described by Pinkus and Mehregan in 1963, is a rare type of adnexal carcinoma which accounts for less than 0.01% of all cutaneous malignancies  and thusA 78-year-old male was referred to the dermatology outpatient department with a 10-year history of a slow-growing, large and fluctuant mass on his right knee. There was no associated discharge, pain or history of trauma. Clinical examination revealed a 7.5 cm x 7.5 cm x 3.5 cm purple lesion over the infrapatellar region with healthy overlying skin Figure . On cons2. There was no evidence of vascular or perineural invasion. As the sample showed incomplete deep and peripheral margins, a wide local excision (WLE) with a larger 2 cm margin was undertaken. Histology of the re-excision sample showed clear histological margins with no residual tumour. A split-thickness skin graft was placed to expedite wound healing. The patient was regularly reviewed in the clinic until full wound healing was achieved and discharged to primary care with planned annual follow-up appointments for five years.Histopathological analysis showed a well-differentiated, partly cystic EPC. Depth was estimated to be 50 mm, Clarke level IV, stage pT3, with low mitotic activity at less than 14 per mmEPCs are rare malignant lesions most commonly affecting the lower extremities (35%), head and neck (24%), and upper extremities (14%). There is equal representation of gender and it is more commonly found in elderly patients (age range 42-90 years old) -7.Surgical resection of the lesion is curative in 70%-80% of the cases, with a 20% risk of local recurrence and 20% risk of metastases to the regional lymph nodes. Metastatic disease has a poor prognosis with relative mortality of 50%-80% and a 10-year overall survival rate of 9% only . It shouThe pathogenesis of EPC remains unclear. Previously reported cases have been characterised by loss of heterozygosity of the TP53 gene -9. WholeTraditionally, the pathogenesis of eccrine carcinomas was hypothesised to be due to the transformation of benign poromas to malignant porocarcinomas -6. This Diagnostic work up of large cutaneous lesions often involves the use of MRI scanning for evaluation. However, accurate differentiation between benign and malignant lesions is highly challenging, especially in soft tissue lesions, due to their non-specific appearance . In geneThe varied and non-specific presentation of adnexal tumours makes correct diagnosis based on clinical assessment and imaging difficult. To confirm the diagnosis, a tissue biopsy is required for examination of histological features. In such instances, a WLE biopsy would achieve adequate marginal resection and with clear margins, both diagnostic and curative in most cases. Therefore WLE, rather than punch or shave biopsy, should be the method of biopsy in most cases.EPCs are a rare but important cause of cutaneous neoplasm. Patients can present through various referral pathways and may be assessed by numerous specialties prior to a diagnosis being made. Therefore, it is important for all clinicians to recognise EPC as a potential differential diagnosis for cutaneous lesions in order to prevent delays in treatment that could significantly affect patient outcomes. Lastly, further imaging data would be necessary in order to identify definitive MRI features for EPC.


Angiofibroma is an uncommon type of vascular benign tumor that is made up of blood vessels and fibrous (connective) tissue. First described in 1997, it usually occurs in middle aged females and is clinically often thought to represent a cyst. Unlike most of the other site specific vulvovaginal mesenchymal lesions, cellular angiofibroma has a marked predilection for the vulva with only occasional examples reported in the vagina. A 17-year adolescent nulligravid girl presented with a history of irregular vaginal bleeding of two-year duration and history of lower abdominal swelling; on examination, she had pale conjunctiva, 20-week sized firm, irregular, nontender abdominopelvic mass, and a firm huge anterior vaginal wall mass, with difficulty to reach at the cervix and hemoglobin of 9.7 gm/dL, and a diagnosis of cervical myoma plus anemia was made, which was supported by imaging studies. Finally it was found to be angiofibroma of the vagina. Angiofibromas are benign tumors, which rarely occur in vagina. Although middle aged females are affected more, angiofibromas can affect females of reproductive age group and can cause abnormal uterine bleeding. Angiofibroma is an uncommon type of vascular benign tumor that is made up of blood vessels and fibrous (connective) tissue. The lesion first recorded by Chelins in 1847 and the name “angiofibroma” was given by Friedberg in 1940. Despite being benign the lesion can present as a local malignancy. Angiofibroma, first described by Nucci in 1997, usually occurs in middle aged females and is clinically often thought to represent a cyst. Since 1997 only few studies have been published in the literature, most of which consisted of single case reports or reviews [Juvenile angiofibroma (JNA) appears almost exclusively in adolescents between 14 and 25 years. In young female population angiofibroma is extremely rare and only about 15 similar cases were identified. According to literature and our own clinical experience the clinician must be aware of the possibility of the occurrence of angiofibroma in unusual sites in prepubertal age. Unlike most of the other site specific vulvovaginal mesenchymal lesions, cellular angiofibroma has a marked predilection for the vulva with only occasional examples reported in the vagina [The pathogenesis of angiofibroma is still unclear but there are several theories regarding the formation of angiofibroma; the most widely accepted is the angiogenic and the histogenetic theory. Few studies have examined the sex hormones (estrogen and progesterone), genetic, and an increased intracellular reactive oxygen species has been proposed .A 17-year-old adolescent nulligravid girl whose last menstrual period was four days back referred with the diagnosis of low lying myoma after being transfused with four units of blood. She presented to the Gynecology Outpatient Department on 22 July 2018, with history of irregular vaginal bleeding of 2-year duration.She gives history of lower abdominal swelling which was small initially and progressively enlarged to attain the current size for the last 13 months. She is sexually active but not married. She has no history of abdominal pain, urinary, or bowel complaint, has no bleeding from other sites, and has no significant past medical and surgical history noted.On examination, patient was conscious, coherent with blood pressure of 100/60 mmHg, pulse 80 /min, and temperature normal and has pale conjunctiva, cardiovascular, and respiratory systems normal. Abdominal examination revealed 20-week sized nontender, firm, irregular, fixed, and lower border unreachable mass. On vaginal examination, a firm huge nontender growth attached to the anterior vaginal wall. It was difficult to reach at the cervix. A clinical diagnosis of cervical myoma was made.Her blood investigations on arrival showed hemoglobin of 9.7 gm/dL and were transfused one unite blood and the hemoglobin elevated to 10.7 gm/dL. Ultrasonography showed empty uterus with normal size echotexture and pushed up in to the abdomen. There is 10 by 12 cm hypoechoic mass arising from the cervix filling the vaginal canal with these the diagnosis of cervical myoma was made. The diagnosis necessitated Computed Tomography (CT) scan of the abdomen and pelvis which helped to know the extent of the mass and reported hypodense contrast enhancing mass seen on the uterus arising from the cervical region measures about 10.3 cm by 14.4 cm. The mass grows down in to the vagina and concluded with the diagnosis of contrast enhancing cervical mass likely myoma .Understanding the complexity of her surgery and possible postoperative morbidity and mortality, surgical, anesthesiology, nursing, and recovery room teams was assembled with gynecologic oncology team. She was prepared for elective laparotomy the day before the surgery. On 18 August 2018, the patient was taken to operating room, after the general anesthesia given; she was positioned in a supine position. The abdomen cleaned with povidone iodine and draped with sterile towels and midline vertical incision was made. Intraoperatively, bilateral fallopian tubes and ovaries, the uterus, and urinary bladder grossly look normal; there is 10 cm by 15 cm sized firm mass between the vagina and the lower uterine segment . VesicouThe excised mass was sent for histopathological examination; the patient recovered completely and discharged on 6th postoperative day. The final pathological diagnosis of the mass was vaginal angiofibroma .Angiofibroma is a small, well-circumscribed, mostly asymptomatic, typically slow growing, and benign stromal tumor and most often found in the distal genital region. It occurs in both the genders with equal predilection; in women, it is mostly observed in the fifth decade (average age: 46.1 years). In one study 79 affected women have an age at presentation ranging from 20 to 77 years with mean age being 46.1 years [The most common anatomic site is the vulvovaginal region; in particular labium major area and vulva overall and vaginal involvements have rarely been reported . In thisAngiofibromas usually grow insidiously and reach a huge size before they are detected. Their largest size has ranged from 3.8 cm to 25 cm . In thisA macroscopic/microscopic description was reported in most of angiofibroma. Grossly is described as white or yellowish nodules, mostly firm and partly gelatinous of cystic in appearance, with a cut surface of white tan to grayish in color . In thisMicroscopically, angiofibroma is a cellular neoplasm, composed of bland spindle shaped cells, proliferating in an edematous to fibrous stroma, containing wispy collagen bundles, numerous small to medium-sized thick-walled, most of the time hyalinized, vessels, and a small component of adipose tissue . In thisIn most of the analyzed cases, treatments with surgical approach consist of a simple local excision or a “shelling out” seems to be adequate . In thisAngiofibroma in women represents a distinct benign neoplasm with a broad anatomic distribution even if it is mainly localized in the vulvovaginal area. This lesion may exhibit some variations in its phenotypic features. Treatment of simple local excision or a “shelling out” of the lesion appears to be adequate and effective to avoid anemia from abnormal vaginal bleeding, recurrences, and injuries to surrounding tissues.


Castleman’s disease is a rare entity and is a benign hyperplastic enlargement of lymph nodes. It can occur anywhere within the body but only approximately 50 cases of mesenteric Castleman’s disease have been reported within the literature.We report a female patient who was thought to have developed a neuroendocrine tumour within the small bowel and a large nodal mass within the mesentery based on nuclear scintigraphy imaging. Following surgical resection the nodal mass found confirmed to be Castleman’s disease.Although rare complete resection of mesenteric Castleman’s disease offer excellent long term outcome although the diagnosis may only be made after surgery.The diagnosis of mesenteric Castleman’s disease is often made post-operatively but complete surgical resection offers excellent long-term survival. CD can classified into three distinct histopathological types; namely hyaline-vascular type, plasma cell type and mixed type comprising the former two types ,2. Unice2The case is reported as per SCARE recommendations . We repo3CD was described for the first time in 1954 by Benjamin Castleman and is a benign hyperplastic enlargement of lymph nodes ,7 and isThe aetiology of CD is unknown but chronic low-grade inflammation, immunodeficiency status and autoimmunity have been proposed as putative mechanisms. There appears to be a critical role for inflammatory mediators such as interleukin 6 as demonstrated in preclinical animal models . DysreguAlthough UCD is a not a malignant condition, different malignancies and other diseases are associated with it . CD can Unicentric disease frequently affects the abdomen-pelvis in only 10% of patients. The location of the disease in mesentery is rare and usually associated with multicentric form unlike the reported case. In a recent case report and literature review , only 53The radiological findings for UCD are non-specific it is often confused with other lesions such as GIST. Homogeneity with intense contrast enhancement reflecting hypervascularity of the lesion is a characteristic finding at CT of abdominal UCD. Mesenteric UCD commonly appears at CT as a well-defined single mass of soft tissue without satellite nodules or surrounded by normal lymphadenopathy ,21. UCD The standard treatment for UCD regardless of histological type is a complete “en bloc” surgical resection, which is a curative approach in almost all cases . When to4The diagnosis of mesenteric Castleman’s disease is often made post-operatively but complete surgical resection offers excellent long-term survival.Not applicable.For this study ethical approval is exempted by my institution  and therefore is not applicable.The patient has consented to publishing case report.RHB – literature review, writing manuscript and editing.AW – histological analysis.AZK – writing the manuscript and critical review.Not applicable.Ricky H. Bhogal.Not commissioned, externally peer-reviewed.The authors have no conflict of interests to declare.


Congenital granular cell tumors are infrequently occurring masses occurring on a neonate's gingiva/alveolus. These lesions are benign with no noted malignant transformation, and treatment of excision is based on its effect on the neonate's respiratory ability and/or nutritional intake. The purpose of this review is to discuss a case of a congenital granular cell tumor and its treatment and review of the literature including demographics, histopathology, and operative treatment. Originally described by German pathologist, Ernst Christian Neumann in 1871 .The patient is an African-American female born at 37 weeks six days gestation to a 19-year-old mother. She was noted to have a 1.5 cm pedunculated soft tissue mass with adjacent secondary 8 mm mass on the oral mucosa along the mandibular alveolar ridge .Due to difficulty with breast-feeding, decision was made for operative excision on the third day of life. In the operating room, she received general anesthesia with oral endotracheal intubation .Local anesthetic of 0.6 cc 0.5% lidocaine with 1 : 200,000 epinephrine was administered at the base of the masses. Excision was performed sharply with scalpel and hemostasis with bipolar electrocautery. Complete closure of the defect was not possible, but was reapproximated to near closure with 5-0 chromic sutures in simple interrupted fashion in a crosshatched pattern .She was allowed to return to breast and formula oral intake postoperatively on the same day. She was monitored for two days and then discharged home. Follow-up after three weeks revealed well-healed mucosa at the surgical site with minimal notching on the alveolar ridge and no evidence of recurrence .Microscopic pathology confirmed squamous mucosa with underlying large polyhedral cells containing granular acidophilic cytoplasm as well as small hyperchromatic nuclei, staining negative for S-100 immunohistochemistry, with extension to the excisional base of the lesion. Centrally dilated blood vessels were seen with mild nonspecific chronic inflammatory changes as well as prominent nucleoli in some cells. No dysplasia or malignancy was noted centrally or peripherally. All microscopic findings appear consistent with that of CGCT.Due to the infrequency of CGCT occurrence, it has mostly been noted in the literature via case reports and literature reviews. Two of the larger works include that of Dash et al. including fifty patient reviews and Lack et al. including 21 patient reviews noting multiple commonalities. There is a tendency for CGCT to develop on the alveolar ridge, particularly that of the maxilla with a threefold predilection over that of the mandible, particularly in the area of canine and lateral incisors, theorized to be secondary to common local occurrences of supernumerary teeth. CGCT presents as a solitary lesion 90% of cases. A female predisposition accounts for eightfold increased incidence above that of males, with no currently known reason, as CGCT has not been found to contain estrogen nor progesterone hormonal receptors , 4. TherGrossly, CGCT appears well developed in the newborn as a variably sized soft tissue mass, with a tan, pink, or red coloration, and an irregular, lobulated, and/or smooth surface, typically arising from the alveolar ridge , 6, 7. M2 laser by Lapid et al., the wound was not closed, allowed to heal by secondary intention, with gingiva reepithelialization noted at ten-day follow-up. There was no discussion as to long-term follow-up, particularly in regard to subsequent dental development [Generalized treatment of CGCT remains debated, unless the newborn patient has respiratory compromise or nutritional intake impairment secondary to the mass causing oral obstruction. If the lesion is small without obstructive signs/symptoms, some propose a conservative approach, demonstrated by Jenkins and Hill in their patient with a 1.5 cm mass, regressing to 3 mm at 12 month follow-up. With obstructive issues, general consensus is simple excision . Others elopment . Narasimelopment . Regardlelopment , 8, 9.


Gastrocolic fistulae have been described for benign conditions including penetrating peptic ulcer and complicated pancreatitis. Malignant etiology can arise from gastric or colon cancer and is a rare and late complication with an incidence of 0.3-0.4%. Usual presentation is the classic triad of weight loss, diarrhea, and feculent vomiting. Barium enema has been shown to have the highest diagnostic accuracy but endoscopy offers additional advantage of biopsy to aid in diagnosis of malignant etiology; the role of computed tomography (CT) scan is controversial. Treatment by one-stage en bloc surgical approach is the current acceptable standard of care with variable recurrence and survival rates. Adjuvant chemotherapy would be based on lymph node involvement and patient discussion. Gastrocolic fistula, an abnormal communication between the colon and stomach, is known in literature. Etiology varies and can be of both malignant and benign causes; they have been reported to be secondary to gastric tumors, gastric ulcers, and complication of pancreatitis –3. HistoAn 85-year-old woman presented to our emergency room (ER) with severe epigastric pain for one day. Pain was associated with nausea and coffee ground vomiting with feculent odor. Prior to this admission she had nonspecific abdominal discomfort with dark stools for one week and objective weight loss of 37 pounds since her last visit to the ER three years earlier. Her medical history included hypertension, diabetes mellitus, and osteoporosis. In the ER, her vitals were within normal limits, and physical examination was unremarkable except for mild abdominal tenderness and palpable prominence in the left upper quadrant. Her laboratory investigations revealed hemoglobin of 9.3g/dl, mean corpuscular volume of 76fl, white blood cell count of 9.5 k/ul, platelet count of 529 k/ul, BUN of 63 mg/dl, and creatinine of 2.1 mg/dl.Computed tomography (CT) scan of the abdomen without contrast done in the emergency room showed gastric wall thickening with possible gastric mass. She was admitted to the medical service and had an upper endoscopy showing a large cratered gastric ulcer in the greater curvature of the body with excessive amount of feculent material see  which raGastrocolic fistula secondary to colon cancer is very rare; this may be attributed to prevention and early diagnosis of colon cancer with screening and surveillance colonoscopy . GeograpOur patient did not have the typical triad of diarrhea, weight loss, and feculent vomiting that characterizes gastrocolic fistula . She preVarious modalities exist for diagnosis of gastrocolic fistula, with a sensitivity of 90%; barium enema has been described as the most accurate investigative method for diagnosis . EndoscoTreatment modalities would depend on the staging of the primary malignancy, patient's ability to withstand surgery, and the presence of metastatic spread. Surgery remains an option for patients that are good surgical candidates and has changed over time. In the 1940s, patients had two- and three-stage surgeries but this has since evolved to the current one-stage en bloc resection . When coInvasive adenocarcinoma of the distal transverse colon due to its close proximity to the greater curvature of the stomach rarely can present with a gastrocolic fistula. Diagnosis can be made with imaging studies like barium enema or CT scan, with barium enema being the preferred approach. Endoscopic studies allow for direct visualization and opportunity to obtain biopsies. Treatment approach is usually en bloc surgical resection with favorable outcomes and variable recurrence and survival rates. Decision regarding chemotherapy should be individualized with lymph node involvement playing a crucial role.


Stercoral sigmoid perforation is a dangerous surgical emergency. It is also a life-threatening situation because the spillage of fecal contents into the abdominal cavity leads to sepsis with many postoperative complications. Chronic, intermittent constipation can lead to fecal impaction, especially in older patients.An 80-year-old male patient presented with intestinal abdominal pain and distention for three days. His chest X-ray showed air under the diaphragm. On laparotomy, a small rent was discovered in the rectosigmoid junction with fecal contamination. The presence of a fecaloma is the speculated reason for the perforation. Primary closure of the defect with a diverting transverse colostomy was performed, and subsequently, the patient recovered well. A colostomy closure was performed six weeks after the primary surgery.It is imperative to understand the incidence of stercoral perforation in a normal bowel. Early treatment and intervention are the important aspects of stercoral pathology. We report a rare case of stercoral sigmoid colonic perforation with fecal peritonitis. Fecal impaction is one of the common causes of subacute intestinal obstruction in elderly patients . It is mStercoral perforation is due to the hard impacted stool which affects the normal defecation process. Any delay in diagnosis and treatment could result in catastrophic consequences. The hard fecal mass may compress the ureter causing hydronephrosis or the vascular structures, resulting in limb ischemia . TherefoPerforation followed by fecal contamination in peritoneal cavity leads to sepsis. Diverticular anomalies and malignancies are the common causes for stercoral peritonitis. Sepsis due to fecal contamination has a high morbidity and mortality rate. Perforation preceded by an ischemic colonic wall usually occurs due to high colonic pressure. Sometimes these conditions activate inflammatory sequences which lead to stercoral colitis . The mosAn 80-year-old male patient was admitted to the emergency ward with the complaints of abdominal distention, vomiting, and constipation for three days. On examination, the patient was dehydrated with stable vital signs. The abdomen was distended with generalised guarding and rigidity. The bowel sounds were not heard. On rectal examination, rectum was empty with minimal fecal staining and no palpable mass lesion. After initial resuscitation, imaging studies, including an ultrasound of the abdomen, were done. Chest X-ray showed air under the diaphragm Figure .2 rent in the rectosigmoid junction  which leads to stercoral perforation. Instead of pressure necrosis, ischemic necrosis also plays a role in ischemic colitis. The most common site of stercoral perforation is the rectosigmoid junction . PerforaOld age, frequent intake of NSAIDS , and intermittent constipation are common risk factors for stercoral pathology . StercorStercoral pathology should be suspected in elderly patients with altered bowel habits, especially chronic constipation. Stercoral perforation is a diagnosis of exclusion, and its diagnosis should be ruled out when another bowel pathology coexists. Chronic constipation may be due to drug-induced or neurological problems. More often, laboratory parameters may not diagnose the underlying pathology. Abdominal x-rays are rarely useful to diagnose fecaloma. A CT scan is the ideal investigation for suspected stercoral pathology. An adequate knowledge about stercoral pathology can significantly reduce the mortality rate (35%) . Since iIn elderly patients with a chronic history of severe constipation presenting with symptoms of acute intestinal obstruction, the possibility of stercoral perforation should be considered. A preoperative CT scan is the ideal investigation to diagnose stercoral pathology. Early diagnosis and early intervention can significantly reduce mortality due to fecal peritonitis.