Pseudoaneurysms of the superficial temporal artery are an uncommon vascular lesion of the external carotid system and most often the result of blunt head trauma. The frequency of pseudoaneurysms of the superficial temporal artery developing after craniotomy is exceedingly low and only a few cases have been reported. We present a case of pseudoaneurysm of this type in a 45-year-old male who underwent craniotomy for excision of meningioma. One month postoperatively, the craniotomy flap exhibited an enormous diffuse pulsate swelling. The suspected diagnosis of pseudoaneurysm arising from superficial temporal artery was confirmed on angiography. Surgical excision was done and no recurrences of the tumor or aneurysm were noted on subsequent follow up. A pseudoaneurysm is a dilation of an artery that includes a defect in one or more layers of arterial wall . PseudoaA 45-year-old male presented with a complaint of a headache lasting 3 months. On fundoscopy, he had papilledema. A CT Scan Brain revealed a large space occupying lesion arising from the sphenoid ridge along with hyperostosis. Brain MRI with contrast showed a homogenously enhancing lesion with significant mass effect. Radiological findings were consistent with meningioma.After angioembolization, frontotemporal craniotomy was done and the lesion was excised completely. The patient had a smooth recovery in post-operative phase and he was discharged 10 days after surgery.diffusely homogenous, normal in color, pulsatile in nature and indolent (Figure During his follow up 1 month after surgery, he presented with a diffuse swelling of craniotomy flap, although the edges of wound were healthy. The swelling was t Figure  and 3. AThe first case of superficial temporal artery pseudoaneurysm was described by Thomas Bartholin , 2, 4, 6The anterior branch of the STA is most vulnerable to injury from blunt trauma due to its superficial course and close proximity to the underlying bony structures , 4, 10. The time period from craniotomy to pseudoaneurysm in the literature varied between 4 days and 3 months , and in Differential diagnoses for STA pseudoaneurysm include vascular tumor, arteriovenous fistula, meningeal artery aneurysm with bony erosion, subcutaneous lipoma, abscess, and localized hematoma –5, 7.Many authors believe that superficial temporal artery pseudoaneurysm should be diagnosed clinically from history and physical examinations , 2, 4. HIndications for surgery are cosmetic, treat headache, and avoid pain and hemorrhage , 4. SurgThis case is intended to caution surgeons dealing with craniotomy of this rare complication. A post-craniotomy temporal mass should be considered a STA pseudoaneurysm until proven otherwise, and needle decompression should not be attempted. Surgical excision of the pseudoaneurysm of superficial temporal artery results in a good clinical outcome.The patient to which the case study refers provided oral and written consent to be featured in this article.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.


Imaging revealed giant bilateral adrenal masses. He subsequently underwent bilateral adrenalectomy found to be myelolipomas measuring 30 × 25 × 20 cm on the left and weighing 4.1 kg and 25 × 20 × 13 cm on the right and weighing 2.7 kg. Adrenal myelolipomas are found to coexist with many other conditions such as Cushing's syndrome, Addison's disease, and CAH. We discuss the association with high adrenocorticotropic hormone (ACTH) states and review the studies involving ACTH as proponent leading to myelolipomas. Massive growth of these tumors, as in our case, can produce compression and hemorrhagic symptoms. We believe it is possible that self-discontinuation of steroids, in the setting of CAH, may have resulted in the growth of his adrenal masses.Myelolipomas are rare and benign neoplasms, predominant of the adrenal glands, consisting of adipose and mature hematopoietic tissue, commonly discovered incidentally with increased use of radiologic imaging. Few cases of giant bilateral adrenal masses are reported, especially in the setting of congenital adrenal hyperplasia (CAH). We report the case of a 39-year-old male with a history of CAH secondary to 21- Although benign and endocrinologically inactive, myelolipomas are rare tumors of the adrenal gland that still present to surgeon's clinic for further evaluation. They consist of adipose and hematopoietic tissue and have been increasingly discovered due to the increased use of imaging such as computed tomography and magnetic resonance imaging for other medical conditions. Their incidence has been reported to be less than 0.4%, with a few growing to the size of giant bilateral adrenal masses. The development of these tumors has been associated with congenital adrenal hyperplasia (CAH) as in this case and with other adrenal hormonal diseases, which will be the focus of this discussion.α hydroxylase deficiency as a child, presented to the clinic with fatigue, headaches, decreased libido, easy bruising, and increasing abdominal distension. It was not clear from the history how he was diagnosed at birth, but the patient had been on steroids throughout his childhood but had self-discontinued them during adolescence due to concerns of weight gain. Imaging done as part of his adrenal pathology workup revealed bilateral adrenal masses measuring 16 × 12 × 15 cm on the right and 20 × 20 × 25 cm on the left one year prior to presentation to surgeon's clinic. The patient was then restarted on steroids and underwent a repeat computed tomography (CT) scan one year later, which showed interval increase in the adrenal masses , 17-hydroxy-progesterone was 14, 076 ng/dL (42–196), and ACTH level was 42 pg/mL (6–50). He had been restarted on hydrocortisone 10 mg by mouth twice daily and fludrocortisone acetate 0.1 mg by mouth daily by his endocrinologist for a year prior to presentation.Utilizing a midline incision, a Maddox maneuver was performed, releasing the splenic flexure and descending colon inferiorly to the sigmoid colon. Using blunt dissection, the left-sided adrenal mass was easily freed from the kidney, which was identified at its inferomedial aspect. The left adrenal vein was found, clipped, and divided. The left adrenal mass was freed from its surrounding attachments using sharp dissection. This was followed by a Cattel-Brach maneuver, which freed the ascending colon up to the hepatic flexure as well as the gastrohepatic ligament. A Kocher maneuver was then performed which freed the duodenum and allowed better access to the right-sided adrenal mass in the retroperitoneum. The right adrenal mass was then released from its surrounding attachments by elevating the liver and retracting the right colon medially, as well as a combination of sharp and blunt dissection. The right adrenal vein was identified coursing into the inferior vena cava and divided using an endovascular stapler. The mass was then removed and both fossae were evaluated for bleeding. Attempts were made throughout the operation to identify a plane separating the masses from normal adrenal tissue, but due to the sheer size of these masses, no such plane could be found and thus the entire adrenal glands were removed. All other organs were inspected and found to be normal, and two drains were placed to drain the retroperitoneal fossae bilaterally and the abdomen was closed.Postoperatively, the patient was transferred to the intensive care unit as a precaution to monitor for an Addisonian crisis. His postoperative course was marked by persistent tachycardia but appropriate blood pressure. He was started on the appropriate steroid dosage, and supportive care with fluids was continued. A CT scan of the chest was done in the postoperative period to rule out pulmonary embolism due to persistent sinus tachycardia unresponsive to fluids or steroids. The CT scan was requested by the cardiologist involved in the case and was negative for pulmonary emboli showing only a small left-sided pleural effusion. The tachycardia resolved upon return of bowel function and the patient was transitioned to medications by mouth. The drains were removed by postoperative day 7 as the output decreased. The patient was discharged on postoperative day 8. The final pathology showed bilateral benign myelolipoma measuring 30 × 25 × 20 cm on the left and weighing 4.1 kg and 25 × 20 × 13 cm on the right and weighing 2.7 kg .Since surgery, he has followed up every 6 months and has complained of incisional pain but no other abdominal symptoms. The pain responded to an intercostal nerve block, which was done by his pain specialist. His postoperative hormone levels while continuing on his preoperative steroid medications and dosage showed an initial drop in testosterone levels to 34 ng/dL gradually returning to 227 ng/dL (241–827) on his next visit. He was not interested in testosterone replacement and does not wish to have any children in the future. His 17-hydroxy-progesterone level did normalize to 175 ng/dL (42–196), and his ACTH level was 46 pg/mL (6–50).Myelolipoma is a rare, benign, and endocrinologically inactive neoplasm. It is predominantly found in the adrenal glands and consists of adipocytes and mature hematopoietic tissue. It was first described in 1905 by Gierke as a mass lesion that is composed of mature fat tissue and mixed myeloid and erythroid tissue . In the In the majority of the cases, adrenal myelolipomas are unilateral and rarely exceed 4 cm. However, very large and bilateral myelolipomas have been reported. Tumors exceeding 8 cm are referred to as giant myelolipomas . The larMassive growth of this neoplasm can produce symptoms such as flank pain and abdominal discomfort due to rupture, hemorrhage, or necrosis . More seAlthough myelolipoma was first reported 100 years ago, its tumorigenesis still remains a mystery. There are many barriers that prevent detailed investigation of its etiology. The limited incidence of this neoplasm leads to highly inconclusive experiments. In addition, its unique mixture of fat and mature hematopoietic cells makes establishment of cell lines almost impossible limiting in vitro studies . Finallyα-hydroxylase deficiency [Adrenal myelolipomas are found to occur concurrently with other conditions with hormonal dysfunction such as cortical adenoma , ganglioficiency , 27. Amoficiency . There aficiency , 28, 29.ficiency , 30, 31,ficiency , and Addficiency  also supficiency , 35. In ficiency . Anotherficiency . On the ficiency . In addificiency .After reviewing the literature, we have found that there is no definite consensus on surgical management of adrenal myelolipomas. Although hormonally inactive, we discussed the possibility of accelerated growth of these tumors in the setting of congenital adrenal hyperplasia. Although the patient showed no signs of obstruction at the time of presentation, we felt that a discussion with the patient about surgical resection was warranted due to his mild discomfort and distension. This is especially the case in the setting of a young and relatively healthy patient undergoing an elective procedure, as opposed to a more urgent operation secondary to obstruction from progressively enlarging masses.


We encountered a case of gallbladder volvulus in an 88-year-old thin female in which the initial presentation was more consistent with that of acute appendicitis. After complete work-up, including physical exam, lab work, and computed tomography, the definite diagnosis of gallbladder volvulus was not made until intraoperative visualization was obtained. Gallbladder volvulus is a rare but serious condition, which requires a high clinical suspicion so prompt surgical intervention can be undertaken. Gallbladder volvulus (GV), also known as gallbladder torsion, is a rare cause of acute abdominal pain and an uncommon surgical emergency. First described by Wendel as a “floating gallbladder” in 1898 . A systeThe common contributing factor for GV is an abnormality in the anatomy of the gallbladder vascular pedicle . BasicalThroughout the years GV has been described on multiple occasions in the literature. We report a case of GV in an elderly female, who was initially suspected to have acute appendicitis given her clinical presentation and laboratory findings. Such a case of GV mimicking acute appendicitis in the elderly has only been reported two other times in the literature , 8.μL and by hospital admission day #9, her WBC had come down to 9.9 K/μL and her respiratory status was dramatically improved. The patient was getting ready to be discharged when later that night she suddenly developed right lower quadrant abdominal pain and therefore the surgical service was consulted.An 88-year-old female was initially admitted to the hospital for hypoxemia secondary to community acquired pneumonia (CAP) and acute chronic obstructive pulmonary disease (COPD) exacerbation. Her past medical history was only significant for COPD and she had never had any previous surgical intervention. She lived at home at the time and had a remote history of smoking. Upon admission, she was treated with appropriate antibiotics and aggressive pulmonary toilet. Her white blood cell count (WBC) upon admission was 18.3 K/μL. Because of this acute elevation in WBC and concern for appendicitis on physical exam, we ordered a computed tomography (CT) scan of the abdomen and pelvis. The CT scan demonstrated an 8.2 cm × 4.8 cm heterogeneous “fluid collection” within the right lower quadrant. An abscess could not be ruled out from the imaging nor could acute cholecystitis. The appendix did appear normal however. Figures The patient was evaluated by surgery on hospital admission day #10. By the time surgery evaluated the patient, she had four bowel movements, one of which was loose in nature, and she stated her abdominal pain was much improved. Physical exam did reveal abdominal pain with light or deep palpation in the right lower quadrant, directly over McBurney's point. An abdominal X-ray was obtained which was unremarkable and new labs were sent at this time. The complete blood count (CBC) did show an acute elevation of the WBC to 16.4 K/At this point, the patient's antibiotics were adjusted to cover for cholecystitis, appendicitis, and an intra-abdominal abscess as we did not know the exact pathology at this point. She was scheduled for surgery, which was performed laparoscopically. Initially, we placed a 5 mm Visiport trochar just superior to the umbilicus and a laparoscope was inserted. Much to our surprise, the previously described “fluid collection” on CT scan was actually a very distended, necrotic gallbladder that was torted a full 360° in the counterclockwise direction . LuckilyPostoperatively the patient did very well. She was started on a diet shortly after her surgery and her pain remained well controlled. The pathology report revealed acute gangrenous cholecystitis. The patient was discharged to a rehab center on postoperative day #2 due to some deconditioning she developed from her underlying pneumonia. At the patient's follow-up appointment in the clinic three weeks after surgery, she was found to be doing remarkably well.Over 750,000 cholecystectomies are performed annually in the United States ; howeverIn an attempt to help make the diagnosis of GV preoperatively, Lau developed what has become known as the “Triad of Triads” in 1982, which is used to help identify the clinical features of GV , 13. TriDelay in the diagnosis of gallbladder torsion can result in serious complications that include gallbladder necrosis, gangrene, and subsequent perforation resulting in peritonitis and prolonged hospital stay , 8. UltrIn conclusion, GV should remain on the differential diagnosis especially if there are multiple criteria for the “Triad of Triads” met or the patient has radiographic evidence of GV. Laparoscopic cholecystectomy remains the current treatment option of choice , 7, 18 r


Angiomyolipoma is a benign mesenchymal tumor composed of variable amounts of smooth muscle, adipose tissue and thick-walled blood vessels, and usually named PEComas (perivascular epithelioid cell tumors). PEComas share overlapping histopathological features with epithelioid cells along a perivascular distribution and characteristic immunohistochemistry with coexpression of myoid and melanocytic markers (HMB-45 /or Melan-A). We report the first case of primary orbital angiomyolipoma with negative melanocytic marker.An 80-year-old Asian woman had a 2-year history of progressive swelling in the left upper eyelid. External examination revealed 3 cm of relative proptosis of the left eye and a palpable mass in the left superonasal orbit. Computed tomographic scan demonstrated a circumscribed, heterogeneous orbital mass. Excision biopsy was done and the histological finding demonstrated the orbital mass was composed of mature adipocytes, intermingled with spindle or oval-shaped cells, and accompanied by thick-walled blood vessels. Immunohistochemically, tumor cells were positive for CD34 and HHF-35, but negative for cytokeratin, HMB-45 and Melan-A. The diagnosis of angiomyolipoma was made. No recurrence was noted at 2-year follow-up.In our case, the HMB-45 negativity may be explained by the rarity of the epithelioid cells, and the HMB-45 positivity is often weaker or absent in spindle cells. Angiomyolipoma, although rare, should be added to the differential diagnosis of space-occupying orbital lesion. Angiomyolipoma, originally thought to be a hamartoma, is a benign mesenchymal tumor composed of variable amounts of smooth muscle, adipose tissue and thick-walled blood vessels, and usually named PEComas (perivascular epithelioid cell tumors). It occurs most commonly in the kidney as a sporadic case or as part of the tuberous sclerosis complex . We presAn 80-year-old woman had a 2-year history of progressive fullness in the left upper eyelid. External examination revealed 3 mm of relative proptosis of the left eye and a nontender palpable firm mass in the left superonasal orbit Fig. . The remPrimary orbital angiomyolipoma is a rare entity of orbital tumor. Until now, only 4 cases of ocular perivascular epithelioid cell tumor (PEComa) have been reported, and all had positive melanocytic markers –4. All rApproximately one third of renal angiomyolipomas occur in patients with tuberous sclerosis. However, this association has been rarely reported in extrarenal angiomyolipoma, including of ocular angiomyolipoma. Because most angiomyolipomas contain varied amounts of adipose tissue, image features of fat attenuation at unenhanced CT may help in diagnosis. Although most angiomyolipomas show a benign course, some reports have suggested that histologically atypical angiomyolipomas are potentially malignancy. Therefore, wide excision and regular follow-up are warranted.In summary, we report a case of primary orbital angiomyolipoma, which showed different immunohistochemical features from prior reported ocular PEComa. Although rare, angiomyolipoma should be added to the differential diagnosis of space-occupying orbital lesion.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor of this journal.


Gossypiboma is defined as a mass caused by foreign body reaction developed around the retained surgical item in the operative area. When diagnosed, it should be removed in symptomatic patients. Minimal invasive surgery should be planned for the removal of the retained item. The number of cases treated by laparoscopic approach is rare in the literature. We present a case of forty-year-old woman referred to emergency room with acute abdomen diagnosed as gossypiboma and treated successfully with laparoscopic surgery. Gossypiboma defines a mass lesion shaped by foreign body reaction developed around sponge and such substances retained in the operative area. The abdominal cavity is the largest inside space of the human body. The most frequently retained objects are the cotton sponges which are often retained in the abdomen during general surgery operations. Surgical items including needles, clamps, retractors, and drains are reported to be retained in the abdominal cavity. They can either stay asymptomatic for years or present with abscess/peritonitis symptoms. The presence of foreign body is suspected by radiological imaging. The foreign body should be removed when diagnosed in symptomatic patients , 2. The A forty-year-old female patient was admitted to the emergency room due to abdominal pain and vomiting. She had no passage of gas and stool for two days. She had no fever and her vital findings were stable. Physical examination revealed a mass of eight centimeters in diameter palpated on the epigastric region. She had leucocytosis; the other blood analyses were normal. She had hysterectomy operation with Pfannenstiel incision four years ago and has been occasionally having abdominal pain after the operation. Air-fluid levels in a few intestinal loops and multiple opaque substances accumulated as a strip in the mid-line were noticed in the direct abdominal radiography .The patient underwent contrast enhanced abdominal computed tomography (CT). A mass lesion suggesting gossypiboma among small bowel loops with dimensions of 107 × 60 mm in the level of L2–4 vertebrae, closely related with anterior abdominal wall, was detected. Inside the right half of the mass linear metallic hypodense artefacts and peripheral contrast enhancement were noticed .The patient was hospitalized and submitted to the operation on the same day. Laparoscopic approach was preferred in the operation. 10 mm camera port was inserted under direct vision below the umbilicus. Three 5 mm working trocars were inserted from left inguinal region, left subcostal region, and epigastric region. The jejunal and ileal loops adherent to the mass were separated with sharp and blunt dissections .The mass was removed with laparoscopic (tissue) extraction bag after dissection of the adhesions completely. The umbilical trocar incision was extended to 6 cm length for the removal of the mass . When thSurgical items left in the patients' bodies after completion of the operation can lead to serious medical, legal, and social problems both for patient and surgeon . It is eFactors associated with retained surgical items include emergency surgical procedures, unexpected changes in the course of operation, duration of the operation, excessive loss of blood, alteration of surgical team or nurses during the operation, and inexperienced and insufficient number of personnel. Moreover, there are some other factors which are related to the patient's condition such as obesity and female gender . The majThe common items which are left during the operations are cotton sponges and laparotomy pads whose colours and patterns may change after contact with blood and other body fluids . In addiThe morbidity and mortality are low when noticed and removed in the early postoperative period. However, the longer it stays in the body, the more the complications rise. In the early postoperative period, the patient usually present septic findings, whereas it might be asymptomatic or present with vague symptoms. The retained foreign body causes histopathologically two types of foreign body reactions. In the first one, adhesion, encapsulation, and granulation take place with an aseptic fibrotic reaction around the foreign body . In suchIt is difficult to diagnose retained items in asymptomatic patients. These items can sometimes be noticed incidentally in radiological imaging like X-ray, magnetic resonance images (MRI), CT, and ultrasonography (USG) . RadiopaOnce gossypiboma is diagnosed, the treatment is to remove the retained material. It can be done both with open or laparoscopic surgery, as well as endoscopy. A foreign body transmurally migrated to stomach or colon can be removed by endoscopy . LaparosThe main reason we preferred laparoscopic approach in this case is that diagnosis was clear and clinically and hemodynamically stable and the mass was uniformly bounded in the CT images. The mass has been put into the laparoscopic extraction bag and removed by minilaparotomy as the dimension of the mass was too large. We therefore believe that laparoscopy can contribute to patient satisfaction by providing less hospitalisation and better cosmetic appearance.The important point to prevent the occurrence of gossypiboma is to take necessary actions, follow the operation procedure properly, and take necessary precautions into account throughout the operations. Some of the necessary precautions are to count all the equipment both at the beginning and at the end of the operation, to keep good record, to have radiological markers on sponges and pads, and to use scope if any doubt is present . NursingGossypiboma may be a life-threatening problem causing serious results. Differential diagnosis should be kept in mind in patients who had an operation background and in whom intra-abdominal mass was detected. Surgery should be planned in symptomatic patients since legal and medical problems may occur. Laparoscopic surgery provides the advantages of smaller incision, less pain, shorter hospitalisation, and reduced haemorrhage and infection ratios compared to open surgery. Laparoscopy can be safely implemented in appropriate cases by experienced surgeons. But it should not be forgotten that prevention is easier than treatment.


We report a case of a 14-month-old girl with undiagnosed Currarino triad presenting acutely with meningitis caused by enteric commensals. Head CT demonstrated a large pneumocephalus. A fistulous neurenteric tract through a presacral mass was present on spine MRI and abdominal CT. The patient had a history of constipation for the last three months. However, an underlying diagnosis of Currarino triad had not been suspected. In retrospect, a sickle-shaped sacral anomaly was present on a previous abdominal radiograph. The patient succumbed to complications of meningitis. The purpose of the case report is to highlight the potentially fatal complication of Currarino triad and sensitize radiologists to look actively for sacral anomalies on abdominal radiographs, especially of children with chronic constipation.  Currarino syndrome is a rare congenital complex disorder characterized by triad of partial sacral agenesis, anorectal malformation, and presacral mass . CurrariScimitar or sickle-shaped sacrum is the hallmark of the triad. The sacral abnormality is most often identified on an abdominal or pelvic radiograph. In older children, these radiographs may have been obtained for workup of chronic constipation or urogenital problems which are the most common symptoms of this syndrome –8.It is important to identify this syndrome early to prevent future complications like meningitis, which occurs in 7–11% of cases and has a high mortality of 50% , 7.A 14-month-old girl presented to the emergency department (ED) with high fever, abdominal distension, vomiting, and neck stiffness. The patient had a history of chronic constipation which had got worse in the preceding three months. She had delayed gross motor milestones. The immunizations were up-to-date. Her parents were consanguineous. She had four siblings. Her oldest brother had history of surgically repaired anal atresia at birth.On examination, the patient had clear signs of meningeal irritation. Her abdomen was significantly distended with visible peristalsis.9/l, neutrophils 53%, and bands 19%) and thrombocytosis (616 × 109/l). ESR was elevated at 89 mm/hr. Lumbar puncture showed purulent material. The CSF culture results were available on the next day and showed growth of polymicrobes, including extended-spectrum beta-lactamases E. coli, in addition to Enterococcus faecium. Urine and blood cultures were negative.At presentation she had peripheral leukocytosis , and the Klippel-Feil syndrome . Caudal As indicated by embryology, a high correlation of lumbosacral defect with anorectal and urogenital malformations is well described , 16, 17.The identification of sacral anomaly in an older child with constipation is challenging as the defect can be obscured by large fecal load in distal colon and rectum. A diligent evaluation of sacral spine on abdominal radiograph, especially in children with chronic lower gastrointestinal and urogenital symptoms, can lead to better detection or a dedicated sacral radiograph can be obtained. The sacral defect is sometimes identified on images obtained for vesicocystourethrogram. It is imperative to get a spine or pelvic MRI when a bony sacral defect is detected. The presacral mass when present is ideally removed surgically to prevent future complications.Patients with Currarino triad who are asymptomatic or have less severe chronic complaints and no visible anorectal malformation pose a clinical and radiological diagnostic challenge. The disease is rare enough to not warrant early consideration. These patients may present late with unexpected serious complications like meningitis or malignant degeneration of presacral mass. The first-degree relatives of patients with Currarino triad should be offered pelvic radiograph to identify asymptomatic heterozygotes of this autosomal dominant, variable penetrance disorder. Once a mutation has been detected, all family members should undergo genetic counseling to raise awareness and for pregnancy planning . The oldOur patient deteriorated rapidly and became unfit for surgery. In literature, appropriate management of these patients has been described by a two-step operation. The first step is to perform a functional colostomy to cut out the source of infection. The second stage involves definitive repair of the fistula and anorectal malformation along with tumor resection by posterior sagittal anorectoplasty after three months of antibiotic therapy , 5, 10.We emphasize the importance of careful evaluation of lower spine on abdominal radiographs of children with chronic constipation or urogenital complaints. Dedicated sacral radiographs can be done, if lower spine is not visualized optimally on abdominopelvic radiographs. Apart from detecting other disorders, it may lead to early identification of Currarino triad, thus preventing possible future serious complications. It is important to evoke the diagnosis of Currarino triad in the setting of meningitis with abnormal sacrum. These cases should be evaluated emergently by MRI and lumbar puncture with wariness. Early appropriate treatment can reduce morbidity and mortality.


Regional spinal and epidural anesthesia are used commonly in operative procedures. While the most frequent complication, postdural puncture headache (PDPH), is a clinically diagnosed positional headache that is usually self-limited, subdural hemorrhage (SDH) is a potentially fatal complication that cannot be missed. We report a case of an otherwise healthy female who presented with persistent positional headache and was ultimately found to have a large subdural hematoma with midline shift requiring surgical evacuation. Spinal and epidural anesthesia are commonly used in regional anesthesia and are considered standard of care in obstetric anesthesiology. Complications occur in approximately 0.05% of cases . The mosA 33-year-old female presented to the Emergency Department (ED) with a chief complaint of headache. The headache began three weeks before, shortly after she completed a normal spontaneous vaginal delivery without complication. During labor, she had one unsuccessful attempt at placing an epidural catheter; the second attempt was successful. She reported that, for the past three weeks, the headache was constant but varied in intensity. During her pregnancy, she was diagnosed with gestational diabetes mellitus, which was managed conservatively. She denied history of chronic headaches.Earlier, she had presented to another ED twice for treatment of the headache. Her primary care physician had diagnosed this headache as sinusitis and had prescribed her amoxicillin and pseudoephedrine. Her outpatient physician ordered an MRI to definitively diagnose the sinusitis; a radiologist read the MRI and asked her to go to an ED without discussing the results with her.Upon arrival in the ED, she rated the headache as 9/10. The headache was worsened by moving her head and relieved when lying supine. She described mild photophobia. She denied blurred vision, nausea, numbness, weakness, or vomiting. Her review of systems was negative except for left ear pain for a week. She had sustained a very mild head injury one week before when she lost her balance and hit her forehead on the door of the bathroom while rising from the toilet. She denied loss of consciousness and stated that the intensity of the headache did not change. She denied smoking, alcohol, drug use, and recent travel. She denied family history of bleeding disorders. She adamantly denied domestic violence.On examination, her vital signs were normal. She was awake, alert, and oriented ×3 with normal mood, affect, and speech. Her physical exam including a detailed neurological examination was normal.Her laboratory tests revealed no coagulopathy. Computed tomography (CT) of the head was performed as the MRI was not immediately available. CT of the head  revealedThe patient necessitated a neurosurgical consultation given the large right subdural hematoma with mass effect and left midline shift. A burr hole was placed in the operating room to drain the subdural hematoma. She also underwent a vertebral and carotid arteriogram that was negative for arteriovenous fistula and aneurysm. She received a blood patch and was discharged home with no neurological deficits. It is unlikely that the SDH resulted from her minor fall since her headache had been going on prior to that and was accompanied with ataxia. Therefore the minor fall was a sequel of an already existing subdural hematoma.Intracranial hemorrhage following spinal or epidural anesthesia for obstetric or other anesthetic reasons has been reported with both large and small gauge needles, with patients ranging from young adult to elderly . In manyIt is prudent to consider intracranial hemorrhage in the postpartum patient with headache who underwent an epidural procedure. Many patients with postdural puncture SDH required surgical evacuation and delay in diagnosis may cause significant morbidity and mortality, especially in an often otherwise healthy population .


Oligodendroglioma is an infiltrating glial neoplasm frequently seen in adults. Pediatric oligodendrogliomas are rare, with very few cases presenting in infancy and only rare congenital examples. In contrast to adult oligodendrogliomas, pediatric cases typically lack 1p/19q codeletion. Herein we report a case of WHO grade II oligodendroglioma diagnosed in a 7-month-old male infant. The patient initially presented at 3 months of age with symptoms suspicious for seizure. Initial workup including electroencephalography (EEG), electrocardiogram (EKG), and computed tomography (CT) of the head was negative. His symptoms persisted, and subsequent magnetic resonance imaging (MRI) performed at age of 7 months revealed a 2 cm contrast-enhancing left temporal lobe mass. The mass was excised and the microscopic appearance was that of a classic low grade oligodendroglioma composed of cells with uniformly round nuclei, perinuclear halos, delicate branching capillaries, and an absence of high grade features. Mutant specific (R132H) isocitrate dehydrogenase-1 (IDH1) immunohistochemistry was negative, and the tumor lacked detectable 1p or 19q deletions by fluorescent in situ hybridization (FISH). The onset of neurological symptoms in early infancy followed by the positive MRI findings suggests that this case represents a rare example of congenital oligodendroglioma. As a group, gliomas are the most common primary central nervous system (CNS) neoplasms in both adult and pediatric populations, whereas infiltrative gliomas, in particular glioblastoma, make up the bulk of adult glial tumors, pilocytic astrocytoma, and ependymoma predominate in children. Oligodendrogliomas may be encountered at any age; however, they are generally infrequent in the pediatric population. Congenital examples, those presenting at or shortly after birth, are even rarer. Here we describe a case we believe to represent a congenital oligodendroglioma, the patient initially presenting with seizure-like activity at three months of age.A 3-month-old male infant was brought to the Emergency Department (ED) for evaluation of multiple episodes of presumed seizure activity. The episodes, which lasted 20–25 seconds, were described as staring spells accompanied by apnea and perioral cyanosis. A period of deep sleep followed, and upon waking the infant returned to baseline activity. No seizure activity was identified on electroencephalogram (EEG), and computed tomography (CT) of the head was negative for the presence of an intracranial abnormality. He was diagnosed with reflux and started on an antacid and specific feeding regimen. Seizure-like activity continued and follow-up magnetic resonance imaging (MRI) performed at 7 months of age revealed a 2 cm left temporal lobe lesion which was hyperintense on both T2-weighted  and FLAIHistologically, tumor consisted of a monomorphous population of cells with round, regular nuclei surrounded by clear perinuclear halos. Delicate, branching capillaries were interspersed throughout the tumor and calcifications were present focally. High grade features such as necrosis, microvascular proliferation, frequent mitoses, and nuclear pleomorphism were absent. The morphologic appearance was that of a classic low grade oligodendroglioma Figures . By immuFollow-up revealed that at five years of age the patient is clinically stable. A small focus of enhancement was identified on MRI at his one-year follow-up; however, this lesion has remained stable to date.As a group, glial neoplasms are by far the most common CNS tumors arising in the pediatric population, with astrocytomas and ependymomas representing the majority of these tumors. Oligodendrogliomas account for less than 3% of primary CNS tumors in children . CongeniA number of alternate diagnoses should be considered when an oligodendroglial-like lesion is encountered in a child. These include neurocytoma, other gliomas such as astrocytoma and clear cell ependymoma, and dysembryoplastic neuroepithelial tumor (DNET). In the current case, S-100 positivity confirms a neuroectodermal origin. The lack of synaptophysin positivity makes a diagnosis of neurocytoma unlikely. Other glial neoplasms are made less likely by the classic oligodendroglial morphology seen in this tumor, including round, regular nuclei surrounded by perinuclear halos and interspersed fine, branching capillaries; there was likewise a lack of astrocytic morphology or classic features of ependymoma, such as perivascular pseudorosettes or ependymal canals. Pilocytic astrocytomas may contain areas with oligodendroglioma-like morphology; however, the current tumor lacks the typical piloid processes and biphasic architecture of a pilocytic astrocytoma, and no Rosenthal fibers or eosinophilic granular bodies were identified. DNETs can contain areas resembling oligodendroglial morphology, with small, round cells with perinuclear halos, but these lesions also have patterned nodules and a neuronal component not seen in the present tumor. Another rare entity that should be considered is leptomeningeal oligodenrogliomatosis. The histologic features are that of a classic oligodendroglioma and can have low or high grade features; however, the radiologic appearance consists predominately of focal or diffuse leptomeningeal enhancement as opposed to a mass forming lesion within the cortex , 8.Codeletion of 1p and 19q is a frequent finding in oligodendroglial neoplasms in the adult population but is much less common in pediatric oligodendrogliomas, especially in children less than 10 years old , 9, 10. Structural neuroimaging plays an important diagnostic and prognostic role in children presenting with acute onset epilepsy. Choosing the correct modality early in the disease process provides crucial information regarding etiology and allows identification of lesions requiring surgical intervention. Although MRI is the imaging modality of choice in these cases because of superior anatomic resolution –15, compIn conclusion, this case of a low grade oligodendroglioma presenting within the first few months of life represents a rare example of congenital oligodendroglioma and underscores the importance of maintaining these tumors in the differential diagnosis of infants presenting with new-onset seizures. Similar to previously reported pediatric oligodendrogliomas, this congenital tumor was negative for 1p/19q codeletion as well as for R132H mutant specific IDH1 by immunohistochemistry. Though as a group pediatric oligodendroglioma patients have demonstrated good overall survival, particularly in those patients with nonanaplastic tumor histology , our exp


Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a subtype of Hodgkin lymphoma (HL), and is a rare disease manifestation in the adrenal gland, which is difficult to be diagnosed and treated. In the present study, we report a case of primary adrenal NLPHL in a 36-year-old male patient. The patient was without specific clinical signs and the definitive diagnosis was achieved by histological study. The patient underwent a laparoscopic left adrenalectomy and chemotherapy regimen of doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). There is no standard treatment for adrenal NLPHL and therefore, treatment is based on that for other types of NLPHL, which includes radiotherapy and ABVD chemotherapy. Given the rarity of this disease, there are limited experiences with regard to its diagnosis and treatment. This study is useful for the differential diagnosis and treatment of adrenal masses. The majority of adrenal lesions are benign adrenal cortical adenomas. However, nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a rare disease manifestation in the adrenal gland. NLPHL is a subtype of Hodgkin lymphoma (HL), which represents ~5% of HLs and involves peripheral lymph nodes. NLPHL is a ‘benign’ disease which is characterized by an indolent course ,2. MortaA 36-year-old male presented at The Second Xiangya Hospital of Central South University  with high fever and weight loss lasting for 10 days, as well as a left adrenal mass that had been identified one week previously. The patient had no history of hypertension and physical examination showed no abnormalities. A total body computed tomography (CT) scan revealed the presence of a large left adrenal mass measuring 4.5×5.5 cm in size . No obviThe adrenalectomy specimen measured 5.5×4.0×4.0 cm. Microscopic examination revealed tumors of lymphoid-hematopoietic tissues in the adrenal tissue, which destroyed the adrenal gland and formed a mass in the retroperitoneum. Morphologically, the majority of atypical cells resembled lymphocyte-predominant (LP) cells. Immunohistochemical analysis showed that the tumor cells were negative for cluster of differentiation 30 (CD30) and EBV-encoded small RNAs (EBERs), and positive for CD20, paired box protein 5, CD79a, octamer binding protein 2 and epithelial membrane antigen (EMA). Additionally, very few cells were positive for CD15. The tumor cells were surrounded by T cells, which were positive for CD3 and CD57 . Accordi2 doxorubicin (day 1 and 14), 10 mg/m2 bleomycin (day 1 and 14), 6 mg/m2 vinblastine (day 1 and 14) and 375 mg/m2 dacarbazine (day 1 and 14), to be repeated every four weeks. The patient has been followed up for 16 months from the end of chemotherapy, with a stable condition and no recurrence.Systemic positron emission tomography (PET)-CT examination was conducted following surgery, and there were no obvious abnormalities. Postoperative adjuvant chemotherapy was administered; the patient received four cycles of doxorubicin, bleomycin, vinblastine and darcarbazine (ABVD) regimen. This comprised 25 mg/mal  . cHL repal demonstraal ,11 and oal .Ultrasound, CT and magnetic resonance imaging have become the preferred methods for identifying adrenal tumors. PET-CT is not only able to distinguish between benign and malignant tumors of the adrenal gland in order to make a diagnosis, but also plays a significant role in the staging, evaluation of therapeutic effects and prediction of patient prognosis in HL .+ T cells. The immunophenotype of NLPHL is useful for the diagnosis. LP cells are positive for B-cell markers including CD19, CD20, CD22 and CD79a, in addition to CD45 and EMA; however, they lack expression of CD15 and CD30, which are the characteristic markers for cHL. In the background, CD3+ or CD57+ T cells typically surround the LP cells, forming what are commonly referred to as T-cell rosettes  treatment with radiotherapy alone has been recommended in the past. Clinical studies on 202 patients in Australasia showed that the 15-year overall survival (OS) rate was 83% and the freedom from progression rate was 82% in patients with I-II stage LPHL treated with radiotherapy alone . AnotherPatients with early-stage NLPHL who have received ABVD chemotherapy and/or radiotherapy have a good prognosis; studies have shown that the 10-year overall survival rate is >90%, even up to 100% . PatientThe current recommendation for advanced-stage NLPHL consists of standard cHL protocols, with ABVD chemotherapy and combined therapy including radiotherapy .et al (The LP cells in NLPHL express high levels of CD20 antigen, rituximab, which has emerged as a potential treatment option for NLPHL. Ekstrand et al  conducteet al . It was et al . Treatmeet al .Primary adrenal NLPHL is extremely rare, and pathological analysis and immunohistochemical examination are key in achieving a diagnosis. Due to the rarity of NLPHL, there have been few prospective studies, and as a result, a wide range of management approaches are available. Thus, the optimal management strategy for NLPHL is unclear. Patients with limited stage NLPHL treated with ABVD chemotherapy followed by radiotherapy have more successful outcome compared with those treated with radiotherapy alone. The current recommendation for advanced-stage NLPHL consists of standard cHL protocols, with ABVD chemotherapy and combined therapy including radiotherapy and rituximab. Rituximab has emerged as a potential treatment option for NLPHL. The optimal treatment of NLPHL in the era of targeted therapy should be further explored. Further studies, particularly long-term, prospective randomized clinical trials are required to improve the diagnostic techniques and the optimal treatment of NLPHL. Additionally, the differential diagnosis of adrenal tumors should be considered.


Metastatic spermatic cord (SC) tumor is extremely rare. Recently, we experienced a case of late-onset metastatic SC tumor from cecal cancer. This case is a 68-year-old man presenting with a painless right SC mass. He had undergone a right hemicolectomy for cecal cancer 6 years ago. Radical orchiectomy and adjuvant chemotherapy with S-1 were performed. No recurrence was found after one year of follow-up. We identified a total of 25 cases, including our case, on a literature search via PubMed from January 2000 to April 2015. The most frequent primary sites of the tumors metastasizing to the SC were the stomach  and the colon , next the liver , and kidney . The majority of the cases underwent radical orchiectomy for the metastatic tumors of the SC. Over half of the cases received adjuvant interventions based on the regimens for the primary tumors. Prognosis in the patients with metastatic tumor of the SC was unfavorable except for late-onset metastasis. In patients with a mass in the SC and a history of neoplasm, especially in gastrointestinal tract, the possibility of metastasis from the primary cancer should be considered. Tumors arising from the spermatic cord (SC) are rare and most of these tumors are benign such as lipoma. However, approximately 25% are potentially life-threating malignant neoplasms . The mosOn the other hand, metastatic SC tumor is even more unusual . SeveralA 68-year-old man was referred to the Department of Urology from the Surgery at Higashimatsuyama Municipal Hospital with a right painless inguinal mass in April 2014. He had noticed it 6 months previously and observed an increase of its size. He had undergone right radical hemicolectomy for cecal cancer 6 years ago. Histological examination of the extirpated colon specimen showed moderately differentiated adenocarcinoma  with depOn physical examination, an approximately 4 × 3 cm palpable relatively fixed unpainful mass was observed in the right inguinal region. Abdominal computed tomography (CT) scan showed a heterogeneously slight-enhanced mass with noncapsulated irregular shape, 3.7 cm in diameter, suspicious of extending to the adjunct structures . Serum cThe patient underwent right radical orchiectomy. During the operation, the tumor was located in the SC and showed relatively invasive growth to the adjunct structures but did not invade the epididymis and testis. The resected specimen involved a 4.5 × 3.5 × 3 cm solid mass, with grayish-white tumor in the cut surface, and was located in the lower part of the SC .A histological examination of the SC tumor showed moderately differentiated adenocarcinoma . In an iThe postoperative course was uneventful. The patient received adjuvant chemotherapy with tegafur/gimeracil/oteracil (S-1) which is a combined oral chemotherapeutic agent and has been doing well without evidence of recurrence for one year following the surgery.The SC is an extremely rare site for distant metastasis from a malignant neoplasm. In an autopsy study there were only two metastatic sites (0.01%) of the SC among 13,500 autopsy cases, both of which were from a primary gastric cancer . That reThe vast majority of cases as well as our case underwent radical orchiectomy for the metastatic tumors in the SC, while tumor resection alone with preservation of the testis was found in two cases (8%). Over half of the cases received adjuvant interventions such as chemotherapy, molecular therapy, or hormone therapy based on the regimens for the primary tumors.The prognosis of a metastatic tumor in the SC has been typically unfavorable as previously reported . In thisThe mechanisms of metastasis to the SC and paratesticular tissues from primary malignant neoplasms have not been precisely elucidated. However, several possibilities have been proposed. The main routes have been postulated to be vascular and lymphatic routes. Other routes involving retrograde extension through the vessel, either along its lumen or by direct extension via the wall of the vessel, and transperitoneal seeding through the patent tunica vaginalis have been proposed , 4. In oIn conclusion SC solid masses are usually not considered as SC metastasis from primary neoplasms such as gastrointestinal tract cancers previously treated with a curative intention. We did not initially consider this case to be a metastasis from cecal cancer. However, in patients with solid mass of the SC and a history of neoplasm, especially in the gastrointestinal tract, and even though the primary neoplasm has been treated with a curative intent long time earlier, the solid mass of the SC should be kept in mind in a possibility of metastasis from the primary tumor.


Ancient schwannoma is an uncommon variant of schwannoma, a benign tumor arising from the nerve sheath. It is reported to arise from any nerves except optic and olfactory. However, only six cases of ancient schwannomas arising from ansa cervicalis nerve have been reported to date in English literature. Proper preoperative evaluation is necessary to rule out other causes of neck mass such as thyroid lesions, lymphadenopathy, and carotid body tumor. We report a case of ancient schwannoma arising from the ansa cervicalis nerve. The origin of the lesion from ansa cervicalis was confirmed by intraoperative finding. Postoperative histopathological examination revealed degenerative changes including pleomorphism, cellular atypia, large nuclei with prominent nucleoli, and paucity of mitotic figures. Periphery of the mass showed nuclear palisading with characteristic verocay bodies. Immunohistochemical evaluation for S-100 showed diffuse positivity of the tumor cells, thereby confirming the diagnosis of schwannoma. We consider that schwannoma of cervical region can have origin from any nerve and should try to identify the origin pre- and intraoperatively. The postoperative complications depend on the nerve of origin and the precision of the surgery performed. Schwannomas are benign tumors arising from nerve sheath, also named as neuromas, neurilemmomas, or neurinomas , 2. AnciA 62-year-old man presented to the surgical department, with a two-year history of asymptomatic swelling in the right side of neck. The swelling was insidious onset, slowly growing, and was not associated with pain or fever. There was no history of any period of rapid growth, cough, or dysphagia. On examination of the swelling, it was a globular, nontender swelling with a diameter of five centimeters, located in the submandibular triangle. It was not fixed to the overlying skin and was partially mobile. The swelling was firm in consistency with pulsations felt, transmitting from adjoining carotid artery. The swelling was clinically suspected to be a cervical lymph node. Other systemic examinations including laboratory investigations were uninformative.Ultrasonography of the neck revealed the swelling to be of heterogeneous echo texture and increased vascularity, besides which a few nonsignificant lymph nodes were present in the vicinity of the swelling. The swelling had displaced the internal carotid artery and internal jugular vein anteriorly. A fine needle aspiration (FNA) was performed which revealed spindle cell neoplasm. Contrast enhanced commuted tomography (CECT) showed a heterogeneously enhancing mass with cystic change marked on contrast enhancement, with anterior displacement of the carotid artery and the internal jugular vein.The patient was operated through a right submandibular skin crease incision. The tumor was laying posterolateral to the internal jugular vein . The vagGrossly the specimen was globular in shape, encapsulated, and greyish brown in color, with measurement of 4.5 × 3 × 2.5 cm. The cut section was variegated, solid-cystic with areas of cystic haemorrhagic changes along with foci having soft mucoid consistency .Microscopically, it showed a well encapsulated tumor composed of cellular and hypocellular areas with compressed neural fascicles at the periphery. The tumor is composed of fusiform cells with elongated fibrillary cytoplasm and wavy buckled nuclei. Degenerative changes were found in a good proportion of cells including pleomorphism, cellular atypia, large nuclei with prominent nucleoli, and paucity of mitotic figures . CentralAncient schwannoma of ansa cervicalis is a rare disease and only a few cases had been reported till date. Park et al. reported a case of schwannoma of ansa cervicalis, but the origin of the schwannoma from ansa cervicalis is confirmed intraoperatively by the contraction of the strap muscles on stimulation . de DiegContrast enhanced CT scan and MRI are often helpful in diagnosis, but exact origin of the schwannoma is difficult to know preoperatively . The ancAncient schwannoma, also known as degenerative neurilemmoma, is characterized by degeneration and proportionate increase in hypocellular areas (Antoni B). The changes include increased deposition of matrix, perivascular hyalinization, ectatic vessels with thrombus within them, cystic degeneration, and cellular atypia with paucity of mitosis. The changes are attributed to the long duration of schwannoma during its evolution. The predominance of Antoni B area over Antoni A area is radiologically correlated with increased contrast uptake in CECT. As these lesions have diffuse hypocellularity they are difficult to diagnose by fine needle aspiration cytology .Complete surgical excision of the tumor is the treatment of choice, because these are radio-resistant tumors. During excision of the tumor, all efforts should be made to preserve the nerve but it is difficult because of its dense attachment to the tumor. Surgeon needs to be very careful during the operation, as the vagus nerve may be mistaken to be ansa cervicalis. Incomplete excision may result in slow recurrence over months to years . RecurreSchwannoma can arise from all types of nerves, but origin from the ansa cervicalis is a rare occurrence. It is difficult to diagnose ansa cervicalis as the nerve of origin preoperatively. So to conclude, surgeons should consider that schwannoma of cervical region can have origin from any nerve and should try to identify the origin pre- and intraoperatively. The postoperative complications depend on the nerve of origin and the precision of the surgery performed. This entity may be considered as the differential diagnosis of cervical lymphadenopathy.


A 55 year-old Caucasian man, with Diabetes Melitus type 2 history, presented to our department with complaints of multiple, dark red papules located on the scrotum. The diagnosis of Fordyce angiokeratoma was clinically established. No special treatment was recommended, apart from patient's reassurance for the benign nature of this clinical entity. Fordyce angiokeratoma or angiokeratoma of the scrotum was first described in 1896 by John Addison Fordyce. Its etiology remains unclear, while its incidence is believed to increase with age. Genetic background of the disease has not been documented. Complications are generally uncommon, however bleeding of the papules can occur. Differential diagnosis mainly includes angiokeratoma corporis diffusum, malignant melanoma and nevomelanocytic nevus. In cases of diagnostic dilemma, dermoscopy can be useful, but biopsy of the lesion is the gold standard method for the establishment of the diagnosis. Specific treatment is unnecessary, still, excision, electrodessication and laser therapy have been described in complicated cases or for aesthetic reasons.


Despite the long recognition of thisdisease, its origin classification and pathology remain controversial. The highestincidence is between the third and fourth decades of life, with 75% of those diagnosedafter ten years with a slight female predominance. The term lymphangioma isappropriately used when there is hemodynamic isolation, or the injury is not related tothe blood system13. Lymphangiomas are a major group of so-called vascularhamartomas, which result from a failure in the evolutionary development of the vascularsystem, including lymphatic and/or arteries and veins3.Lymphangiomas are benign tumors, probably congenital, are more common in the cervicaland axillary regions. They are unusual in abdominal and pancreas location. Its incidenceis estimated at around 1:100,000 and 1:20,000 admissions in adults and in children. Thefirst excision was performed by Tillaux (quoted Chung) only in 18026. This is the most common type, and the most affected sites arehead and neck. The main differential diagnosis is hemangioma, branchial cysts, lipomasand rabdmiossarcoma. Diagnosis is made by biopsy of suspicious nodules, and the maintreatment is surgical excision.These lymphatic tumors are divided in: 1) simple, with capillary lymphatic channels; 2 )cavernous, with dilated lymphatics and the presence of capsule; and 3) macrocysticmalformations, clinically termed "cystic hygroma"Fifty-eight years man came to San Francisco Hospital in Taquaral of Goiás,Brazil, after previous medical care without diagnosis or treatment. He had a history ofa large mass over a year of slow evolutionary character. He denied pain, headache,fever, diarrhea and other symptoms. Physical examination revealed good generalcondition, acyanotic, afebrile, hydrated, normotensive, rhythmic, symmetrical heartsounds without murmur. His abdomen had a moving mass of 10 cm in diameter, painless tosuperficial and deep palpation. Ultrasonography showed an intraperitoneal cystapparently mesenteric .With the uncertain diagnosis was conducted to computed tomography of the abdomenreviling a hyperdense mass of cystic aspect, not contrasted, measuring 9.0x7.1 cm in itsgreatest transverse axis located in the hypogastrium, without being adherent to thebladder . Was opt11reporting 18 cases showed abdominal pain and mass (72%), vomiting and constipation; onepatient presented with acute abdomen pain. Palpation usually presents itself painless,smooth contour and well defined with mobility in the transverse direction and around itsaxis 11 The increase in abdominal volume is slow, progressiveand late noticed in some cases, mingling with ascites in about 18-20%. There are fewreports of malignant mesenteric cysts, usually low-grade sarcomas. Kurtz et al. reviewed162 cases and found only 3% of malignant transformation, all in adults. Are incidentalfindings during laparotomy or imaging, up to 40 % of cases. Acute abdomen occurs whenthere is rupture, infection, bleeding or twisting of the cyst, and confused withappendicitis or aortic aneurysm.There are no pathognomonic signs and symptoms of mesenteric cyst; However, paperpresented by Santana et al.Laboratory tests little help the diagnosis. Simple X-rays of the abdomen may showcalcifications; arteriography and intestinal transit may show compressive mass. However,ultrasonography, computed tomography computed and magnetic resonance imaging are theexams that provide better diagnosis.11, recurrence, malignant transformation and possiblecomplications 12. Internal drainage may be an option when there ispossibility of short bowel syndrome. In selected cases laparoscopic approach can beused15.Once diagnosed, all mesenteric cyst should be resected in order to avoid theircomplications11 classified them aspathologically serous, bloodserous, chylous, with blood. In this case hydatid cist wasalso placed on judgment in the differential diagnosis, before the end oflymphangioma.Santana et al.


The etiology of tooth agenesis may be related to several factors, among them, the genetic alterations that play a fundamental role in the development of this dental anomaly, so that knowledge about it helps the clinician to have a greater understanding of their patients. Thus, the aim of this study was to report the case of a nonsyndromic child, with tooth agenesis of one premolar, three first permanent molars, and all second permanent molars. In addition, a genetic research between polymorphic variants in genes MMP3 and BMP2 was performed in order to observe the association between changes in these genes and congenital tooth absences. For this purpose, DNA from child was extracted and polymorphisms were investigated. It was clinically and radiographically observed that this was a case of oligodontia, in which the authors suggested an association between the polymorphisms found and tooth agenesis diagnosed in that child. Tooth agenesis may be defined as the congenital absence of one or more teeth, with the exception of third molars, with this being one of the most prevalent dental developmental anomalies, with rates ranging from 3.2% to 13.3% in different populations , tooth aWhen considering isolated cases or the nonsyndromic form, many studies have investigated the correlation between tooth agenesis and genetic mutations present in individuals belonging to one and the same family, attributing the mutations to genes PAX9, MSX1, AXIN2, and EDA –9. HowevSince lip, palate, and tooth development are influenced by the same genes, the aim of the present study was to report the case of a child with oligodontia, in whom an investigation between the polymorphic variants in genes MMP3 and BMP2 was performed.A 9-year-old girl, leukoderma, presented at the Pediatric Dental Clinic of “Universidade Veiga de Almeida,” accompanied by her guardian, with the complaint of misaligned teeth. A term of consent was obtained, authorizing the present case report to be made. Her medical history revealed a normal birth, presenting absence of systemic compromise or any other relevant datum. On extraoral clinical exam as well, no alteration was observed. Considering the dental history, it was revealed that the child had already been submitted to dental appointments only to have prophylaxis and fluoride application.After meticulous intraoral clinical exam, it was found that the child was at the stage of mixed dentition, with absence of three first permanent molars, deviation from the midline, bilateral posterior crossbite, and deep palate . After rIt is worth adding that the patient was referred for orthodontic treatment, and at the appropriate age, after correcting the bone and tooth discrepancies, she will undergo prosthetic rehabilitation. In addition, follow-up consultations will be scheduled regularly for oral hygiene instructions.Epithelial cells from the oral mucosa were collected as a source of genomic DNA, following a procedure based on a previously published protocol . Only thWe selected genes involved in craniofacial development and a polymorphism (rs522616) that was previously investigated in a Brazilian population affected by oral clefts. According to Letra et al.  a genetiConsidering gene BMP2, a recent study  identifiCandidate genes, such as PAX9, MSX1, AXIN2, and EDA –9, 19–24The functional SNPs were chosen due to the fact of being capable of influencing genic expression, increasing or diminishing the final quantity of protein coded by that gene . A recenApart from the literature cited, it is important to stress the point that dental anomalies including tooth agenesis are subclinical phenotypes (mild forms) of over clefts mainly observed in unaffected relatives . It is wThe diagnosis of tooth agenesis is dependent on the anamnesis and clinical and radiographic exams being performed with acuity by the dentist. Moreover, in the early diagnosis of tooth agenesis, it has become imperative to use panoramic radiographs. This exam was requested in order to make the diagnosis of the tooth absences in the present case, in which ageneses of the following permanent teeth were found: maxillary left second premolar, maxillary right and left first molars, mandibular right first molar, and all second molars. The prevalence of absence of second premolars, lateral incisors , and thiAccording to the literature , there iWhen we consider the ageneses of the permanent second molar germs, we should take into consideration that Moyers  reportedThe inevitable consequences of oligodontias include malocclusions due to the inadequate position of the teeth during growth, deficiency of the alveolar processes due to the lack of teeth, and excess of spaces between the dental arches . In the In summary, tooth ageneses constitute a clinical and public health problem, because patients in these conditions may suffer a reduction in their masticatory capacity, malocclusions, phonoaudiological problems, and compromised esthetics. These problems may also affect the behavioral pattern and social life of these persons, so that early diagnosis and guidance with regard to treatment are necessary, thus being a condition that pediatric dentists must be capable of diagnosing.


Retroperitoneal pseudotumor is an extremely rare presentation of extrapulmonary tuberculosis. The diagnosis of this paucibacillary disease is difficult which is usually misdiagnosed as a malignant tumor. High index of suspicion is required for early diagnosis and treatment of retroperitoneal pseudotumor which can affect prognosis of this disease. Because of its rarity and difficult diagnosis, we report an 18-year-old immunocompetent girl who presented with abdominal pain and vomiting. Upper endoscopy showed an exudative mass between the second and third parts of duodenum. Abdominal computed tomography (CT) revealed a large retroperitoneal mass with extension into small bowel. Exploratory laparotomy and histopathological examination of tissue showed calcified granuloma. Ziehl-Neelsen staining and PCR confirmed the tuberculosis. The patient was successfully treated with standard antituberculosis therapy. M. tuberculosis or nontuberculous mycobacterial infections can present as a rare and distinct entity called mycobacterial pseudotumors. M. pseudotumors affect immunosuppressed patients with or without AIDS [out AIDS . One of out AIDS . Tubercuout AIDS . Pseudotout AIDS , 3–6. Inout AIDS . The diaout AIDS . The abdout AIDS , 8–11; aout AIDS –12. To fWe report a young female with abdominal pain and vomiting who was referred to our institution with a primary diagnosis of malignancy.The patient was an 18-year-old girl who presented with periumbilical abdominal pain, nausea, vomiting, fatigue, and powerless four months prior to admission that these symptoms had gradually increased. She had five kg weight loss. She had no history of any diseases.On physical examination, she appeared ill. Vital signs were normal. Abdomen was soft; a periumbilical mass was detected in deep palpation; no hepatomegaly, splenomegaly, or lymphadenopathy was detected.3  and the platelet count was 291000/mm3. The aspartate aminotransferase was 32 U/L and alanine aminotransferase was 28 U/L. The total bilirubin was 1.3 mg/dL and direct bilirubin was 0.5 mg/dL. The alkaline phosphatase was 250 U/L. The serum lactate dehydrogenase (LDH) was 110 IU/L. The blood urea nitrogen (BUN) was 25 mg/dL and the creatinine was 0.5 mg/dL. The erythrocyte sedimentation rate was 30.The hemoglobin level was 10.2 g/dL. The leukocyte count was 5400/mmSmall bowel barium study revealed a cut-off area between the second and third parts of duodenum . Upper gOur primary differential diagnosis was retroperitoneal lymphoma, GIST, or desmoid tumor. Patient underwent surgery. Laparotomy was performed and a large fragile mass was seen with adhesion to transverse mesocolon and small intestinal tension; significant vascular involvement was seen; pancreas, liver, biliary tree, spleen, and the ovaries appeared normal; multiple biopsies were taken and gastrojejunostomy was performed for obstruction.Microscopic pathologic examination revealed reactive tissue with necroinflammatory infiltration, langerhans cells, and calcified granuloma . Ziehl-NQuadruple therapy for tuberculosis with isoniazid, rifampin, pyrazinamide, and ethambutol was prescribed for a two-month initial phase of treatment followed by a four-month continuation phase of isoniazid and rifampin. In patient's follow-up, general condition was good and no problem was reported.The pseudotumors of tuberculosis have mostly been reported in mediastinum , 6, 7; sRetroperitoneum is an extremely rare region of involvement of tuberculosis and can be misdiagnosed as a neoplastic tumor in imaging study , 3, 7. AThe differential diagnosis of retroperitoneal mass is lymphoma, leiomyosarcoma, GIST, desmoid tumor, Wegener's granulomatosis, inflammatory pseudotumor, and tuberculosis –17.Tuberculosis may be detected by chest X-ray 33%) and abdominal CT (88%), but there were no pathognomonic criteria and the diagnosis is ultimately based on histopathological and microbiological confirmation –20. In t3% and abThis patient's manifestation was an obstructive lesion in small intestine and further evaluation revealed a large retroperitoneal tumor with extension to the small intestine.Our primary impression was lymphoma or leiomyosarcoma but surgery and pathologic examination revealed that the retroperitoneal tuberculosis has been manifested as a pseudotumor. M. tuberculosis may be because of individual immunological response of the patient [This form of tuberculosis usually manifests in setting of underlying tumors and immune deficiency . Clinici patient , 4. Iran


Perforated cystic teratomas are rare. Our patient was a 16-year-old female who presented with severe chest pain two years ago. A right-sided pleural effusion was accidentally detected by chest radiography performed at her school. Computed tomography revealed a high density area with multiple small, thickened, lobulated lesions and a low density area with pleural effusion adjacent to a thinned wall. Pathognomonic inhomogeneous computed tomography findings led to an accurate diagnosis of a mature teratoma that had ruptured long before presentation. Thoracoscopic resection was performed, and the final histological diagnosis was a mature teratoma with partial rupture. Before puberty, approximately 20% of patients with primary mediastinum tumors have germ cell tumors . Germ ceWe describe a patient who underwent thoracoscopic resection for a mature teratoma that had ruptured two years earlier. A definitive diagnosis was made on the basis of the results of preoperative computed tomography (CT).A 16-year-old female presented with severe chest pain two years ago. She reported occasional right-sided chest pain and dyspnea on exertion but had never visited a hospital for her condition. Her past history was not significant. Right-sided pleural effusion was identified at an annual health screening conducted at the high school. Contrast-enhanced chest CT  confirmed two inhomogeneous patterns, that is, a high-density area with multiple, small, thickened, lobulated lesions of a maximum diameter of 25 mm on the anterior mediastinum  sebaceous materials or digestive enzymes derived from tumor tissue cause inflammation, infection, ischemia, and necrosis , 3 and C. Hirawateratoma . The seret al. also reported no significant difference between ruptured and unruptured teratomas in terms of wall thickness, location of the mass, and tumor size [On the basis of their analysis of 17 tumors, Choi mor size . In the et al. reported their short-interval CT finding that an increase in the soft tissue area of the anterior chest wall adjacent to the tumor was extremely helpful for making a definitive diagnosis of teratoma rupture, thereby facilitating prompt treatment by surgical resection [Approximately 90% of unruptured teratomas present as homogeneous in CT findings . Homogenesection . In the In conclusion, CT is a useful modality for diagnosing a ruptured teratoma. It is important for surgical resection that a definitive diagnosis is obtained with these CT findings. To the best of our knowledge, there is second report of a ruptured teratoma diagnosed more than two years after the onset of perforation.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Meningioma accounts for approximately one-third of primary central nervous system tumors. Most meningiomas are benign, although up to one third are classified as atypical or malignant. We describe a 63-year Caucasian male presenting with pleural metastases from an intracranial meningioma. Distant metastases from meningiomas are infrequently found in clinical practice and mostly are associated with atypical or malignant meningiomas. There is no standard treatment; however surgical resection of both the primary and metastatic lesions is the safest therapy. The overall prognosis of atypical meningiomas is poor. Our patient died one week after discharge from our hospital. A 63-year-old Caucasian man was referred to our hospital for further analysis of slowly progressing pleural effusion with a history of cough and dyspnea. The patient had a long history of epilepsy and meningioma. He was working as head in a department of administration. He was married and had two healthy kids. As a medication he took Pantoprazol, Tegretol and Dorsolamide and had stopped smoking a long time ago.3 resection) and postoperatively irradiated  atypical left parieto-occipital meningioma (WHO grade-II). Re-resection of the tumor (Simpsom4) was performed and histopathology showed a malignant meningioma (WHO grade-III). In the follow up after re-resection there was an obvious evidence of a residual tumour at the falx cerebri. One year later an asymptomatic re-recurrence was diagnosed  scan. Histopathology was consistent with malignant meningioma  atypical left parieto-occipital meningioma (WHO grade-II). Re-resection of the tumor was performed and histopathology showed a malignant meningioma (WHO grade- III). After reoperation, re-irradiation  was given."Which radiation technique was used? It is not clear whether the radiation dose applied upon recurrence was only 60Gy with the boost, and if the “additional” 70 Gy is the cumulative dosage applied including the boost, or just the boost itself.I would also recommend verifying in the literature whether radiation therapy has been offered for histologically confirmed metastatic extracranial lesions.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. I fully agree with the reviewer from Bonn, Matthias Simon. Meningiomas grade III are fortunately rare and they do metastasize through vascular pathways. Of course a register of such cases would be a valuable tool to get an idea of the prevalence of such events. The case reported by Basunaid is a tragic one as the patient asked for euthanasia one week after dismissal from hospital. This shows that he could not be offered any therapeutic option able to provide enough solace for staying alive.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. I would like to thank Dr. Marosi for her time spent on reviewing this case report, and the valuable comments given. I would like to leave my current version as it is. I completely agree regarding the facts about the rarity of the case and the termination by the euthanasia declaration. et al. describe a patient with a recurrent meningioma who ultimately developed pleural metastases. The primary tumor was assigned to WHO grade II, and the recurrent tumor to grade III. While this paper by itself does not provide truly novel information, in my view such rare patients should be reported in the literature. This and similar reports will help to build a database which may at some point help to improve our understanding and management of rare conditions. The report may benefit from a more comprehensive and detailed (tabular?) review of the literature.BasunaidI have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. I would like to thank Dr. Simon for his time and valuable comment. I wish to leave my current version as it is. This case report documents an unusual spread of a malignant meningioma. It doesn't add any further information and doesn't contribute any new knowledge, neither diagnostic nor therapeutic to the current available medical literature.I have read this submission. I believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.


The current study presents a case of extraskeletal mesenchymal chondrosarcoma (ESMC) involving the vena cava that originally occurred in the retroperitoneum of a 61-year-old female. Following excision of the masses, pathological examination confirmed a diagnosis of primary ESMC. Mesenchymal chondrosarcomas are extremely rare in comparison to conventional chondrosarcomas and even more so when arising in an extraskeletal location. In the current report, the major characteristics of ESMC are discussed and a review of the current knowledge regarding this rare disease entity is presented. Mesenchymal chondrosarcoma is a rare and aggressive variant subtype of chondrosarcoma, which represents ~1% of all chondrosarcomas. It commonly arises in the bone, however, in ~30–40% of cases, it occurs in an extraskeletal location  may occur in any location that contains mesenchymal cells, however, the majority arise in the lower extremities (particularly the thigh), leptomeninges or the orbit . Other s12 cells/l. In addition, the patient’s serum lactate dehydrogenase levels were 487 U/l  and mannosylated antigen CA125 levels were 206.5 U/ml .On 27th June 2013, a 61-year-old female presented to Zhongnan Hospital of Wuhan University  with a six-month history of persistent abdominal pain and distension, occasional reflux and nausea, as well as depression, fatigue and weight loss of 10 kg. The patient had no history of any fever, night sweats, chest pain, diarrhea or blood loss in the stools. The patient’s general physical and chest examinations were unremarkable, however, the abdominal examination revealed right subabdominal tenderness and multiple hard lumps of different sizes. The patient’s past medical and personal histories included cardiac disease, hysteromyoma and peritoneal myxoma of 12 years. The laboratory results revealed the patient’s hemoglobin levels to be 80 g/l with a red cell count of 2.61×10Abdominal and pelvic ultrasound examinations were performed and revealed two huge, heterogeneous retroperitoneal masses located on the rectouterine fossa adjacent to the inferior vena cava, which measured between 126×103 and 95×78 mm in size . The tumThe plain radiography revealed extensive calcifications in the abdomen . FurtherThe patient also underwent abdominal and pelvic magnetic resonance imaging (MRI)  examinations and corresponding gadolinium-based contrast enhancement. On T1-weighted images (T1W1), all lesions showed low signal intensity and on T2-weighted images (T2WI), all lesions predominantly showed slightly high signal intensity, whereas the central area exhibited low intensity in the two images . FurtherSubsequently, the patient underwent resection of the masses and the histological examination of the masses revealed observations consistent with those of ESMC . In addiChondrosarcomas are a heterogeneous group of malignant neoplasms that produce a cartilaginous matrix. Although the majority of chondrosarcomas arise from cartilaginous or bony structures, they may also develop in extraskeletal locations, such as the soft tissues, where cartilage is not usually found. The histological subtypes of extraskeletal chondrosarcoma include myxoid, mesenchymal and well-differentiated, with the myxoid subtype being the most common . This hiESMC has a marginal female predominance and has two peak ages of incidence in adults, depending on its location; 23.5 years old  for EMSC patients with central nervous system involvement and 43.9 years old  for ESMC patients with soft-tissue and/or muscular involvement . The patUltrasonography is not a conventional diagnostic tool for mesenchymal chondrosarcoma, however, it can be used as the first imaging modality when these masses arise from soft tissue. The images usually reveal a solid, heterogeneous mass, often containing scattered areas of increased echogenicity and posterior shadowing consistent with the features of multiple foci of calcification ,9.Conventional radiography has less impact on the diagnosis of ESMC due to a lower density resolution and the overlapping of adjacent structures. CT depicts ESMC as a soft tissue mass with ring- and arc-like, stippled and highly opaque calcifications. Contrast-enhanced CT depicts EMSC as a soft tissue mass, with a portion of enhancing viable tumor in the periphery and central focal low attenuation areas that possibly present necrosis . In the MRI of ESMC patients often show equal or low signal intensity on T1W1 and mixed high and low signal intensity on T2WI. Since the intratumoral calcified and non-calcified components of ESMC demonstrate low and high intensity on T2WI, respectively, they are visible as areas of high signal intensity surrounding areas of low signal intensity or as the ‘salt and pepper’ sign. Such observations have previously been reported and are considered an important characteristic of the disease . In addiHowever, the imaging results of the present study did not enable the differentiation of ESMC from other neoplasms. Thus, a definitive diagnosis was determined based on the histological features. Microscopically, the most common feature of mesenchymal chondrosarcoma is a biphasic pattern composed of sheets of undifferentiated round, oval or spindle-shaped cells, as well as small, usually well-defined, islets of well-differentiated, benign-appearing cartilaginous tissue . Immunohet al  Calcification, particularly the ring- and arc-like calcifications; ii) ‘salt and pepper’ sign on T2WI; iii) diffuse heterogeneous or nodular enhancement; and iv) areas strengthened by calcification. Therefore, typical dense and arc-like calcifications may confirm the diagnosis of mesenchymal chondrosarcoma of extraskeletal origin.


Fluid collections are common findings of pancreatitis and spread, more often, along preferential drainage pathways in the abdomen. In some rare cases, fluid collections may spread towards extra-abdominal sites like the mediastinum leading to the formation of mediastinal collections. We present the case of a 52-years-old man with pain in the right upper quadrant of the abdomen and mid-epigastrium lasting for some hours. Laboratory tests suggested a diagnosis of pancreatitis. CT and subsequent MRI revealed changes consistent with acute exacerbation on chronic pancreatitis spreading to the mediastinum and to the greater omentum. The patient received medical treatment and reported gradual improvement in his laboratory results and CT findings. Fluid collections and pseudocyst formation are the most frequent findings of pancreatitis.Extrapancreatic fluid collections are more often detected in the lesser sac, in the anterior pararenal space, in the posterior pararenal space, in or around the left lobe of the liver, and in the spleen . Extra-aWe report an unusual case of ascending acute exacerbation on chronic pancreatitis with mediastinal involvement detected by CT and MRI.A 52-year-old man came to our emergency department with a severe noncolicky pain in the right upper quadrant of the abdomen and mid-epigastrium, radiating to the back and to the retrosternum, lasting for some hours. He had also nausea and vomiting.On clinical examination, the patient was found to be afebrile, not jaundiced, with stable vital signs.Abdominal examination at presentation revealed a smooth abdomen, without sign of peritoneal irritation, with tenderness in the epigastrium and the right hypochondrium.Abdominal auscultation revealed mild diminished bowel sound.His past medical history was significant for a previous myocardial infarction. Furthermore, he had type II diabetes mellitus, combined hyperlipidemia, and gastroesophageal reflux symptoms.His medications included acetylsalicylic acid, rosuvastatin, pantoprazole, and metformin.There was no history of alcohol ingestion.Laboratory tests showed an increased amylase level of 2247 mg/dL , an elevated lipase level of 2011 mg/dL , an increased glycemia level of 156 mg/dL , a higher ESR (erythrocyte sedimentation rate) of 55 mm/h , and an elevated C-reactive protein (CRP) level of 5,23 mg/dL .Blood count, electrolyte levels, renal function panel results, and cardiac and liver enzyme levels were in range. Admission electrocardiogram revealed normal sinus rhythm with changes suggestive of previous anterior wall myocardial infarction.The patient was referred to radiology department for an ultrasound examination of the abdominal cavity that showed hepatic steatosis but excluded cholelithiasis, biliary sludge, and biliary duct dilatation. The pancreas was not well seen due to overlaying bowel gas.The patient had also a chest, abdominal, and pelvis CT scan that showed enlargement of the pancreatic tail with some pancreatic fluid collections (diameter about 4 cm) surrounded by a peripheral thin wall. On CT, the pancreatic fluid collections extended as a long cystic lesion along the greater curvature of the stomach up to the greater omentum .CT showed the fluid collections extending also upward as a long vertical cystic lesion from the retroperitoneum to the right mediastinum, being posterior to the gastroesophageal junction, right lateral to the esophagus and thoracic aorta, and posterior to heart up to the level of left atrium (diameter about 3 cm). In this case, the close relationship between the fluid collections in the mediastinum and the esophagus suggested that the route of dissection was through the esophageal hiatus.There were signs of peripancreatic inflammation identified as increased thickening and contrast enhancement of fascial planes . CT revealed also changes consistent with chronic pancreatitis such as small parenchymal calcifications and mild dilatation of the pancreatic duct (3 mm) and some small lymphadenopathy and bilateral pleural effusion.An acute exacerbation on chronic pancreatitis with extrapancreatic fluid collections spreading to the mediastinum was diagnosed. The patient was admitted to the surgical unit.After 7 days, the patient had a contrast-enhanced MRI of the abdomen combined with MR cholangiopancreatography (MRCP) that showed normal biliary tree and excluded gallstones and/or biliary sludge.MRI showed multiple fluid collections extending from the abdominal cavity to the mediastinum that were homogeneously hyperintense on T2-weighted images and slightly isointense on T1-weighted images, with mild peripheral enhancement after administration of contrast medium . The isoDuring his hospital admission, he received medical treatment, such as total parenteral nutrition, gabexate mesilate, octreotide, and ceftriaxone.He reported gradual improvement in his symptoms and in his laboratory results.After 40 days, patient had an amylase level of 484 mg/dL , a lipase level of 642 mg/dL , and an ESR of 41 mm/h .About five weeks after admission, follow-up chest, abdominal, and pelvis contrast-enhanced CT scan revealed the development of a fully encapsulated pseudocyst (3 cm), with a thin capsule (2 mm) and a low attenuation fluid content, in the pancreatic tail. CT scan showed also reduction of the intra-abdominal fluid collections and complete resolution of both mediastinal fluid collections and pleural effusion .The patient was ultimately discharged on a low-fat diet and did have a 1-month and 3-month follow-up in the gastroenterology outpatient clinic. He is asymptomatic so far.We report an unusual case of an acute exacerbation on chronic pancreatitis complicated by extrapancreatic fluid collections spreading to the mediastinum detected by CT and MRI.The fascial planes and perirenal bridging septa can be recruited to rapidly drain developing fluid collections that are formed by extravasated pancreatic secretions, debris, inflammatory exudate, fat necrosis, and hemorrhage .Fluid collections spread more often along preferential drainage pathways , such asWhen secretions breach the thin layer of connective tissue that surrounds the pancreas, they are immediately involved with the anterior pararenal space and the lesser sac: if fluid leaks from the posterior part of the gland or from the tail, the anterior pararenal space is filled first, while an anterior perforation of the posterior layer the parietal peritoneum leads to direct extension of fluid in the lesser sac . In mostThoracic involvement in pancreatic disease results from an acute disruption of the pancreatic duct on the posterior side, resulting in the leak of pancreatic secretion into the retroperitoneal space –8. Once Other less frequent sites of entry into the mediastinum are the foramen of Morgagni and the inferior vena cava hiatus, into the retrocrural space by penetrating the left diaphragm , 4, 6, 9Xu et al.  tried toIn our case, the fluid collections in the mediastinum were in close relationship to the esophagus, suggesting that the route of dissection was through the esophageal hiatus.In most of the reported cases of mediastinal extension of pancreatic fluid collections, patients had histories of previous upper abdominal trauma or surgery, alcoholism, or previous hospitalization for pancreatitis . Indeed,It would be interesting to speculate the cause of pancreatitis in our patient. Indeed, the patient had no history of alcohol abuse; gallstones and other abnormalities in the biliary system were excluded. Autoimmune pancreatitis was ruled out because immunoglobulin G4 fraction (IgG4) antibody was negative. Trauma was denied and other rare causes were unlikely.We speculate that hyperlipidemia was the etiologic factor in this case, even though it has not been conclusively confirmed.Also, our patient had no past history of pancreatitis although he had CT signs of chronic pancreatitis. On retrospective questioning and examination, the patient reported previous recurrent episodes of abdominal pain treated as gastro-oesophageal reflux. Thus, we speculate that he could have previous unrecognized episodes of pancreatitis.Our report underlines the importance of CT and MRI findings in the diagnosis and characterization of ascending pancreatitis, thanks to evaluation of features and extension of the fluid collections provided by these two diagnostic tools.Important in the case of ascending pancreatitis with mediastinal involvement is also the characterization of pleural effusion; indeed, pancreatic pathologies can be complicated by two types of pleural effusion .The first type is associated with attacks of acute pancreatitis (in 4% of cases of mild pancreatitis and in 24% of cases of severe pancreatitis) , 12 and The second kind of effusion is related to the presence of pancreaticopleural fistula in the course of chronic or recurrent pancreatitis, which can penetrate to the pleura, bronchi, mediastinum, or pericardium due to the gradients of pressure between the abdomen and the thorax . The effThese two forms of pleural effusion should be clinically recognized, in view of their different complication rate, prognosis, and treatment .A timely and accurate diagnosis of ascending pancreatitis is important due to the potentially life-threatening thoracic complications, such as mediastinal pancreatic pseudocysts, pericardial effusion, and pancreaticopleural fistulas , 4, 13. The treatment options of the pancreatitis are dictated by the severity of symptoms, the size of the fluid collections, the ductal anatomy, and the surgical expertise available .The treatment options include medical management, drainage of fluid collection , and surgery . In the Peripancreatic fluid collections are a common finding of pancreatitis and tend to extend to peripancreatic tissue, more often along preferential drainage pathways in the abdomen. In some rare cases, as the one presented in this paper, fluid collections may spread to the mediastinum leading to the formation of mediastinal collections. A prompt and accurate diagnosis of the mediastinal involvement is important due to its potentially life-threatening complications.