Epignathus, is a rare oropharyngeal teratoma arising from the head and neck region. Sporadic cases have been described with associated intracerebral teratoma. Even more infrequent and extraordinary is the circumstance of a teratoma with oropharynx destruction. We describe the case of a fetus with pharyngeal mass that completely destroyed the oral cavity. The histological examination revealed an immature teratoma (G3); only one other G3 case has been described. The histological examination revealed an immature teratoma (G3); only one other G3 case has been described.Here we report the prenatal case of a 22- to 23-week GA fetus of a 30-year-old Italian, primigravid woman and her nonconsanguineous, healthy 31-year-old husband. There was no reported exposure to teratogenic agents. Serologic tests for cytomegalovirus, toxoplasmosis, and rubella gave negative results. The family and early gestational history were unremarkable.A morphological ultrasound scan, performed at GA 21 weeks and 3 days, showed a fetal malformation. A solid formation of 49 × 36 × 51 mm, moderately vascularized to the color Doppler extended from the lower part of the face to the upper part of the chest. The lower lip and mandibular bones, plus the esophagus and trachea were not recognizable. Posteriorly, the growth came into contact with the cervical spine. This formation presented the characteristics of a suspected malignant nature. The fetal and neonatal prognosis was very poor.The pediatric consultant surgeon spoke of an injury that could not be surgically managed and was incompatible with life; thus, termination of the pregnancy was planned beyond 90 days GA according to Italian legislation. The molecular swab for Covid-19 was performed and was negative.Fetus was well developed for its GA and was female .Nose, nasal choanae, oral cavity, tongue, palate, and chin were affected by multilobate neoformation. The lesion extended throughout the oral cavity, involving the tongue that appeared incorporated in the mass; the tumor protruded to a small extent from the open mouth along with the tip of the tongue. The neck appeared very swollen due to the lesion itself, which extended its full length up to the jugular dimple; a subcutaneous venous reticulum was very evident .To remove the neoplasm, a median cutaneous incision was made until the neoformation was fully exposed. The tongue, hypopharynx, submandibular glands, larynx, esophagus, great vessels, lymph nodes, and thyroid gland were altered in position and shape due to the presence of a large neoplasm .The neoformation was multilobate  mainly solid, fleshy, and whitish in color with greyish areas; it did not present cystic, hemorrhagic, or necrosis areas.It was immediately evident that the lesion infiltrated the entire floor of the mouth, incorporating the tongue, with compression and antero-posterior displacement of the pharynx, larynx, and trachea. In particular, the root and body of the tongue were not recognizable because they were incorporated and destroyed by the neoplasm; only the apex of the tongue was identifiable. The floor of the mouth was completely destroyed, and the trachea and larynx were not discernible. The tumor only marginally reached the superior mediastinum.The neoformation, starting from the roof of the pharynx, extended throughout the pharynx (rhino and oropharynx) destroying the floor of the mouth, most of the tongue, larynx, and trachea. It protruded to a small extent from the mouth and infiltrated the sphenoid (straddling the pituitary dimple and the sella turcica) in a minimal portion .Histological examination showed neoformation with growth at times infiltrative and destructive with only expansive growth. It was composed of immature tissues, largely tubules and neuroectodermal rosettes, interspersed with tissues of endodermal and ectodermal origin in various differentiation stages . The neuOverall, the tumor had an abundant immature neuroepithelial tissue component occupying more than three low-magnification fields (40×) in each examined slide of the lesion. The neoplasm was therefore classified as a malignant neoplasm of the immature grade 3 or high-grade teratoma type. It was a particularly aggressive and rare lesion; in fact, approximately 12 surgically inoperable cases have been described in the medical literature.,The word “teratoma” was first coined and defined by the famous scientist Virchow in the first edition of his book on tumors published in 1863. Teratomas range from benign to malignant, and solid to cystic. Teratoma arises from totipotent cells—the cells that give rise to ectoderm, endoderm, and mesoderm. These tumors typically are midline or paraxial with the most common location being sacrococcygeal (57%). Cystic teratomas occasionally occur in sequestered midline embryonic cell restsClinically, a hard palate teratoma appears as a bulky, single mass or multiple little lesions with a pedicle or sessile. Airway obstruction is the main complication and is related to the size and site of the lesion occurring in 80% to 100% of cases.Most epignathus teratomas were identified during the second and third trimester by two-dimensional or three-dimensional ultrasound.In selected cases it is possible to remove the lesion and save the life of the newborn. Early radical removal is the treatment of large head and neck teratoma without an intracranial component.There were reports of successful delivery of live fetuses by ex utero intrapartum treatment of the fetus with isolated epignathus.,-By studying all the English medical literature, we found 18 cases of epignathus with immature teratoma. This tumor always originates from the hard palate. In six cases the lesion also had an intracranial component,,,,Much more rarely, only in four cases,This kind of lesion frequently has a wide component that bulges from the oral cavity. In our case, the extra-oral component was small; however, the oropharyngeal and hypopharyngeal components were very extensive with expansive and destructive growth. The particularities of the case we described are the high degree of malignancy, the destructive oropharyngeal and hypopharyngeal growth, and the scarce extra-oral component.Congenital hard palate teratomas or epignathus teratomas are rare tumors that can be diagnosed during gynecological visits by a simple investigation modality such as ultrasonography. The correct plan can be made to terminate the pregnancy in cases of large and fatal lesions with a high rate of morbidity and mortality.,-The case we describe is very rare. When a fast-growing fetal epignathus is detected early, pregnancy termination should be measured. In selected cases it is possible to plan the resection of the lesion; unfortunately, in our case, this was not possible.


Testicular torsion is an emergency. It usually occurs spontaneously, without an apparent cause but has been associated with anatomical, traumatic, and environmental factors. In the case of the acute scrotum, a high degree of clinical suspicion is the most important factor in early diagnosis. Scrotal Doppler helps to confirm the diagnosis of testicular torsion. Prompt recognition and treatment are critical for testicular viability. Surgical intervention, even in late-diagnosed selected cases may yield desirable results. We report a case of a 16-year-old boy who came to the urology outpatient department (OPD) with a history of scrotal pain for approximately 12 hours. For males of the age 25 years and younger, testis torsion is more than three times more common than testis cancer. It has an estimated incidence of 4.5 cases per 100,000 per year -5. TestiA young boy aged 16 years presented to the urology OPD of the hospital with a history of right testicular pain for more than 12 hours. There was associated waist pain but no history of trauma, fever, nausea, or vomiting. He was voiding well. On physical examination, the right testis was larger in volume as compared to the left, high riding, and tender to touch. Prehn’s sign (pain relief on lifting the affected testicle) was negative. Cremasteric reflex was absent on the affected side. Testicular Workup for Ischemia and Suspected Torsion (TWIST) score was 6. The clinical diagnosis of the right testicular torsion was made. The radiologist was informed over the phone regarding the need to do an urgent scrotal Doppler to confirm the diagnosis. At the same time, the anesthesiologist and emergency operation theatre (OT) team were also informed. Scrotal Doppler showed enlarged right testis with no blood flow; contralateral testis was normal , horizontal lie, and mal-descended testis increase the possibility of testicular torsion ,9. It maOne scoring system that can aid physicians in diagnosis is Testicular Workup for Ischemia and Suspected Torsion (TWIST). This scoring system was developed to diagnose testicular torsion on clinical grounds, thus decreasing the need for ultrasound . TWIST cMultiple review studies have confirmed that a score of >5 has a positive predictive value (PPV) of 100% and a score of <2 has a negative predictive value (NPV) of 100%. This scoring was initially derived from the pediatric population. It may still be helpful to the physician to make a quick diagnosis, especially when the USG facility is not available.Filho et al. reported a correlation in time and degree of torsion in the orchidopexy group in 117 patients . The viaFamily physicians, who may be the first level of contact with the patient, should have a high index of suspicion to avoid delay in diagnosis and appropriate management. Children presenting with abdominal pain, especially in cold weather should have their testicles examined to rule out torsion . Early sTesticular torsion is one of the leading causes of acute scrotum presenting in the emergency room. A high degree of clinical suspicion is essential to timely diagnosis and proper management. Scrotal Doppler helps to establish a clinical diagnosis and predict testicular viability on the basis of parenchymal echotexture of the torsed testis. Surgical exploration is the treatment of choice. Patients who present late may still have viable testis


Krukenberg tumor is a rare metastatic tumor of the ovary with histopathological features known as signet ring cells. It usually develops in women around 45 years of age. However, here we describe an uncommon case in a 38-year-old pregnant woman. We report this case due to our unusual findings, the uncommon presentation in this younger age bracket, its diagnostic challenge, and poor prognosis.We describe a unique case of a young Mexican woman with a history of painful vaginal bleeding at 13 weeks of pregnancy and treated for abruptio placentae. In her routine prenatal visit at week 20 of pregnancy, she was found to have a uterine fundus exceeding the expected measure for her gestational age and was referred to the hospital to discard polyhydramnios. Upon admission, a pelvic ultrasound was performed displaying normal findings in a 25-week pregnancy, and also showing bilateral enlarged ovaries with heterogeneous echogenicity. Magnetic resonance imaging revealed a left tumoral lesion with dimensions of 22.1 × 13.6 × 16.3 cm presenting regular lobulated contours with displacement of peripheral structures and mild compression of the bladder, the left ureter, and the inferior vena cava. The lesion was heterogeneous with irregular borders. The patient was scheduled for a cesarean section; during the operation, the abdominal cavity showed bilateral tumors compatible with MRI findings. The ovarian tumors were sent to pathology, and the results showed poorly differentiated mucinous adenocarcinoma  with extensive signet ring cells, indicative of a Krukenberg tumor.This case report describes an uncommon example of a young pregnant woman without identifiable risk factors for gastric cancer who manifested a Krukenberg tumor. This incidental finding suggests that pregnancy obscured the cancer’s clinical appearance. The rapid deterioration in the patient’s condition corresponds to what is described in the literature. The limited information regarding this neoplasm in Mexico and the torpid evolution of the case highlight the importance of conducting additional studies to generate therapeutic interventions aimed at increasing overall survival. Krukenberg tumor (KT) is a rare tumor of the ovary, characterized by poor prognosis. The tumor was named after Friedrich Ernst Krukenberg, who first described five cases of a new ovarian malignancy in 1896. Years later, it was discovered that KTs are ovarian metastases secondary to specific malignancies (signet ring cell carcinomas), most of which derive from the gastrointestinal tract. The stomach was previously reported to be the most common primary site, followed by the colon, appendix, and breast. Recent literature reveals an increased incidence of tumors originating from the colon. Of all ovarian tumors diagnosed, KTs make up about 1–2% [The tumors are often bilateral (over 80%), given their metastatic nature. The average age of diagnosis is 45 years. Symptoms of KT can be very nonspecific, one of the most common being abdominal distension, which in pregnancy can be due to non-pathological components of pregnancy such as fat, fluid, fetus, flatus, or feces. A physician should also consider other causes such as sepsis, organ failure, and tumors. Specifically, symptoms of KT typically manifest due to ovarian involvement and mass effect, which causes abdominal pain, bloating, nonspecific gastrointestinal symptoms, or ascites with malignant cells , 3. The A 38-year-old Mexican female patient attended the hospital with a pregnancy of 20 gestational weeks  for a routine prenatal visit. The patient was only complaining of abdominal fullness. During the physical examination, she was found to have a uterine fundus exceeding the expected measure for her gestational age. She was therefore referred to our hospital for further assessment.T0) week of pregnancy, she was found to have a uterine fundus greater than her gestational age, for which she was referred to our hospital to discard polyhydramnios. A pelvic ultrasound was performed, finding a normal intrauterine pregnancy of 25 gestational weeks with cephalic diameter consistent with gestational age, normal cardiac activity, and an adequate amount of amniotic fluid. The ultrasound showed bilateral enlarged ovaries with heterogeneous echogenicity. Due to these findings, pelvic magnetic resonance imaging (MRI) was performed, which showed occupation by an intrauterine pregnancy . During surgery, the uterus was opened using a median incision, and the neonate was obtained without complications. The abdominal cavity showed bilateral tumors compatible with the MRI findings. A hysterectomy with right oophorectomy was performed; the patient was discharged 2 weeks later without complications.The patient was provided fetal lung maturation therapy with dexamethasone and scheduled for a cesarean section at 26 weeks of gestation  with extensive SRCs.Two days after discharge, she presented with nausea and vomiting of gastric content accompanied by abdominal pain. She was admitted to the hospital due to the described symptoms and ascites findings; an abdominal paracentesis was then performed. The ascites fluid analysis showed glucose of 20 mg/dL, proteins 1.28 g/dL, and lactate dehydrogenase 1551 U/L, with the presence of gram-positive cocci. Due to the physical and analytical findings, we initiated management with intravenous fluids and antibiotic therapy.There was no relevant past medical history, risk factors, or family history of cancer. The patient lived at home with access to all essential services of water and electricity.T0), she was cachectic, with abdominal distention due to ascites fluid, bulging flanks, and abdominal pain at profound palpation. A 1 cm dehiscence on the vaginal vault was found on the pelvic examination, with fecal material drainage. Her blood pressure remained constant at 100/70 mmHg.On admission (3 u/L), as well as leukocytes (10.0 × 103 u/L), neutrophils (87%), and potassium (5.30 mEq/L).The laboratory assessments showed decreased hemoglobin levels (8.0 g/dL), hematocrit (25.8 %), albumin (2.04 g/dL), proteins (4.60 g/dL), globulin (2.56 g/dL), sodium (132 mEq/L), and chloride (96 mEq/L). Additional laboratory tests showed mildly elevated platelet count  examination of the thorax, abdomen, and pelvis with oral contrast Fig.  showed bAccording to the symptoms, physical examination, imaging, and histopathology findings, this patient was diagnosed with gastric mucinous adenocarcinoma with metastases to the ovary, commonly known as KT. The patient received a poor prognosis due to tumor extension and was offered palliative treatment, which consisted of no further surgeries, providing psychological and emotional support, and pharmacological intervention with opioids for pain management. As she attended a public hospital, there was no financial burden on the patient or the family.Intervention with exploratory laparotomy yielded the following findings: abdominal sepsis, intestinal perforation, and peritoneal carcinomatosis.T2).After the surgical findings, oncology deferred treatment due to peritoneal involvement, intestinal carcinomatosis, and unresectable gastric cancer. The patient was given palliative therapy and died 2 months later , once the incidental ultrasound findings were inconclusive, we performed an MRI to further study the suggestive images while avoiding the teratogenic threshold radiation dose (5 to 15 rad).Optimal treatment for synchronous pregnancy with KT of gastric origin is yet to be established. The available options for treating this neoplasm are cytoreductive surgery (CRS), adjuvant chemotherapy (CTx), neoadjuvant CTx, and hyperthermic intraperitoneal chemotherapy (HIPEC). These treatments may be used alone or in combination .In this patient, CRS was performed, which is the treatment option most associated with an increase in overall survival (OS). In 2019, Lionetti and colleagues conducted a systematic review of the literature and concluded that CRS—particularly CRS in the absence of residuals—presented the clearest results in improving OS in KT patients .Our patient was not treated with CTx. Even though its use is still controversial, some authors recommend CRS + HIPEC as a therapeutic combination, with survival benefits showing more than acceptable morbidity and mortality rates , 11.Despite CRS being performed, oncology deferred further treatment due to peritoneal involvement, intestinal carcinomatosis, and unresectable gastric cancer. We identified ascites, carcinomatosis at the exploratory laparotomy, and the lack of radical surgery for primary cancer as unfavorable prognostic factors that have been associated with poor maternal 2-year survival rates , 13.Kodama and coworkers conducted a study among pregnant women with KT treated with radical surgery (57.1%) or no surgery/palliative surgery (42.9%). The overall maternal survival rate was insufficient in both groups, exhibiting 1, 2, and 5-year rates of 45.6%, 45.6%, and no survival after 5 years .To the best of our knowledge, this is the first case report of a KT diagnosed during pregnancy in Yucatan. More descriptive studies are needed to construct an epidemiological characterization of this cancer in this Mexican region to provide effective therapeutic interventions. The limitation of our study lies in the description of an isolated case of KT, limiting absolute conclusions regarding the standard of care and prognosis of this condition.This case report depicts an uncommon example of a young pregnant woman without identifiable risk factors for gastric cancer who manifested a KT. This incidental finding suggests that pregnancy obscured the cancer’s clinical appearance, and the patient’s rapid deterioration corresponded to what is described in the literature. The limited information regarding this neoplasm in Mexico and the torpid evolution of the case highlight the importance of conducting additional studies to generate therapeutic interventions aimed at increasing overall survival.


A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain. The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension. The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control.A rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications. A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented to the emergency department (ED) with 10 days of abdominal and flank pain. She also had alternating constipation and diarrhea, nausea, anorexia, and chills. She delayed her presentation due to cost. At presentation, the patient was tachycardic (heart rate 116 beats per minute), normotensive (blood pressure 106/58 millimeters of mercury), and afebrile. Physical examination revealed a five-centimeter erythematous, tender, abdominal wall mass. The initial differential diagnosis included incarcerated hernia, diverticulitis, and abscess. Point-of-care ultrasound (POCUS) revealed an irregular, heterogenous, extraperitoneal fluid collection with intraperitoneal communication, consistent with abdominal wall abscess extending beyond the surgical mesh into the peritoneum , Image 1Computed tomography confirmed the enterocutaneous fistula (ECF) and abscess secondary to mesh migration and erosion into the small intestine . The patErosion of surgical mesh into the intestinal wall and subsequent ECF formation is a rare complication of hernia repair with mesh. One series of 695 patients with mean follow-up of 4.9 years developed no ECFs,3Abscesses are frequently diagnosed with POCUS in the emergency department;What do we already know about this clinical entity?Enterocutaneous fistula (ECF) is a rare complication of hernia repair with surgical mesh, which occurs later than other surgical complications.What is the major impact of the image(s)?This image demonstrates ECF occurring 18 years after hernia repair, diagnosed using point-of-care ultrasound in the emergency department.How might this improve emergency medicine practice?Distant surgery does not rule out mesh infection and ECF, and point-of-care ultrasound may be useful in making the diagnosis.Video.Point-of-care ultrasound of the abdominal wall abscess, demonstrating a heterogenous fluid collection (C) associated with surgical mesh (M) extending across the peritoneum (P) and communicating with intraperitoneal abscess (A).


Enterocutaneous fistula commonly occurs in the post-operative setting. However, a handful of cases have been reported to occur secondary to strangulation of hernia, mostly femoral due to the narrow femoral ring through which this type of hernia passes through.We encountered a case of spontaneous fecal fistula, which occurred in the setting of an incarcerated femoral hernia. The patient did not develop peritonism, or obstruction, throughout the course of the disease. The hernia ruptured on day 7 of incarceration. Exploratory laparotomy under epidural anesthesia revealed a femoral hernia with ileum as content, arising approximately 20 cm from theileocecal junction. Reduction of the contents was done, and a resection performed along with repair of the hernia.As very few literature describe the formation of spontaneous fecal fistula, we discuss the presentation in this report. Femoral hernia is one of the types of groin hernia, with approximately 20% incidence amongst all abdominal hernias in females and 5% in males . The herA 72-year-old multiparous female presented to the Emergency Department at Nepal Medical College and Teaching Hospital, with a history of on and off groin swelling since the past 2 months, which had become irreducible in the last 10 days prior to presentation. She had no history of nausea, vomiting, fever, colicky abdominal pain, or abdominal distention. However, 3 days prior to her visit, she noticed that the skin around the swelling had become red and had started to ooze purulent material. The next day, there was discharge of fecal matter from the lump.At presentation, her vitals were stable and there was no evidence of peritonitis on physical examination. She did not have any features of obstruction, however, there was an enterocutaneous fistula in the right groin Fig. . There wThe patient was admitted, resuscitated, and a contrast enhanced computed tomography scan was done, which showed findings consistent with enterocutaneous fistula coming out through the femoral ring Fig. . The patMost of the femoral hernia have a segment of bowel herniating through them, which is eponymously termed as Richter’s hernia. This type of hernia will rapidly progress to gangrene as the constricting ring exerts pressure on the bowel wall, compromising blood flow. Features of intestinal obstruction are typically absent, especially when less than two-thirds of the circumference of the bowel is involved, which leads to late diagnosis or bowel ischemia . Our patAn enterocutaneous fistula (ECF), as the name describes, forms when there is an abnormal communication between the gastrointestinal tract and the skin . The most common cause of ECF is iatrogenic, i.e., it follows a visceral surgery , 7. OnlyFemoral hernia commonly presents with obstruction and strangulation, formation of ECF in these patients is a rare entity, like the presentation of our patient . FurtherTreatment of ECF comprises of using the SNAP guideline, which has been proven effective in treating such cases . The firAlthough a surgical repair of hernia in an elective setting utilizes synthetic mesh placement to reinforce surgical closure of the defect, this is contraindicated in patients with an enterocutaneous fistula, such as our case. Hence, a mesh was not placed in this patient , 11.Most patients presenting in our setup are poor, lack the appropriate level of knowledge required for timely consults and neglect their health care till an emergency arises. These factors may play a role in formation of such fistulae, even when in this modern era such complications can easily be prevented by timely interventions. However, even delayed presentations can be managed, like in our case, by adhering to a set of fixed protocols like the SNAP guideline.


Persistent sciatic artery (PSA) is an extremely rare condition that is present in around 0.05% of the population and is commonly associated with many complications. The management is conservative or through surgical intervention and depends on the type of complication. The case presented is of a 40-year-old man who complained of persistent pain in the buttock region. On radiology, bilateral PSAs were observed exiting through the infra-pyriformis compartment of the greater sciatic foramen accompanying the sciatic nerve. The femoral artery and the external iliac artery are small in caliber. In this case report, we discuss the underlying embryology that might have led to the persistence of this vessel with illustrations and the abnormal radiological pattern of this anomaly. Increased awareness of PSA can improve patient care and prevent potentially hazardous complications during hip and renal transplant surgery. Persistent sciatic artery (PSA) is an extremely rare vascular anomaly resulting from a lack of regression of an embryonal artery to the lower extremity. It is present in around 0.05% of the population, and only around 49 cases have been published in the world literature since 1832 [This anomaly should be kept in mind in the clinical assessment of a pulsatile gluteal mass as it presents potentially hazardous complications during hip and renal transplant surgery . In thisA 40-year-old man underwent a CT angiogram (CTA) investigation due to a six-month history of pain in the buttock region, which showed bilateral arteries exiting through the infra-pyriformis compartment of the greater sciatic foramen accompanying the sciatic nerve. The axial CTA images taken at levels of ischial tuberosity Figure  and uppePSA, especially the bilateral variant, is a very rare congenital vascular anomaly due to the abnormal developmental process of the axial limb vasculature. Knowledge of the embryological patterning of the lower limb vessels, which involves vasculogenesis, angiogenesis, sprouting, and resorption, is essential for understanding the persistence of the sciatic artery. The major arteries of the body wall and limbs are derived from the intersegmental arteries. Around 30 or more pairs arise serially at each segmental level and run between the somites . In the A literature search revealed that PSAs are classified into five types according to the Pillet-Gauffre classification. Type 1 represents complete PSA with normal SFA, type 2 represents complete PSA with incompletely developed SFA, and type 3 represents incomplete PSA with the persistence of proximal SFA. Type 4 represents complete development of SFA but the axial artery (represents the sciatic artery) is persistent at the lower part. Type 5 is a mix of the above . The axiAs seen in the radiological images, these arteries are located superficially and need to be further evaluated as they tend to result in pathologic vascular complications such as aneurysm formation. Symptoms such as lower limb pain, claudication, cold lower extremities, black toes, neurological deficits (sensory and motor), and pain along sciatic nerve distribution are some of the clinical presenting signs and symptoms of this anomaly. A minority of patients also present with a palpable popliteal pulse in the absence of femoral pulse (Cowie’s sign) . This anThe management of these types of cases is variable depending on the pathology as well as the classification type. While types 1 and 2 are typically treated medically, arteries in the other types are prone to embolism and aneurysm formation and are treated by interventional radiologists with coil embolization .PSA is an extremely rare condition and is commonly associated with many complications. In this case, bilateral PSAs were observed exiting through the infra-pyriformis compartment of the greater sciatic foramen accompanying the sciatic nerve. The management is dependent on the type of complication. As the patient in our case presented with pain in the gluteal region, and the CT failed to reveal any aneurysm or embolism, he was managed conservatively with pain control medications.


We describe herein an extremely rare case of intracardiac ectopic thymoma—only two pure cases have been reported to date—associated with myasthenia gravis, an infrequent complication of ectopic thymoma.A 71-year-old woman with superior vena cava syndrome was found to have a large mass mainly located in the right atrium. Tumor resection under cardiopulmonary bypass was performed. The pathological diagnosis was type AB ectopic thymoma. The postoperative course was complicated by progressive respiratory failure, and she was diagnosed with myasthenic crisis based on clinical signs and the edrophonium test. The patient recovered and was weaned from prolonged mechanical ventilation after receiving intravenous immunoglobulin, and was subsequently discharged uneventfully.This is the first report of myasthenic crisis due to intracardiac ectopic thymoma. Residual thymoma is a risk factor for the development of post-thymectomy myasthenia gravis, and long-term follow-up is required. Ectopic thymoma is a rare neoplasm accounting for 4% of all thymomas, arising mostly in the cervical region, lungs, pleura, thyroid, pericardium, and middle/posterior mediastinum . Intraca2) narcosis with a PaCO2 of 66.7 mmHg and a PaO2 of 54.6 mmHg. The patient was immediately reintubated and again required mechanical ventilation support. She complained of dyspnea again 4 h after another attempt at weaning from ventilation on postoperative day 18, and histopathological diagnosis of the resected mass identified ectopic thymoma. The possibility of myasthenic crisis (MC) was therefore considered despite negative results for anti-acetylcholine receptor (AChR) antibody and anti-muscle-specific tyrosine kinase (MuSK) antibody. An edrophonium test showed temporary improvement of tidal volume (from 350 mL/min to 400 mL/min) and grip strength  on postoperative day 19 resulted in a diagnosis of MC. Intravenous immunoglobulin (IVIg) was initiated at 20 g/day for 5 days from that day. She was extubated on postoperative day 32 after confirming a negative response to the edrophonium test. Postoperative CT revealed no masses in the SVC or RA  revealed a large mass with a diameter of around 12 cm occupying the RA and extending into the SVC and left brachiocephalic vein (LBCV) (Fig. The excised specimen showed a bosselated mass measuring 85 × 70 × 35 mm, elastic hard in consistency with a smooth surface Fig. a. The cuThymomas are epithelial neoplasms of the thymic gland, with 96% arising in the anterior/superior mediastinum. The remaining are ectopic thymomas that mainly arise from ectopically dispersed thymic tissue, mostly in the neck, lungs, pleura, thyroid, pericardium, and middle/posterior mediastinum . The hisThe thymoma in our patient occupied the RA, SVC and LBCV, and had not spread outside the heart and vessels. The main mass was located in the RA lumen almost freely from which tumor branches extended in the lumen of SVC and LBCV. Because the original thymus had involuted into a small, solid tissue, the intracardiac thymoma was reasonably thought to have originated from the RA. To the best of our knowledge, four cases of intracardiac ectopic thymoma have been reported in the English literature –4. HowevAnti-AChR or anti-MuSK antibodies are found in over 80% of patients with MG. Cases of MG without detectable antibodies against AChR or MuSK are seen in around 15%, and are termed “double-seronegative MG” . In our Approximately one-third of patients with thymoma display MG . ThymectWe herein report a case of MC due to intracardiac ectopic thymoma. The tumor was resected radically and the patient has remained symptom-free. Residual thymoma is a risk factor for the development of post-thymectomy MG, and long-term follow-up is required in our patient.


Presacral dermoid cysts are rare, benign tumors of developmental origin that primarily affect women. Surgical resection is the mainstay of treatment for these cysts, even if asymptomatic, with the laparoscopic approach being safer and more efficient. Presacral dermoid cysts are rare, benign tumors of developmental origin that primarily affect women. Surgical resection is the mainstay of treatment for these cysts, even if asymptomatic, with the laparoscopic approach being safer and more efficient. Their true incidence in the general population is not known; however, they are estimated to account for about 1 in 40,000 hospital admissions.Presacral tumors range from simple benign cysts to complex malignant masses, with dermoid cysts accounting for fewer than 5% of the tumors.2A 22‐year‐old female patient presented to our center with a chief complaint of insidious‐onset, continuous, and non‐radiating lower back pain for the past 6 months. She had no history of nausea, vomiting, fever, hematochezia/melena, abdominal distension, weight loss, or trauma. Her bowel and bladder habits were normal, and she had no significant past medical history or family history of malignancy.On examination, the patient was afebrile, hemodynamically stable, and fully conscious. Her abdomen was soft and non‐tender with normal bowel sounds, and digital rectal examination revealed no abnormalities. Examination of all other systems was normal. Blood counts were within normal ranges, and liver and renal function tests were unremarkable.Transabdominal ultrasonography of the pelvis showed a complex cystic lesion with dimensions of 10.2 cm × 6.4 cm. A subsequent magnetic resonance imaging (MRI) scan revealed a 10.6 cm × 10 cm × 9.4 cm sized multiloculated cystic lesion in the presacral space with variable signal intensities, giving an impression of a type IV sacrococcygeal teratoma. , posterior , and combined abdominoperineal. Accurate diagnostic imaging is essential in evaluating the location and size of these tumors and their relationship with the adjacent structures, which help determine the surgical approach. Tumors that extend above the level of the S4 vertebra can be removed either through the anterior or combined approach, while for low‐lying lesions, the posterior approach is indicated.4The rare possibility of presacral tumors must be considered in women with suggestive symptoms, which can only be ruled out by accurate pelvic imaging. Surgery is the mainstay of treatment for these tumors, with the laparoscopic approach being safer and more efficient as it reduces surgical trauma and offers excellent visualization of the deep structures in the presacral space.The authors declare that they have no competing interests.Diptee Poudel, Bibek Man Shrestha, and Suraj Shrestha wrote the original draft of the manuscript. All authors contributed to the review and editing of the manuscript. Ankush Kansal, Bishnu Prasad Kandel, and Paleswan Joshi Lakhey were involved in the diagnosis and treatment of the patient. All authors have read and approved the final version of the manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.


GNAS mutation and 1p/22q co-deletion responding to sunitinib in a patient with multiple recurrent meningiomas.Although surgical resection can cure the majority of meningiomas, there are still approximately 20% of patients suffering from an aggressive course with recurrence or progression. In this study, we reported a novel GNAS mutations and 1p/22q co-deletion were both identified, and amplification at 17q and chromosome 19 was also found in the second recurrent sample, based on which WHO grade II/III meningioma was diagnosed. The lesion in the left cerebellopontine angle area enlarged after use of radiotherapy combined with temozolomide chemotherapy for 2 months. When sunitinib was added, the residual lesions began to lessen and continuously reduced.A 53-year-old woman with meningioma was hospitalized due to postoperative tumor progression for 3 weeks. WHO grade I meningioma was pathologically diagnosed after the first three surgeries, but the second recurrence occurred approximately 3 years following the third surgery. Next-generation sequencing was performed on the first two recurrent samples. This typical case suggested that timely molecular diagnosis for refractory meningiomas contributed to guiding the molecular classification and clinicians to make more reasonable individualized therapeutic regimens, consequently benefiting the patients. This case report also highlighted the potential role of sunitinib in the treatment of refractory meningiomas. Meningiomas primarily arising from meningothelial arachnoid cells are the most common intracranial tumors at present, with an estimated annual prevalence of 8.83 cases per 0.1 million people in the Central Brain Tumor Registry of the United States .NF2 alterations in sporadic meningiomas, various oncogenic mutations in KLF4, SMO, TRAF7, PIK3CA, AKT1 and POLR2A are also found to be clinically actionable genetic events in meningiomas  showed a space-occupying lesion between the left cavernous sinus and the left pterygopalatine fossa  was performed on the first two recurrent samples, and somatic inactivating mutations in GNAS gene and 1p/22q co-deletion were both identified. Additionally, amplification at 17q and chromosome 19 was also found in the second recurrent sample. These findings suggested high-grade meningioma (WHO grade II/III). Concurrent chemoradiotherapy  was applied on August 20, 2020. Stereotactic radiosurgery (SRS) boost was used for lesions under the tentorium of cerebellum (8 Gy) and in the left cerebellopontine angle area (5 Gy) on September 18, 2020. Two months after chemoradiotherapy, the lesion in the left cerebellopontine angle area enlarged , which might be associated with response to radiotherapy in a short term. Then, sunitinib (50 mg/d) was orally administrated in combination with temozolomide chemotherapy, the residual lesions lessened after use of 2 months . Sunitinib was totally applied for four treatment courses, in which 6 weeks were as one treatment course. To date of June 9, 2021, MRI showed continued partial remission of residual lesions . The patient was in good condition, and symptoms like facial paralysis and fixed eyeballs improved. The treatment timeline of the patient is depicted in On July 23, 2020, tumor progression was observed. The patient came to our hospital for further diagnosis and treatment. Her symptoms, such as left decreased hearing, left facial numbness, right deviated corners of the mouth and limited left eye movement in vertical direction, were the same as before. MRI showed an abnormal enhancement ratio in the relative left brainstem and an enhanced lesion under the cerebellar tentorium, suggesting tumor recurrence and distant diffusion  for the publication of any potentially identifiable images or data included in this article.WH performed the data acquisition and wrote the manuscript. CGS, MY, YY, and HW performed the radiological images analysis. FD and XZ collected the data of genetic testing. CS and LC reviewed the manuscript. All authors contributed to the study and approved the submitted version.Authors FD, XZ and CS were employed by Jiangsu Simcere Diagnostics Co., Ltd. and Nanjing Simcere Medical Laboratory Science Co., Ltd.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Petrous apicitis and cavernous sinus thrombosis are exceedingly rare complications of acute otitis media with only few reported cases in the post-antibiotic era. Especially in children, the appropriate management is a subject of controversy.Case Presentation: We report the case of a 10-year-old boy who presented to the emergency department with left-sided otalgia, otorrhea, and hearing loss, accompanied by somnolence and high spiking fevers. CT and MRI revealed partially obstructed mastoid air cells including a pneumatized petrous apex. Furthermore, thrombosis of the cavernous sinus and vasculitis of the internal carotid artery on the left side were present. The patient was treated with antibiotics for 6 weeks and anticoagulant therapy for 3 months. Follow-up carried out 3 months post-admission showed complete recanalization of the cavernous sinus on MRI and fatigue as the only remaining symptom.Conclusion: A complicated otitis media with petrous apicitis and cavernous sinus thrombosis in a child can in some cases be managed without a surgical intervention. Otitis media is the most common bacterial infection in children. Complications became rare in the era of antibiotics but can be life-threatening. They include acute mastoiditis, intracranial abscess, cranial nerve palsy, meningitis, petrous apicitis (PA) with or without osteomyelitis of the temporal bone, and otogenic cerebral venous sinus thrombosis (OCVST) , 2. Due With our reported case we would like to present two rare complications of otitis media in the era of antibiotics and illustrate the radiological course under anticoagulant therapy.Informed consent was obtained from the patient and his parents.A 10-year-old otherwise healthy boy presented with left-sided otalgia and otorrhea since 2 days. Further he described hearing loss, somnolence and fever, peaking at 40°C.Otoscopy revealed a perforated left-sided eardrum with purulent secretions. Retroauricular swelling and tenderness were present. Apart from marked somnolence, the neurological exam was normal with intact function of cranial nerves, including ocular motility.Fusobacterium necrophorum was found in hemocultures.A contrast-enhanced computed tomography (CT) revealed partially opacified mastoid air cells including a pneumatized petrosal apex on the left side and obstruction of the left cavernous sinus . MagnetiFusobacterium necrophorum in blood cultures, therapy was adjusted to metronidazole and ceftriaxone. Anticoagulant therapy with low weight molecular heparin,  was initiated immediately after radiological diagnosis. Since the perforated eardrum allowed for a constant clearance of middle ear purulence, no surgical intervention was performed.Broad spectrum intravenous antibiotic therapy was administered immediately after presentation . After identifying In the first week of treatment, symptoms improved slowly. MRI was repeated 7 days post-admission and revealed a progressive thrombosis of the left cavernous sinus and vasculitis of the internal carotid artery . Since sFollow-up including MRI was carried out 3 months post-admission. Complete recanalization of the cavernous sinus and recovery of the internal carotid artery were shown and anticoagulant therapy could be stopped . Apart fStreptococcus pneumoniae and Haemophilus influenzae are the predominant pathogens in acute otitis media amongst children and only a small percentage is caused by anaerobic bacteria. The cultured pathogen in the reported case was Fusobacterium necrophorum. The anaerobic gram-negative rod is traditionally known in the field of Otolaryngology as the most common pathogen in Lemierre‘s syndrome. An increased number of complicated otogenic infections caused by this bacteria have been reported in recent years. Recommended treatment consists of an antibiotic, targeting gram negative bacteria combined with a broad-spectrum beta-lactam antibiotic ' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.YB was the main treating physician, initiated the study, supervised the work, and revised the manuscript. PB and SK drafted the manuscript. A-LK described the radiological findings. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Achieving gross total resection during the first surgical intervention is particularly important for chondrosarcomas and chordomas, as recurrences are frequently impossible to resect due to post-surgical and post-radiation scarring and vascular fragility. Despite overall survival and progression-free survival being strongly dictated by gross total resection, it is reportedly achieved in less than 70% of patients. While the individual utility of several imaging modalities such as intraoperative CT, MRI, ultrasound, endoscopy, fluoroscopy and neuronavigation has already been demonstrated in previous literature; our case series highlights the importance and methodology of their simultaneous, real-time integration in the Advanced Multimodality Image-Guided Operating (AMIGO) suite at our institution to maximize of resection and mitigate complications.Given the difficulty and importance of achieving maximal resection in chordomas and chondrosarcomas, all available tools offered by modern neurosurgery are to be deployed for planning and resection of these complex lesions. As demonstrated by the review of our series of skull base chordoma and chondrosarcoma resections in the Advanced Multimodality Image-Guided Operating (AMIGO) suite, as well as by the recently published literature, we describe the use of advanced multimodality intraoperative imaging and neuronavigation as pivotal to successful radical resection of these skull base lesions while preventing and managing eventual complications. Recent advances in technology have enabled considerable progress in neurosurgical practice and associated clinical outcomes. This revolution has in part been driven by the ever-expanding armamentarium of imaging tools available in the operating room. In skull base surgery, widespread adoption and use of neuronavigation, endoscopes, and intraoperative imaging represent the core of such advances ,2. In liPatients with recurrence of a known chordoma and chondrosarcoma or who were harboring new lesions consistent on imaging with chordoma and chondrosarcoma underwent prospective surgical resection in the AMIGO suite . The surAll patients included within the study underwent a surgical procedure aimed at achieving maximal surgical resection of their skull base lesions. The surgical approach for each patient was determined after a thorough review of both the clinical presentation and preoperative imaging. All preoperative imaging was reviewed, co-registered, segmented, and uploaded to the clinical navigation system prior to surgical intervention. If deemed necessary, intraoperative fluoroscopy was used to place a lumbar drain for CSF drainage. Proper positioning is crucial to the ability to perform multimodality imaging  intraoperatively. Close coordination with the neuromonitoring and anesthesia teams is crucial in the setup, particularly in the iMRI setting. The groin was prepped for rapid femoral artery catheterization if the vascular risk was deemed high. When maximal resection was thought to have been achieved, the patient and surgical room were prepared according to the iMRI safety protocol. Specific sequences were obtained depending on the preoperative appearance of the tumor. Thin cut T2 and T1 without contrast are particularly helpful. MPRAGE T1 with contrast, with and without fat suppression, is also frequently employed. Once acquired, intraoperative imaging was reviewed and discussed by the neuroradiology and operative teams. Segmentation of the residual target volume was completed and transferred to the navigation system to help guide the remainder of surgery and additional resection if needed. In cases where the verification of adequate bony resection was needed, a CT scan was also obtained. A CT scan was also obtained as immediate postoperative imaging in selected cases. Preoperative and intraoperative segmentations and navigation were performed using a commercially available navigation system .www.slicer.org. accessed on 22 June 2021) [For the imaging analysis, a neurosurgeon and neuroradiologist completed the imaging segmentation and review retrospectively. Preoperative, intraoperative, postoperative, and follow-up imaging were co-registered. Postoperative imaging was defined as any MRI obtained within three months of surgical intervention, including intraoperative MRI when it demonstrated gross total resection. Postoperative residual lesions were labeled and segmented based on three-month follow-up imaging and/or given the presence of any suspicious findings that demonstrated progression on subsequent follow-up imaging. The intraoperative residual percentage was calculated based on the initial tumor volume and on the suspected residual volume on the iMRI. The postoperative residual percentage was based on the postoperative residual volume segmentation. Subtotal resection was defined as a resection >90% of initial tumor volume, whereas partial resection was defined for resection <90%. Volumetric analysis was performed using Slicer 3D (ne 2021) .Any events that required reoperation, extended inpatient care, and/or higher-acuity care were classified as major complications; other events were classified as minor complications. The surgical resection performed in AMIGO was considered the index surgery for the surgical follow-up evaluations. Surgical follow-up was calculated from the index surgery to the selected follow-up end date of 31 December 2020. The overall follow-up was calculated based on the initial chordoma diagnosis and on the last available follow-up or follow-up end date. The progression-free survival (PFS) was based on clinical deterioration or local radiological progression after the index intervention. All statistical analyses were performed using Microsoft Excel  and SPSS version 23 .This cohort included nine patients  who underwent 11 surgeries in the AMIGO suite from January 2013 to December 2020 . Three oSix of the eleven surgeries (54%) were performed on recurrent lesions, with an average of two prior surgeries before our index intervention. All three chondrosarcoma cases were newly diagnosed. All recurrent patients had previously undergone proton beam radiation, with one patient having undergone a combination of proton beam and gamma knife treatment . Surgical resection yielded a minimum of 89.4% debulking in our series. Gross total resection was achieved in three surgeries (27%), with four additional surgeries having achieved 98–99% resected tumor volumes. Notably, gross total resection was achieved in all of the three newly diagnosed tumors. When further resection was possible after using iMRI, the resection volume was extended on average from 92.8% to 97.7%. Finally, there was no statistical difference between the overall extent of resection of chordomas versus chondrosarcomas in our AMIGO cohort , with only one death during the follow-up having been recorded. The average overall survival was 2.8 years (0.3–7.2 years). The overall follow-up since initial diagnosis was 11.48 years (±8 years). The two patients with newly diagnosed chordomas underwent proton beam radiation after their index surgeries. One patient developed irradiation-induced panhypopituitarism. A total of two patients developed drop metastases in the cervical and lumbar spine, requiring additional radiation and surgery. The disease continued to progress in one of these patients, requiring salvage treatments including imatinib and erlotinib, which were unsuccessful. This patient succumbed after a total of 22 years from his initial diagnosis, representing the only death in this series.A 26-year-old, otherwise healthy female (patient # 9) presented with progressively worsening double vision. Her neurological examination was notable for a complete right sixth nerve palsy. Her MRI demonstrated an enhancing lesion of the upper clivus with a focal area of dural penetration abutting the basilar artery. The computed tomography (CT) scan demonstrated a partially calcified bony lesion with partial erosion of the right posterior clinoidal process (PCP) . The comA 64-year-old female (patient # 8) presented with recurrence of her clival chordoma five years after her initial transcondylar and occipito-C2 fusion surgery, followed by proton radiation treatment. She presented with worsening aspiration. Her MRI depicted a recurrence extending into the right cerebellopontine angle. She underwent surgery in the AMIGO suite after careful preoperative planning. Tumor resection was obtained through a restrictive window because of the presence of the fusion hardware and the position of the carotid and vertebral arteries, as well as the jugular bulb. The surgical cavity was then filled with harvested abdominal fat. Intraoperative T1 and contrast T1 with fat saturation as well as T2 images showed an island of residual tumor within the retropharyngeal area ventral to the clivus. The residual tumor was segmented, and the intraoperative images were co-registered to the initial surgical space. The updated navigation was employed to guide resection to the segmented area directly. After minimal drilling of residual normal-appearing condylar bone, the residual tumor was visualized, allowing its resection. Postoperative imaging was consistent with resection of the targeted tumor. The patient’s immediate postoperative exam was stable with progressive improvement of lower cranial nerve deficits over the following months .Surgical techniques and outcomes are constantly improving with technological advancements that have been introduced to the operating room over the past decades. Multiple imaging modalities are now available intraoperatively to provide visualization beyond what the surgeon can see directly. The integration of these modalities during surgery guides operative steps potentiating the benefits provided by each technique ,14,15,16High precision can be obtained in the skull base registration and can crucially be maintained throughout the case, as no shift occurs in the skull base during the resection, unlike during intra-axial surgery. Although visualization of the residual tumor via intraoperative imaging is critical, its co-registration to the prior surgical field, thereby allowing direct guidance to the targeted residual, is crucial . As surgIn our case series, the average extent of resection reached 97.7%, which was in line with that which was recently reported by Metwali et al. in their series focused on iMRI, endoscopic endonasal, and transoral approaches . They alDue to the rarity of chordomas and chondrosarcomas, our study involved a limited number of patients. This series contains a high rate of recurrent chordoma, which is associated with limited control and a higher complication rate. The availability of a surgical environment comparable to the AMIGO suite is clearly limited to specific institutions, and generalization cannot be easily made to most surgical environments. However, techniques such as intraoperative CT and MRI, ultrasounds, endoscopes, as well as neuronavigation with intraoperative co-registration, fluoroscopy, and endovascular interventions are becoming widely available, and their use is rapidly increasing as these technological tools become more affordable.Advanced multimodality intraoperative imaging is valuable in the surgical management of skull base chordomas and chondrosarcomas and supports improved surgical outcomes. Immediate availability of intraoperative angiography and endovascular procedures can be vital, particularly during the resection of previously irradiated lesions. We find that intraoperative integration of the different imaging modalities via real-time navigation is pivotal to successful safe radical resection.


Purpose Bochdalek's hernia is a type of congenital diaphragmatic hernia occurring secondary to a defect in the posterior attachment of diaphragm. This condition commonly presents with respiratory insufficiency in infants. To date, there are less than 100 cases of Bochdalek's hernia presenting in adults published in the literature. The mainstay treatment of Bochdalek's hernia involves reduction of hernial contents back into the peritoneal cavity with a tensionless graft repair closing the diaphragmatic defect.Case Presentation We present an atypical case of the Bochdalek hernia presenting in a previously healthy 16-year-old male who presented to the Accident and Emergency department with a 2-day history of dysphagia and loss of breath. The Bochdalek hernia was confirmed on computed tomography (CT) imaging and the patient underwent surgical repair with Gore-Tex mesh.Conclusion The report shows a rare case of the Bochdalek hernia in a young adult, successfully managed with a laparotomy. Bochdalek's hernia is a type of congenital diaphragmatic hernia occurring secondary to a defect in the posterior attachment of diaphragm. It constitutes 85% of cases.We present a case of a left-sided Bochdalek's hernia in a 16-year-old male who was successfully treated. We believe that Bochdalek's hernia being rare in adults can be easily misdiagnosed and should be considered in patients presenting with gastrointestinal and respiratory symptoms. As a result, we believe this case report is a significant addition to the current literature.We present a case of a 16-year-old boy with no significant past medical history who presented with a 2-day history of decreased appetite and dysphagia. He also complained of epigastric pain. He did not experience any fevers, chills, rigors, or hematemesis and experienced one episode of shortness of breath 2 days prior to admission.A chest X-ray followed by a contrast-enhanced computed tomography (CT) scan of the thorax  were peHe subsequently underwent a laparoscopic repair initially which was converted to laparotomy. A large congenital left diaphragmatic hernia was observed with an acutely torted intrathoracic spleen and stomach, as well was left part of transverse colon, and small bowel loops. Despite an attempt to perform a laparoscopic repair, the surgery had to be converted to an open procedure. The hernia was reduced successfully and a Gore-Tex mesh was applied to the diaphragmatic defect, approximately 7 cm in diameter and secured with prolene sutures . In vieThe patient had an uneventful recovery and was discharged 10 days after the procedure.Bochdalek's hernia is a subtype of diaphragmatic hernia, through the posterolateral foramen of Bochdalek.Presentation in adults commonly occurs due to delayed rupture of peritoneal sac which contains the viscera or plugging of the diaphragmatic defect by a solid organ and subsequent herniation after increased intra-abdominal pressure such as in obesity and pregnancy.Since the hernia commonly results in pulmonary hypoplasia and therefore pulmonary symptoms, it is commonly diagnosed in neonates and infants.Symptomatic presentation varies between children and adults. In children, the commonest presentation is that of respiratory distress. Adults tend to present with more chronic symptoms such as pleural effusion, chest pain, dyspnea, abdominal pain, dysphagia, and postprandial fullness.The contents of the hernial sac varies and depends on the size of the herniation. In half of acute presentations, the sac contains colon. In 40% of cases the sac can contain other viscera notably the stomach, liver, gall bladder, small bowel, and spleen. Right-sided herniae commonly include liver and intestine. Left-sided herniae include spleen, small intestine, stomach, and colon.In the absence of trauma, chest X-ray readily diagnoses the presence of Bochdalek's hernia usually heralded by the presence of loops of bowel or soft tissue within the chest.The current mainstay of treatment remains surgical repair due to risk of strangulation and visceral herniation.If left unrepaired, previously reported cases have documented complications such as gastric gangrene, ischemic bowel necrosis, respiratory failure, splenic infarction, and gastric volvulus.The case presented in this report illustrates the pathway employed in the typical diagnosis in an emergency setting and the associated management of Bochdalek's hernia. This report presents only one example of clinical presentation and therefore is not generalizable to all cases of Bochdalek's hernia. However, the management remains common in all documented cases in the literature.The presence of congenital diaphragmatic hernia in adults remains rare and misleading even for experienced clinicians as the condition will mimic other diseases. Timely diagnosis and a high index of clinical suspicion are required to avoid complications. Surgical repair is recommended for all cases of Bochdalek's hernia.


We report a case of a 68-year-old man with medical history of pleural asbestosis and diagnosed with malignant peritoneal mesothelioma. This neoplasm is rare, has a poor prognosis, and is associated with asbestosis in many cases. It manifests clinically insidiously and in relation to the intra-abdominal locoregional effect. Radiological findings are variable, although the finding of “omental cake” by CT scan is characteristic but not pathognomonic, as seen in our case. A biopsy is required for the diagnosis, which can be guided by radiology or surgery. Treatment options available are cytoreductive surgery with intraperitoneal hyperthermic chemotherapy or systemic chemotherapy. However, new therapeutic options are emerging, which are still under development and research. Malignant peritoneal mesothelioma (MPM) is a rare neoplasm that accounts for 10%-15% of all mesothelioma cases and it is associated up to 50% of the time with asbestosis. It usually presents without differences in terms of sex, with a mean age of 64 years and related to the intra-abdominal locoregional effect, insidiously in the form of abdominal pain or distension [We introduce a case of a 68-year-old man, with medical history of being ex-smoker and having pleural asbestosis Figure , who wasLaboratory tests  were normal, except for elevation in CA 125 level (85 U/ml). Subsequently, a complete oral digestive endoscopy and colonoscopy were performed at the same time, with the only finding of a colon with poor distensibility. After that, an abdominal CT scan was done, highlighting a thickening of the nodular anterior parietal peritoneum congruent with “omental cake” . However, cases of MPM have been linked less frequently to asbestos exposure compared to the pleural form, as only 33%-50% of patients diagnosed with MPM report any known prior exposure to asbestos compared to greater than 80% in pleural mesothelioma. The latency period between exposure and the development of mesothelioma is approximately 20 years for MPM and 30-40 years for its pleural counterpart. In addition, MPM induced by asbestos generally requires a higher cumulative dose than its pleural counterpart. Other mineral fibers likely play a causative role, with the silicate fiber erionite also being a potent inducer of MPM. In addition, other factors described include therapeutic radiation, papovirus, simian virus, chronic inflammation, and inherited susceptibility [Although there is a lack of specificity for MPM in imaging tests, they appear as intraperitoneal masses or diffuse irregular or nodular peritoneal thickening  on abdominal CT scans, which are characteristic but not pathognomonic. Other findings of MPM are the presence of ascites and very infrequently lymphadenopathy or distant organ involvement. Among tumor markers, CA-125 is elevated in 94% of patients with malignant mesothelioma. However, definitive diagnosis is by biopsy, which can be guided by radiology (CT) or surgery. MPM includes three histologic subtypes: epithelioid (as seen in our case), sarcomatous, and biphasic . There iOther pathologies such as peritoneal carcinomatosis secondary to gastrointestinal or ovarian neoplasm, as well as peritoneal tuberculosis, must be dismissed -3.The selection of the best therapeutic management should be done by a multidisciplinary team specialized in this type of neoplasm, with the current therapeutic options being both cytoreductive surgery with intraperitoneal hyperthermic chemotherapy or systemic chemotherapy -4,9. TheMPM is a rare neoplasm but one that we should suspect in a patient with abdominal pain and a medical record of environmental asbestos exposure, as seen in our patient. Findings in the imaging tests are varied but not specific, although they could lead to diagnosis of MPM, which is made by biopsy. Treatment options include cytoreductive surgery with intraperitoneal hyperthermic chemotherapy in selected patients and systemic chemotherapy. However, molecular treatment and immunotherapy are being researched, which could change the management of this cancer. At one-year follow-up, our patient is in good clinical condition and is receiving systemic chemotherapy (cisplatin and pemetrexed), as he could not benefit from cytoreductive surgery with intraperitoneal hyperthermic chemotherapy.


The diagnosis of tuberculosis must be made in the face of any cervical swelling, and the treatment is essentially medical. The diagnosis of tuberculosis must be made in the face of any cervical swelling, and the treatment is essentially medical. The clinical manifestations are polymorphic and nonspecific. It is important for clinicians to be aware of this pathology.Mycobacterium tuberculosis or bovis that can affect all organs. In the ENT area, lymph node involvement is the most common. Isolated localization of tuberculosis in the salivary glands, especially the parotid gland, is extremely rare.Tuberculosis is a granulomatous infection caused by We report a case of primary tuberculosis of the left parotid gland simulating a parotid tumor in a 50‐year‐old woman, and we discuss the different diagnostic and therapeutic elements of this pathology, insisting on the need to demand a molecular test (PCR) combined with a histological study.2A 50‐year‐old woman, without any notable pathological antecedent, without any notion of tuberculosis contagion, and consuming unpasteurized raw milk, consulted for cervical tumefaction. The history of the disease goes back to 8 months with the appearance of a left cervical swelling progressively increasing in volume, which presented a month ago a redness with pain. In addition, the patient complains of chills and night sweats and unquantified weight loss.The clinical examination finds a left cervical mass located in the retromandibular and under the auricle of the left ear painful with a red facing skin measuring 3*3 cm hard and adherent, without peripheral facial paralysis and without inflammation of the ositum of the stenon. The rest of the ENT, lymph node, and lung examination is without particularities.Cervical ultrasonography showed a heterogeneous hypoechoic parotid gland process containing areas of necrosis.Cervical CT scan showed the presence of a very limited, hypodense, bilobed formation at the lower pole of the left parotid gland, which rises in the periphery after injection of contrast material, coming into intimate contact with the sternocleidomastoid muscle and measuring 31 × 26 mm  and on liquid medium type MGIT® (Mycobacteria Growth Indicator Tube) which were positive respectively 21 days and 12 days. Therapeutic treatment was initiated based on molecular data.The right parotid gland was without notable abnormalities with no cervical adenopathies. The biological assessment was normal, as was the chest X‐ray. During the explorations, the evolution was marked by spontaneous fistulization of the mass at the cervical level, with pus outcome. A biopsy curettage through the fistulous orifice was performed, with bacteriological and anatomopathological samples. The bacteriological study included a molecular study using GeneXpert MTB/RIF (Cepheid) which allowed the detection of The histopathological study confirmed the molecular diagnosis by showing epithelioid and gigantocellular granulomas with caseous necrosis, with no histological sign of malignancy. Hence, the interest to request a molecular test associated with an anatomopathological study.An extended (9‐month) four‐drug regimen  was initiated according to our usual protocol: 2 RHZE/7 RH. After 6 years, the evolution was satisfactory without any relapse.3First described in 1894 by von Stubenrauch, parotid tuberculosis is rare. More than 90% of described cases occur in developing countries.Parenchymatous parotid localization is most often seen in disseminated tuberculosis, the diffusion being by hematogenous or lymphatic route from a pulmonary focus or isolated, posing a problem of differential diagnosis with the tumor pathology of the parotid gland. In this case, the Mycobacterium, localized at the oropharyngeal level, passes through a retrograde ductal route through the stenon duct. It must be distinguished from a tubercular involvement of the intraparotid nodes, which is much more frequent.Clinically, parotid tuberculosis usually manifests itself as a unilateral parotid swelling of progressive onset, which may be diffuse or nodular, resulting in a pseudotumoral syndrome. On the other hand, the presence of a cutaneous fistula is very suggestive of an inflammatory pathology. General signs of tubercular impregnation are rarely present, but must be sought and may guide the diagnosis, as well as the patient's geographical origin.Radiological examination data  generally do not allow the diagnosis to be made. A chest X‐ray should always be requested in order to look for a possible primary focus. Biologically, an inflammatory syndrome is usually present, and the tuberculin intradermal reaction is not always positive.Thus, there is no clinical, radiological, or biological evidence to support a diagnosis of parotid tuberculosis. Therefore, the differential diagnosis of the diffuse forms is mainly based on lithiasis parotiditis or carcinoma, while the circumscribed form is more suggestive of a cyst, adenitis, or mixed tumor.The challenge for the practitioner is, therefore, to make the diagnosis before the surgical exploration and histological examination of the parotidectomy specimen, especially if this picture is seen in the child who is exceptionally affected and in whom the diagnosis is, therefore, very rarely mentioned.Fine needle cytopuncture with culture of the puncture fluid may be useful, but is only of value if it is positive. It has a specificity of 81% and a sensitivity of 94%.Exofacial parotidectomy has long been recommended for diagnostic purposes and to allow better diffusion of antituberculosis drugs. It is currently abandoned by all the authors because of its non‐negligible morbidity and the effectiveness of medical treatment alone. It is based on the prescription of long‐term antituberculosis drugs, generally for 6‐9 months, allowing a rapid disappearance of the parotid tumor syndrome.4If lymph node localizations are excluded, ENT tuberculosis is a rare condition. It can affect all age groups, although it is more common in young adults. The clinical and paraclinical signs are not very specific; the diagnosis is essentially based on histology and bacteriology, hence, the importance of multiplying biopsy samples if necessary. In doubtful cases, PCR has proven its effectiveness.In an endemic country such as Morocco, tuberculosis should always be mentioned as a differential diagnosis. The evolution under well‐conducted medical treatment is excellent.The authors declare no competing interest.BE, BHM, and SY: involved in drafting of manuscript. BY, MA, CM, and BF: involved in revising of manuscript. ELM: provided final approval of version to be published. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Verbal and written informed consent was obtained from the patient to participate in this study.


Sympathetic ophthalmia (SO) is a rare, severe condition that typically presents as bilateral diffuse granulomatous uveitis secondary to trauma in one eye. The variability of symptoms requires that diagnosis depends heavily on the correlation of these symptoms with relevant imaging. Visualisation of characteristic nodules seen between the Bruchs membrane and the retinal pigment epithelium, and the presence of Dalén Fuchs nodules, can be diagnostic when coupled with the clinical findings. This report discusses the use of spectral domain optical coherence tomography (OCT) to indicate the presence of Dalén Fuchs nodules, which have previously not been identified on OCT in a confirmed case of SO. Sympathetic ophthalmia (SO) is described by Castiblanco et al.  as an inA 60-year-old male patient who had undergone past surgery for retinal detachment repair and cataract removal in his right eye, presented with recent onset photopsia in his left eye. Examination showed multiple small yellow-white Dalén Fuchs nodules at the level of the retinal pigment epithelium in the left eye as shown in Figure A diagnosis of SO was made in light of clinical findings and imaging, with the OCT of the Dalén Fuchs nodule clinching the diagnosis. Since the focus of our report is on the diagnostic imaging findings, subsequent clinical management of the patient post-diagnosis has not been covered. Sympathetic ophthalmia is a rare condition and to date, there is limited imaging of the Dalén Fuchs nodules on OCT. While Correnti et al.  have proIt is also important to distinguish between SO and VKH, as both have similar case presentations including the development of Dalén Fuchs nodules . VKH varIn this case, OCT imaging has been key to identifying Dalén Fuchs nodules in a known case of SO. The imaging juxtaposed with clinical history and progression rules out other differential diagnoses such as sarcoidosis and tuberculosis and allows for a conclusive diagnosis of SO to be made.In our case, OCT imaging has been key to identifying Dalén Fuchs nodules in a known case of SO. We recommend that future research explore the possibility of the role of this diagnostic technique in the early detection of SO.


Extracranial carotid artery aneurysms in children are extremely rare, nevertheless associated with a great potential of thromboembolic episodes and rupture especially those with mycotic origin. The surgical treatment is very challenging, and there is still a controversy concerning revascularisation after the resection of the aneurysm. In this manuscript, we report the observation of an 8-year-old boy with the medical history of Leukemia who is admitted urgently for a mycotic right common carotid artery aneurysm, occurring after a chemoport infection who was operated on in our cardiovascular surgery department with surgical resection and ligation. It is the second report in the pediatric literature of a mycotic pseudoaneurysm situated in the common carotid artery, but the first documented by medical imagery. Through this case, we highlight that ligation of the infected carotid artery can be a safe and efficient alternative especially in Children. The surgical management is challenging and subject to controversy concerning the adequate technique.Mycotic extracranial carotid artery aneurysm (ECAA) in children is extremely rare but associated with a high potential for rupture and thromboembolic episodes.In this article, we present an 8-year-old boy with a case of mycotic ECAA who was operated on in our cardiovascular surgery department. It is the second report in the literature of a mycotic pseudoaneurysm located in the common carotid artery.An eight-year-old male North African child treated for leukemia was referred to our cardiovascular surgery department for management of a right lateral-cervical mass. The patient did not report any history of tonsillectomy or cervical trauma. The child was being followed for acute lymphoblastic leukemia type B for which he was receiving polychemotherapy. He had central venous ports (chemoports) placed via the right internal jugular vein one month prior to admission. The chemoport was complicated by a venous thrombosis with port chamber infection two weeks after its implantation. The chamber and the central venous catheter were removed, and the child received a double intravenous broad-spectrum antibiotic (Amoxicillin-Clavulanic Acid and Sulfamethoxazole) treatment two weeks before admission. The patient subsequently developed a right latero-cervical mass one day before admission.Upon physical examination, the child was in good general condition, awake and alert. He was feverish (temperature = 38.9 EC); cardiac and pulmonary examinations were normal. Neurological examination was normal, notably without signs of facial weakness. Otorhinolaryngological examination was normal, ears and nose were clean. The pharynx exam was also normal, notably without erythema, exudates, or pharyngeal oedema. The patient had a right latero-cervical tumefaction  painful 9/L . The C-reactive protein reached 95 mg/dl. .He also presented a cutaneous ulceration with a diameter of 5 cm, located under the right clavicle (former location of the implantable chamber), with inflammatory signs all around . CompletA cervical ultrasound found a right common carotid artery (CCA) false aneurysm measuring 29-28 mm of axis, with inflammation of the right cervical subcutaneous tissue associated with huge cervical lymphadenopathies. A cervical Angio-Computed Tomography (CT) scan  showed aHaemocultures were carried out but did not find any isolated pathogens.The patient was operated on the evening of his admission. The procedure was carried out under general anaesthesia. The surgical incision was a lateral right cervicotomy extended to the sternal fork. First, the CCA was dissected and controlled at its origin and terminated just before the carotid bifurcation . An arteDuring the postoperative period, the child was hospitalized in the intensive care unit. Excised local lymph nodes and aneurysm tissues were sent for bacteriological and pathologic examination. The culture of bacteriological samples was negative, a predictable result given the probabilistic antibiotic therapy introduced from the first presentation of symptoms. Repeated haematological analysis showed that his leukocyte levels had dropped to normal values.The patient made an ordinary recovery and was discharged after two weeks. Low-dose aspirin (75 mg per day) with 6 weeks of oral antibiotics (Amoxicillin/Clavulanate 15 mg/kg every 12 hours) were prescribed. Upon one-year follow-up, the neurological examination was normal, and in particular showed no neurological sequelae.Extracranial carotid aneurysms are uncommon in the paediatric population. Therefore, their natural history remains unclear. A literature review that was published in 2021 revealed that only 26 cases of infectious extracranial carotid artery pseudoaneurysms had been reported since 1990. The first case of an extracranial pseudoaneurysm of the common carotid artery was reported by Willemsen in 1997; our report is the second one in the medical literature.Most of the infectious extracranial carotid pseudoaneurysms occur in the internal carotid artery. Historically, ear/nose/throat infections are associated with some vascular complications, such as the Lemierre syndrome  and, uncommonly, carotid artery false aneurysm. However, these complications have become exceptional nowadays due to the widespread use of antibiotics.In childhood, ECCA formation is mainly secondary to infection or trauma. This infection was promoted by the state of immunodepression caused by his leukemia. The interval separating the initial infection and the diagnosis of the pseudoaneurysm was 15 days in our case. This is in line with the data reported in the literature.The physiopathogenesis of the carotid false aneurysm in this case is not completely clear. We thought that the contiguous dissemination of infection into the parapharyngeal area appeared to be the main cause. In the study herein, the child had an infection of the chemoport implanted via the right internal jugular vein, which we presumed to be responsible for this deep neck infection. Pseudoaneurysm formation is secondary to fragilization and dilatation of the arterial wall by infectious arteritis. Other clinical signs are dyspnea, dysphagia, and voice hoarseness by compression of adjacent anatomical and nervous structures. Neurological symptoms have been noted in relation with either a cerebral infraction or Horner’s syndrome.Pulsatile cervical mass is the most frequent clinical presentation of ECCA in the surgical literature. This complication is more frequent with mycotic aneurysm. Pourhassanet al., reported a rupture rate of around 42% in their review of literature concerning carotid aneurysms in children.In addition, a patient may present with a haemorrhage secondary to the rupture of the pseudoaneurysm. It is highly necessary to assess the Willis polygon and the structures surrounding the aneurysm, before any possible surgical procedure in order to reduce complications. Cervical angiography is performed only if an endovascular treatment is considered.The diagnosis in this case was based on cervical Doppler ultrasound and CT angiogram.It is important to note the lack of evidence-based treatment guidelines for this complication in paediatric patients. However, given the high risk of rupture, urgent intervention is highly recommended.Several treatment strategies with different levels of efficacy and limitations are available in cases of children with infectious extracranial carotid pseudoaneurysm, including surgical treatment, endovascular treatment, or a combination of the two. However, in children, arterial reparation may not be realizable if the greater saphenous vein is small in diameter. In these cases, ligation can be proposed. In addition, reconstructive techniques are challenging because of inflammation and proximity of cranial nerves.Pseudoaneurysm resection with restoration of the arterial continuity using a saphenous venous graft is the most habitual surgical treatment. The risk of stroke is relatively low in children in contrast with adults. However, we can only perform ligation if the collateral circulation is intact, in order to minimize neurologic consequences.A few cases of ligation of CCA or ICA among the paediatric population, as in our case, have been reported in the literature. However, there is still concern that coil embolization or stenting for infectious area may expose patients to an increased risk of persistent infection. In all cases, we must combine a 4–6 weeks broad-spectrum antibiotic therapy with the chosen surgical or endovascular treatment.Endovascular techniques such as stenting, and coil embolization have provided a less invasive approach to the treatment of infectious pseudoaneurysms in children. However, there is a lack of data on long-term consequences.Like our patient, in the majority of paediatric cases, an uneventful early outcome is reported.Mycotic carotid pseudoaneurysm is a rare complication in children, but associated with a high risk of fatal rupture. When diagnosed, it should be treated urgently. Surgical ligation seems to be a reasonable and viable choice of treatment, especially in children.Written informed consent for publication of the patient’s clinical details and/or clinical images was obtained from the father of the patient. The case presented here is well described by the authors, such as all the possible options for its repair have been deeply analyzed.et al., 2018). If feasible, biological grafts are resistant to infections and guarantee high rates of patency in the long term. In my personal experience, in particular in children or younger people, I always suggest exploring the possibility of arterial reconstruction. My personal experience on a similar case, but without any spread of local infection that could be eventually inserted among the references, was to reconstruct the whole carotid bifurcation using the greater saphenous vein and one of its major tributaries (Giacomini’s vein) . Moreover, a valid backflow, together with the measurements of the stump pressure from the ipsilateral internal carotid, can give further valuable information regarding the status of collateral supply to the brain. The background of the case’s history and progression is well detailed even if, in all these cases, the real event which leads to pseudoaneurysm development can only be supposed.et al. is clearly presented with updates on the most recent literature regarding this niche topic and conclusions are correct and well balanced. The major problem is related to the extreme rarities of such cases and, as reported by the authors, the complete lack of evidence and the absence of guidelines. Anyway, the work of Imtinene In this way, I think that every report on bailout treatments for arterial disease in newborns or children can be helpful for all the surgical community in order to provide and share therapeutic ideas for these really challenging cases. I congratulate the authors for their very interesting study which turns the lights on in this disputed topic.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Vascular surgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. In this paper, an original pediatric case of mycotic aneurysm of the common carotid is presented and well documented. Given the seldomness of such cases, the case deserves publication. Strategy and tactics in emergency are well explained, justified and post-hoc-approved by the uneventful outcome. The paper will be particularly useful for a young vascular surgeon confronted with such an unusual challenge, especially in emergency. Moreover, the discussion on whether or not revascularize is particularly relevant from a medicolegal point of view. Young surgeons may be confronted with septic disasters affecting arteries of potentially vital arteries. There is then a choice between ligating to minimize the hemorrhagic risk but with the sacrifice of an artery of vital or functional importance or revascularizing, a much more complex procedure with an eventual risk of hemorrhagic, therefore vital complications. Strategic decisions must then be taken often in emergency and such decisions medicolegally expose the taker if eventually the vital of functional prognosis of the patient is affected. In our societies where the medicolegal issue is more and more a concern, it is important that published papers like this one show that the decision of ligating a potentially vital artery like the common carotid does not always result in a cerebrovascular disaster. I strongly recommend indexing.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Vascular SurgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Polyarteritis nodosa (PAN) is a medium-sized vasculitis with neuropathy, cutaneous manifestation, and gastrointestinal tract symptoms. An acute surgical abdomen is a severe but rare development of gastrointestinal involvement of PAN, with large bowel involvement and subsequent perforation being sporadic. Here we present a rare case of PAN who had large bowel involvement with perforation due to newly diagnosed PAN, who also had concurrent and separately perforated sigmoid diverticulitis, confusing the clinical picture. High clinical suspicion and timely management are vital in diagnosing and managing patients with PAN and an acute surgical abdomen. Polyarteritis nodosa (PAN) is systemic necrotizing arteritis involving mainly medium-sized vessels -3. PolyaLarge bowel involvement in PAN is rare, with colonic perforation even rarer. Large retrospective studies on PAN have only shown a couple of cases of isolated colonic perforation over many years ,4. Most Here we describe a rare case of PAN involving the sigmoid colonic diverticulitis. Given the similar presentation and dual pathology in this patient, a high clinical suspicion and revisiting histopathology is vital in ensuring patients have the correct diagnosis.A 53-year-old male had three days of right-sided abdominal pain before presenting to our hospital’s emergency department. He had nausea without vomiting, subjective fevers, and was obstipated for three days prior to admission. On arrival, the patient had new-onset atrial fibrillation with a tachycardic up to 144 and without any recorded fevers. He had a surgical abdomen with rebound and percussion tenderness to the right abdomen on examination. He had a background of Rheumatoid Arthritis, diagnosed 10 years ago, and Hypertension; and was on 30mg of Prednisone daily, Methotrexate 5mg daily, and Telmisartan 80mg daily. His White Cell Count was 33 x10^9/L, his C-reactive protein was 200mg/L, and his lactate on Venous Blood Gas was 1.5mmol/L; his creatinine and Estimated Glomerular Filtration Rate were normal. A CT abdomen and pelvis showed a perforated sigmoid colon with free fluid and gas next to the sigmoid colon and widespread luminal thickening of the small and large bowel  is a systemic necrotizing vasculitis involving medium-sized arteries. Historically, PAN was associated with prior Hepatitis B Virus (HBV) infection. However, with an increase in the prevention of HBV infection, diagnosis of HBV-associated PAN is becoming increasingly rare with proportionally increased diagnosis of idiopathic PAN ,3,4,9. IThirty-four percent of patients have gastrointestinal involvement presenting as peritonitis, bowel perforations, bowel ischemia/infarction, intestinal occlusions, acute appendicitis, cholecystitis, and acute pancreatitis . UnfortuTreatment of idiopathic PAN includes high-dose corticosteroids and possibly an immunosuppressant depending on the severity of PAN . Sixty pDiverticulitis is the infective inflammation of diverticulosis that outpouches within the large bowel consisting of only mucosa and submucosa. The descending and sigmoid colon is the most common site of acute colonic diverticulitis. Classical manifestation of acute colonic diverticulitis includes obstipation and abdominal pain localized to the left lower quadrant. At the same time, free perforation has peritoneal irritation, marked abdominal tenderness that may spread to the rest of the abdomen. The severity of diverticulitis is often graded with Hinchey criteria. Treatment is usually antibiotics for uncomplicated localized infection with up to a small abscess (<3cm), while percutaneous drainage or operative intervention is required for higher staged diverticulitis . ImmunosLarge bowel involvement in PAN ranges from colitis, colonic ulcer, colonic ischemia, and colonic perforation ,5,12. WhPAN is a rare medium size vasculitis that frequently has gastrointestinal manifestation. Colonic involvement, however, is uncommon, with colonic perforation even rarer. Patients with PAN and an acute surgical abdomen have a poor prognosis, which is also reflected in colonic perforation. We present a rare case of colonic involvement and perforation with concurrent diverticulitis in the context of PAN, who thankfully, with time management, progressed well.Both colonic perforations in the context of PAN and perforated diverticulitis without PAN may present with similar presentation initially. Indeed, mesenteric vasculitis and necrosis could worsen diverticulitis, especially when the patient was already on corticosteroids. However, the post-operative management of a patient with PAN is different from that without PAN. Severe PAN with at least one major organ involvement, especially gastrointestinal involvement, should be treated with corticosteroids and cyclophosphamide. Given the similar presentation and dual pathology in this patient, a high clinical suspicion and revisiting histopathology is vital in ensuring patients have the correct diagnosis.