Hemiballismus is defined as irregular, involuntary, large-amplitude flinging movements by the limbs, confined to one side of the body. Hemichorea refers to a state of excessive and irregularly timed, non-repetitive and randomly distributed, spontaneous, involuntary, and abrupt movements. It is widely believed that hemiballismus and chorea are suggestive of a lesion to the basal ganglia and subthalamic nucleus (STN). However, there are other etiologies that may influence the clinical presentation. Patients may present with certain common clinical features corresponding to the affected area of the brain. For example, infarctions of the motor cortex present with hemiplegia or paralysis of one side of the body. Similarly, infarctions involving the language areas of the brain present with aphasia and are detrimental to speech production or comprehension and the ability to read and write. Typically, acute-onset hemichorea is suggestive of a lesion in the STN. Herein, we present a rare case of acute hemiballismus and hemichorea following infarction of the left caudate nucleus, as determined by magnetic resonance imaging (MRI) and computerized tomography (CT) imaging modalities. Chorea is a unilaterally presenting involuntary movement disorder described as sudden, brief, spontaneous, non-stereotyped, and dance-like. Classically, the literature establishes chorea as the result of a lesion to the subthalamic nucleus (STN) or the nucleus hypothalamus/corpus Luysi. However, other investigations have identified localized lesions in other parts of the basal ganglia and caudate nucleus as the culprits of the movement disorder . DespiteChorea is a consequence of damage to the inhibitory pathways within the basal ganglia. Normally, the globus pallidus internus (GPi) inhibits the thalamus through inhibitory projections and thus modulates the movement pathways. However, when there is a decrease in the inhibitory transmission from the GPi to the thalamus, the thalamus starts randomly firing excitatory projections that overactivate the corticospinal and corticobulbar tracts. The resulting efferent innervation transmitted to the muscles on the contralateral side creates the abnormal movements described as chorea.The vascular supply of the basal ganglia is also a key component of chorea’s presenting pathology. Overall, the basal ganglia are supplied by a mix of small feeder vessels stemming from the anterior cerebral, middle cerebral, posterior cerebral, and posterior communicating arteries. The lateral lenticulostriate artery stems from the middle cerebral artery and supplies portions of the putamen, external capsule, and upper internal capsule. The anterior cerebral artery feeds the medial lenticulostriate artery and the medial striate artery of Huebner, which supply the globus pallidus and portions of the caudate, respectively. The caudate does receive some supply from the middle cerebral artery as well . The posLike any blood vessel in the brain, the vascular supply to the basal ganglia is at risk of damage from strokes. Strokes causing hemichorea-hemiballismus usually localize to a common functional network, with lesions occurring in regions functionally connected to the posterolateral putamen. To determine treatment efficacy, the neurology-neurosurgical team assesses perioperative neuronal activity. Monitoring studies have demonstrated decreased firing rates of cells within the GPi following pallidotomy, a surgical treatment aimed at reducing hyperkinetic movements. Considering the complex pathophysiology, hemiballismus is suggestive of a lesion to the basal ganglia STN. However, rare cases have demonstrated other etiologies to be responsible, with different etiologies having unique clinical features of their own. Herein, we present a rare case of hemiballismus following a stroke of the left caudate nucleus.A 64-year-old male with a medical history of a non-disabling stroke, tobacco use, and alcohol use disorder was admitted to the hospital due to a four-day history of right-sided weakness and involuntary shaking movements of his right arm and leg. He reported not feeling well and falling to the right with attempts to walk. The patient’s wife reported noticing involuntary choreiform movements in the patient’s right hand and foot and occasional arm-flinging, ballistic-like movements two days prior to admission to the hospital. A computerized tomography (CT) scan of the head revealed hypodensity involving the left caudate nucleus, consistent with an infarction Figure .Magnetic resonance imaging (MRI) of the brain was positive for an acute stroke of the left caudate nucleus with restricted diffusion and signal loss on the apparent diffusion coefficient (ADC) map Figures -1D. MagnOver the next few days, the right-sided weakness improved gradually, but the frequency of choreiform movements increased. The patient was started on low-dose haloperidol, which significantly improved his hemichorea symptoms.Hemichorea-hemiballismus is uncommonly reported following a stroke. The incidence of this hyperkinetic movement disorder following an acute ischemic stroke ranges between 0.4% and 0.54% . These cThe basal ganglia are modulators of motor control. Damage to these basal ganglia structures will lead to hyperkinetic or bradykinetic states. For example, loss of cells in the substancia nigra leads to parkinsonism with bradykinesia. Lesions involving the STN are felt to result in hyperkinetic states, chorea, and/or hemiballismus. Similarly, lesions of the medial globus pallidus increase motor activity . Acute-onset hemichorea has been felt to be caused by a subthalmic stroke . HoweverGiven the caudate’s mixed vascular supply of the anterior and middle cerebral arteries, it normally would be difficult to ascertain which vessel caused a presenting ischemic infarct. Fortunately, in our case, the severe stenosis of the left M1 of the middle cerebral artery leads us to believe that this was the causative vessel. The middle cerebral artery gives rise to the lenticulostriate perforates, which supply the superior head and body of the caudate and suggest possible localized areas of infarction. One caveat for individuals suffering from high levels of intracranial stenosis is the possibility of contralateral supply to the caudate nucleus .Medical management aims to relieve severe hyperkinetic movements using first- and second-generation antidopaminergic drugs that target dopamine receptors (D2Rs) , benzodiazepines (clonazepam), anti-epileptics (topiramate), and tetrabenazine -11. HemiIn the discussed case, the patient presented with multiple stroke risk factors and was found to be positive for stroke on MRI. Based on the patient’s medical history and MRI findings, a lab test was not required . The patWhen assessing patients presenting with involuntary movements in the acute stroke setting, identification of the dysfunctional area of the brain can be a challenge. In this setting, regular and rhythmic movements suggest focal-onset seizures, whereas irregular hemichorea or hemiballismus movements suggest disruption of deep basal ganglia motor control regions. In this instance, neuroimaging is an important tool for establishing a definitive and accurate diagnosis. Furthermore, imaging studies can help expand the current understanding of the impacts of the dysfunction of different brain regions.In the presented case, a patient with hemiballismus and hemichorea following an infarction of the caudate nucleus was identified by CT and MRI imaging modalities. This case highlights the value of diagnostic imaging and the potential for variable anatomic regions to be involved in the pathophysiology of involuntary movement disorders. Although hemichorea and hemiballismus are believed to be consequences of strokes involving the STN, this case demonstrates that infarction of other basal ganglia brain structures, specifically the caudate nucleus, may be responsible for this rare clinical stroke presentation.


Syncope is a frequent reason for elderly patients to present to an outpatient office. The underlying cause of syncope can range from benign to serious. Although serious cases of syncope are rare, appropriate workup can help detect and address potentially fatal pathologies. We present a case of a 74-year-old woman who presented with an episode of syncope with associated epigastric cramping. Sudden syncope without significant comorbidities prompted further diagnostic workup, which revealed a rare cardiac myxoma. This case underscores the importance of ruling out potentially fatal causes prior to favoring more conservative diagnoses when investigating syncope in the elderly population. Syncope in the elderly population can have multiple etiologies, ranging from relatively benign to lethal . Common Cardiogenic syncope is caused by heart abnormalities that prevent sufficient cerebral circulation and thus deprive the brain of the appropriate oxygenation required for consciousness . The undThis case was previously presented as a meeting abstract and poster at the 10th Annual Camden Scholars Forum on May 3, 2023.A 74-year-old woman with a relevant history of hypertension, hyperlipidemia, and asthma well-managed with lifestyle interventions presented to our outpatient office following a fainting episode. She was singing in a choir when she developed a cramp-like discomfort in the epigastric region followed by loss of consciousness. Witnesses reported that her eyes had rolled back into her head, but denied any tongue-biting, urinary incontinence, or convulsions. She regained consciousness within a few seconds, but she was noted to be confused and diaphoretic afterward. She returned to her baseline within a few minutes.The patient endorsed some residual lightheadedness but denied fever, chest pain, palpitations, headache, nausea, or shortness of breath. One week prior to the presentation, she had experienced an episode of vertigo. Her physical exam was notable for hypertension and a unilateral erythematous tympanic membrane. She had a negative Dix-Hallpike maneuver. The orthostatic supine-to-standing test resulted in only a 10 mmHg drop in systolic blood pressure. The rest of her vital signs and physical examination findings were within normal limits.Her recent episode of vertigo was attributed to an acute otitis media, for which she was treated with a 10-day course of twice daily oral amoxicillin-clavulanate antibiotic. Given her co-presenting epigastric pain with syncope, the differential diagnosis for the syncopal episode was expanded to include vasovagal syncope, cardiogenic syncope, sick sinus syndrome, seizure, or myocardial infarction.Her in-office electrocardiogram showed normal sinus rhythm with no other abnormalities, which indicated that sick sinus syndrome and recent myocardial infarction were less likely. No tongue-biting, urinary incontinence, myoclonic movements, post-ictal state, and prior history indicated seizures were not a likely cause of the episode. Additional diagnostic tests, such as a complete metabolic panel, complete blood count, and chest radiograph were within normal limits.A transthoracic echocardiogram (TTE) was performed to examine structural cardiac pathology before favoring a diagnosis of vasovagal syncope. The TTE demonstrated a 2x2.3 cm, non-mobile, heterogenous mass in the left atrium tethered to a thickened interatrial septum Figures -3. This Although the mass is relatively small, the obstruction of forward blood flow likely was exacerbated to a symptomatic degree due to hypovolemia. At the time of the syncopal episode, she was engaging in physically demanding activity  in a warm room, which contributed to a dehydrated state. Consequently, the patient's volume status was likely key to why an otherwise silent cardiac mass was able to induce a transient flow obstruction.She underwent an excision of the atrial mass. The pathology findings confirmed the diagnosis of AM. Grossly, the mass had evidence of hemorrhagic components and calcifications. Microscopically, there were polygonal cells forming cords scattered within a myxoid stroma. Cells were positive for cytoplasmic calretinin and S100 but were negative for SMA, desmin, CD68, and cytokeratins.Her postoperative course was complicated by the development of tachycardia-bradycardia syndrome, which required a permanent pacemaker placement. Subsequently, she remained asymptomatic and was medically managed long-term with metoprolol succinate, rosuvastatin, and rivaroxaban.AM is a benign cardiac mass; approximately 50% of primary cardiac tumors are AM . AM is eIn our patient, syncope was the chief presenting symptom. This case demonstrates the diagnostic challenge while identifying AM, given its nonspecific stigmata within the larger possibilities for syncope and other mimics, including vasovagal, cardiogenic, orthostatic, neurologic, endocrinologic, pharmacological, hematological, and psychiatric causes -3,5. HowIn conclusion, syncope is a common chief complaint for elderly patients presenting to an outpatient office. Syncope, particularly in patients co-presenting with atypical symptoms, such as epigastric cramping, should prompt further diagnostic testing to evaluate for potentially life-threatening cardiac etiology before favoring more conservative diagnoses such as vasovagal syncope. This case of syncope in an otherwise healthy elderly patient ultimately diagnosed as atrial myxoma illustrates the significance of maintaining a broad differential diagnosis when characterizing a common, non-specific symptomatic presentation to ensure potentially fatal etiologies have been adequately evaluated for and ruled out.


General surgeons are all too familiar with sacrococcygeal pilonidal disease and its various manifestations. The term pilo‐nidal was coined in 1880 by R.M. Hodges, defined by pilus (hair) and nidus (nest).A 62 year old man presented to his GP with complaints of pain around his umbilicus and purulent discharge. Over the last few months, he had trialled multiple courses of oral antibiotics, which would settle the infection for a short period, but then the symptoms would recur. There was no previous surgical history. An abdominal ultrasound was performed, and this showed an isoechoic ovoid focus tracking towards the peritoneum, measuring 8 × 9 × 7 mm Fig. . There wThe patient proceeded to surgery for excision of the cyst. Examination of the abdomen showed a deep umbilicus with purulent discharge and surrounding hair, and minor skin erythema secondary to dressings due to the constant discharge Fig. . During Umbilical discharge is uncommon in the adult population, and especially in patients with no previous surgical history. Crucial differential diagnoses include umbilical pilonidal sinus, urachal remnant or omphalomesenteric duct remnant. The main predisposing factors for UPS include young age (twenties and thirties), male gender, hirsutism with the distribution of the distal ends of hairs pointing towards the umbilicus, a deep navel, and to a lesser degree obesity, hyperhidrosis and poor personal hygiene.Treatment options vary for patients suffering with UPS. Some studies have reported on successful conservative management of the disease with removal of hairs from the sinus as well as the surrounding hair, antibiotics, washing of the sinus with iodine and drainage of any concurrent abscess under local anaesthetic.The diagnosis of UPS is frequently overlooked in routine clinical practice because of lack of awareness. Persistent umbilical discharge that does not resolve with medical management should proceed to definitive management with surgical excision.Informed consent was obtained from the patient prior to publication.Bushra Othman: Conceptualization; data curation; writing – original draft; writing – review and editing. Vinna An: Supervision; writing – review and editing.


Hamartomas are non-neoplastic tissue abnormalities commonly found in various organs but rarely in the upper aerodigestive tract. Respiratory epithelial adenomatoid hamartoma (REAH) is a rare benign proliferation affecting the nasal cavity and sinonasal tract. It often mimics other nasal masses, leading to diagnostic challenges. We present the case of a 25-year-old female with recurrent epistaxis and chronic bilateral nasal obstruction. Diagnostic endoscopy revealed a polypoidal mass, later confirmed as REAH through histopathological examination. CT scans demonstrated soft tissue opacity but no erosion of surrounding bony structures. The patient underwent endoscopic excision, and the excised mass exhibited characteristic histological features of REAH. Endoscopic excision with careful postoperative follow-up can lead to successful outcomes in REAH cases. A year of follow-up revealed no recurrence. The term hamartoma was first used in 1904 to describe a tumor-like mass, but they are non-neoplastic malformations or inborn abnormalities of tissue development. Hamartomas are often seen in the lung, kidney, liver, and spleen but are uncommon in the upper aerodigestive tract ,3. This A 25-year-old female patient presented with chief complaints of recurrent epistaxis and chronic progressive bilateral nasal obstruction for one year associated with bilateral nasal discharge. The patient had no history of nasal allergies, headaches, facial pain, swelling over the face, or previous nasal surgeries. Diagnostic nasal endoscopy revealed a pink polypoidal mass admixed with mucoid discharge in the floor of bilateral nasal cavities. Upon probing, it was found to bleed on touch and insensitive to pain, and it was determined to have arisen from the posterior part on the left side of the nasal septum, extending posteriorly into the nasopharynx and entering the opposite nasal cavity. Subsequently, a biopsy was done, and a small bit of tissue was taken from the mass and sent for histopathological study. The study reported it as a case of REAH. A non-contrast CT scan was performed on the paranasal sinuses, revealing soft tissue opacity in the bilateral middle and inferior meatus, extending posteriorly into the choana, and filling the nasopharynx. It showed a blocked bilateral osteomeatal complex associated with the left concha bullosa, mucosal thickening in the left maxillary sinus, and bilateral ethmoidal sinuses. There were no signs of erosion or destruction of the surrounding bony structures.The patient was then scheduled for endoscopic excision. After obtaining informed consent, the mass was excised endoscopically under general anesthesia. During surgery, the mass was observed to be attached to the posterior part of the left side of the nasal septum with a pedicle. The mass was excised from its attachment, and electrocautery was used to stop the bleeding. The excised mass was then pushed into the nasopharynx and carefully delivered from the oral cavity. The procedure was uneventful, and the excised mass was presented for histopathological evaluation. The study reported histological features of respiratory ciliated epithelium with glandular stroma and multiple glands of varying sizes with no evidence of cellular atypia, and the lesion was identified as respiratory adenomatoid hamartoma. Based on the comprehensive clinical, radiological, and histopathological study, the patient was diagnosed as a case of REAH. Subsequently, the patient received appropriate treatment and was discharged. Follow-up after a year showed no recurrence.REAH is a benign, glandular proliferation of the surface epithelium of the nasal cavity and paranasal sinuses . REAH isOn gross examination, REAH appears to have a polypoidal appearance with a friable-to-firm consistency and a yellow-to-white color. Their appearance might also be edematous or glistening, as shown in Figure Histopathological reports of multiple serial and deeper sections from the nasal mass show surface epithelium lined by pseudo-stratified ciliated columnar epithelium with submucosal glandular proliferation of varying sizes, lined by ciliated respiratory epithelium Figure . A few gOn radiological examination, common findings on a CT sinus of REAH are sinus opacification and their ostea being obstructed by a posterior nasal cavity with a polypoid lesion . AnotherHistopathological findings and CT imaging confirmed the diagnosis of REAH. Immunohistochemistry of REAH is usually positive for CK7, p63, and 34betaE12 and negative for CK20, CDX2, smooth muscle actin, calponin, and S100 protein [According to a recent study, REAH may be considered a benign neoplasm rather than a hamartoma . For youInflammatory nasal polyps are benign, inflammatory lesions that develop from the nasal and sinus mucosa. They are grape-like edematous masses that occlude nasal passages and result in symptoms such as nasal obstruction, nasal discharge, hyposmia, facial pain, and epistaxis . Polyps Histologically, they exhibit many similar features, but the presence of more glandular proliferation of varied sizes, basement membrane thickening, and goblet cell metaplasia in our case favored the diagnosis of REAH. Histopathology of inflammatory nasal polyps reveals edematous stroma with inflammatory cell infiltrates, primarily eosinophils, lymphocytes, plasma cells, and mast cells, and histopathology also shows seromucinous gland proliferation . Hence, Low-grade sinonasal adenocarcinoma is another differential diagnosis for REAH. Low-grade sinonasal adenocarcinoma can originate from the surface epithelium and mucoserous glands of the submucosa .To date, no guidelines for differentiating REAH (with a metaplastic mucinous gland component) from low-grade sinonasal adenocarcinoma have been made available. In the review of Wenig and Heffner’s description of this uncommon subtype, the authors discussed that a subset of lesions demonstrated florid mucinous gland metaplasia, with lumina filled with mucinous or amorphous material and stromal hyalinization seen surrounding glandular proliferation . If a loCapillary hemangioma closely resembles REAH, where both present with nasal obstruction, epistaxis, and bleeding with touch-on probing. Capillary hemangioma is distinguished from REAH based on the histopathological picture. A case study by Meshal et al. diagnosed a 30-year-old female based on radiological findings, which included contrast-enhanced CT findings that have shown heterogenous enhancement in multiple areas and MRI findings that have shown hypointense lesions on the non-contrast T1 image and heterogeneously hyperintense lesions with multiple flow voids in the T2 image. The mass showed inhomogeneous enhancement, particularly at the periphery, after contrast administration . HistopaOlfactory neuroblastoma (ONB) arises from the olfactory epithelium and presents with unilateral nasal obstruction and epistaxis in most cases. Clinically, ONB is seen in the superior nasal cavity, which presents as a unilaterally arising large, polypoidal, glistening red-gray mass, often extending into the orbits, cranial vault, and paranasal sinuses . ONB is In our case, a simple endoscopic surgical excision was performed, followed by thorough postoperative care. Postoperative follow-up was done with nasal endoscopy, which showed no signs of recurrence.REAH, a rare benign hamartomatous growth in the sinonasal tract, is characterized by a respiratory epithelial lining and glandular stroma. It often manifests with clinical symptoms such as obstruction, epistaxis, and sinusitis. Fortunately, the treatment is straightforward: surgical excision, which typically yields excellent results. However, diagnosing REAH can be challenging for both surgeons and pathologists, as it requires careful differentiation from other neoplastic conditions such as adenocarcinoma and IP. Misdiagnosis can lead to extensive surgeries and postoperative procedures, underscoring the importance of raising awareness about this condition to prevent unnecessary patient morbidity.


Lupus vulgaris (LV) is a common type of cutaneous tuberculosis and commonly presents as a single erythematous plaque either on the face or buttocks with scarring and an active spreading edge. Multiple lesions of LV are sparingly reported in the literature. We hereby report a case of LV in a male presenting with multiple lesions over the buttock, thigh, and trunk. The diagnosis was done on the basis of clinical findings, histopathology, positive tuberculin test, and response to a standard anti-tubercular regimen. Cutaneous tuberculosis (TB) accounts for 2% of TB cases . ScrofulA 38-year-old immunocompetent male presented to an out-patient section of a dermatology clinic with asymptomatic, non-healing plaque over the right side of the trunk, right buttock and left thigh for the past two years. All three lesions started as a small papule and slowly increased in size over a period of two years. There was a history of occasional pruritus over the lesions. Cutaneous examination showed three verrucous hyperkeratotic, dusky red plaques with irregular regions of atrophy, and adherent yellow-brown crusts over multiple sites. There were three plaques with well-defined borders and irregular margins. Lesion on the right buttock, measured about 15 cm x 10 cm Figure , while t Cutaneous TB can be classified as multibacillary  and paucibacillary . Clinical presentation depends on the portal of entry of bacilli, host immunity status, and antimicrobial resistance ,2. LV isTo conclude, we report a case of multifocal LV in a male which in India, shows a slight female preponderance. we emphasize its presentation as multiple lesions including an uncommon site (trunk) while lupus usually presents as a singular lesion. We based our diagnosis on typical clinical appearance, histopathology, and positive tuberculin test.


Propionibacterium acnes (P. acnes) is a slow-growing, anaerobic, gram-positive bacillus that commonly colonizes the skin and is a rare cause of CNS infections. It was previously viewed as a culture contaminant but is now recognized to infrequently cause indolent cases of CNS infections. It is even more rarely associated with abscesses in patients without a prior history of neurosurgical intervention. Due to being a slow-growing bacteria, P. acnes is frequently discovered to be the causative organism after 16S rRNA sequencing. In this case, the culture was positive. There are only five other reported cases of patients with a P. acnes abscess without prior neurosurgical intervention. Here we present the sixth case of an immunocompetent young male who was found to have a P. acnes brain abscess. Inflammation of the brain can be due to infectious or noninfectious causes. Among infectious etiologies, the most common route of infection is through direct or indirect invasion of the blood-brain barrier. Infection and inflammation of the brain parenchyma can also lead to abscess formation. The rate of uncomplicated recovery for patients with brain abscesses has increased from 33% to 70% over the past five decades ,2. DespiThe most common clinical presentation of patients with brain abscesses is a triad of fever, headache, and focal neurological symptoms. Most importantly, the focal neurological deficit can be the sole presentation of a neurological disorder coexisting with a brain abscess. Approximately 86% of patients with abscesses have predisposing conditions such as sinusitis, otitis media, mastoiditis, and meningitis. Neurological surgical interventions are the main cause of brain abscesses, but brain abscesses can also rarely develop in patients without any pre-existing risk factors ,4.In immunocompetent individuals, approximately 95% of brain abscess cases are usually polymicrobial and bacterial in origin. The most commonly identified bacterial microorganisms are streptococci , staphylococci , anaerobes , and Enterobacteriaceae. Empirical antibiotic treatment with third-generation cephalosporins and metronidazole is the standard of care. Neurosurgical interventions in the form of abscess aspiration and placement of an external ventricular drain, collection of biopsy fluid, and biopsy of brain parenchyma for diagnostic analysis are helpful diagnostic and therapeutic interventions [A 21-year-old African American male with no significant past medical history (except migraine headaches) was transferred to the University of South Alabama Health Hospital emergency department with a chief complaint of left-sided weakness. The patient reported that he had been hit in the head two weeks ago with a wooden stick, was knocked off balance, and started having some headaches and left-sided weakness. On physical examination, the patient denies blurry vision, headache, nausea, vomiting, chest pain, diaphoresis, or confusion. Emergency laboratory evaluation revealed an elevated WBC count; otherwise, the remaining labs were unremarkable. Workups for sexually transmitted diseases (STDs), including HIV, rapid plasma reagin (RPR), and hepatitis, were negative. Neurological examination revealed 4/5 grip strength (grips) in the left upper extremities, 5/5 grip strength (grips) in the right upper extremities, 2/5 strength in the left lower extremity, and 5/5 strength in the right lower extremity.A CT of the head without contrast revealed a right periventricular white matter mass measuring 1.2 cm in greatest dimensions. The mass was peripherally hyperdense with an extensive amount of surrounding vasogenic edema, most suggestive of an intracranial abscess. MRI of the brain with intravenous gadolinium revealed a peripherally ring-enhancing lesion in the right corona radiata adjacent to the cingulate gyrus measuring 1.6 x 2.1 cm with continuous ring enhancement. The enhancing portion of the mass measured approximately 0.4 cm. There is significant T2/fluid attenuated inversion recovery (FLAIR) hyperintensity representing edema, which extended into the right frontal, temporal, and parietal white matter. Edema also crossed the midline via the corpus callosum. Edema also crossed the midline via the corpus callosum with a stable 0.8 cm leftward midline shift , and neurosurgery was consulted. A right burr hole craniotomy for biopsy with stealth navigation was performed. Pathology department was consulted, and a frozen section was performed for intraoperative diagnosis to confirm malignancy versus abscess formation. Evaluation of the frozen section revealed minute fragments of predominantly necrotic tissue with a few atypical glial cells Figure . No defiHistologic examination of permanent sections revealed fragments of benign brain parenchyma with gliosis, macrophages, and a focal dense perivascular inflammatory infiltrate. Abundant amounts of necrotic tissue were also identified, and multiple immunohistochemistry stains were ordered to rule out an infectious etiology Figure .Immunohistochemistry (IHC) was performed to rule out infectious etiologies and malignancies, and highlight the normal brain parenchyma. Immunoperoxidase stains using antibodies against glial fibrillary acidic protein (GFAP), CD68, CD34, CD3, herpes simplex virus (HSV), periodic acid-Schiff (PAS) with diastase (PASH+D), toxoplasma, acid fast bacilli (AFB), Gram stain, Grocott methenamine silver (GMS), cytomegalovirus (CMV), and Ki-67 were performed on representative sections of formalin-fixed paraffin-embedded (FFPE) blocks Figures . GFAP shThe specimen was sent to microbiology for culture and identification; the culture was positive for Propionibacterium acne ( P. acnes) Figure .Our patient was hospitalized with left upper extremity and left lower extremity hemiparesis, incoordination, and a headache. A CT scan revealed a 1.2 x 1 cm lesion with vasogenic edema in the right corona radiata, with spectroscopy findings concerning glioblastoma multiforme. The patient underwent a burr-hole craniotomy for a biopsy. Tissue culture was positive for P. acnes after five days. An attempt was made to have 16S rRNA sequencing on the specimen, but the specimen was determined to be inadequate. We do not believe this influenced our conclusion because the slow growth of the organism was consistent with P. acnes. Despite the fact that P. acnes is normal skin flora and a potential contaminant, the sequencing may have provided proof of the infection. The slow growth does not imply contamination or poor collection, as it might with other organisms.In our literature review, we looked at other cases of P. acnes causing a CNS infection in patients without immunosuppression or prior neurosurgical intervention. In Table A case report by Odunkan et al. describes that the mechanism for the translocation of P. acnes across the blood-brain barrier is unknown . The risKim et al. reported a case of a subdural empyema with P. acnes as the causative organism . They suViewing the demographic characteristics of the five cases of CNS abscess caused by P. acnes, two cases involved young adult patients. The patient we present is also a young adult, making up half of the reported cases of P. acnes in young adults with the characteristics we describe of being immunocompetent and without prior neurosurgical intervention. It raises the question of whether there is a risk factor in these young adult patients that has yet to be identified.There are many questions to be raised in this case and the other reported cases involving immunocompetent hosts without prior neurosurgical intervention. Are there other risk factors not being considered in these patients? Are there cases being missed due to the slow growth of P. acnes? The possibility of missed cases is supported by the slow growth of the organism and its high susceptibility to penicillin and cephalosporins, which decrease the need for further investigation in some patients. What is the method of transmission in immunocompetent patients? In immunocompromised patients, it could be suggested that the transmission could be through a break in the skin, as P. acnes is part of the normal skin flora. In immunocompetent individuals, the etiology of transmission remains unclear.Intracranial infections by P. acnes are not frequent, but this agent should be considered a potential cause of post-surgical brain abscesses. We emphasize the need to send tissue samples for culture and proper identification of the causative microorganism before giving negative results. We also emphasize the relevance of the Gram stain as a rapid method to guide the diagnosis; the microbiology laboratory must have an adequate methodology for the recovery of this type of microorganism.


ASPSCR1-TFE3 gene fusion revealed by next-generation sequencing. ASPS most commonly occurs as a painless mass in the lower extremity, with likely involvement in the lungs if metastasis is present. Here we report a case of ASPS that exhibited the characteristic ASPSCR1-TFE3 gene fusion along with a reciprocal fusion of TFE3-ASPSCR1, which presented in the nasolabial fold of a 31-year-old female. An intraoral approach was utilized for complete surgical resection of the malignancy, resulting in continued remission after 11 months.Alveolar soft part sarcoma (ASPS) is a rare malignancy that is morphologically characterized by a distinctive nodular, organoid, or nested growth pattern in which the cells are separated by vascularized septa. The diagnosis is based on a combination of pathologic and immunohistochemical findings and the presence of an  ASPSCR1-TFE3 gene fusion, with ASPSCR1 located on chromosome 17 and the TFE3 gene on the X chromosome, thus accounting for female predilection. ASPS is characterized as a delayed, metastasizing tumor that most commonly spreads to the brain and lungs decades after diagnosis, with a higher five-year survival rate in patients without metastasis. To date, there have been fewer than 20 reported cases of ASPS occurring in the buccal/oral region in literature. We report a case of ASPS with the characteristic ASPSCR1-TFE3 gene fusion and positive tumor markers presenting in the nasolabial region of a 31-year-old female patient.Alveolar soft part sarcoma (ASPS) is a rare, slow-growing malignancy that accounts for approximately one percent of all sarcomas and 80 new diagnoses per year . ASPS isA 31-year-old female presented to the plastic surgery office for the excision of a mass located in her left nasolabial fold . The current follow-up protocol for this patient includes yearly PET scans as well as clinical re-evaluation every six months for the first three years, then subsequent yearly evaluations as suggested by the multidisciplinary tumor board.We report a case of alveolar soft part sarcoma (ASPS) of the nasolabial fold in a 31-year-old female. ASPS is an infrequent type of soft tissue sarcoma (STS), comprising less than 0.0001% of new adult malignancies . ASPS moThere have been fewer than 20 reported cases of ASPS in the buccal/oral region, with the lingual region being the most frequently observed location. As a result, its occurrence in the nasolabial fold is a remarkably unique presentation of ASPS . FurtherThe five-year survival rate for ASPS is estimated at 86% for those without metastatic spread and 62% for patients reported with metastasis . MetastaGrossly, ASPS is usually characterized by a well-circumscribed lesion that has a soft and rubbery consistency and can vary in color from yellow to gray to tan; areas of necrosis and hemorrhage can also be demonstrated ,13. The The aforementioned histologic patterns were observed in our patient, as the pathology report described the malignant epithelioid neoplasm as being lobulated with vaguely nested growth patterns. Cytologically, the cells were described as large, mostly uniform, with round to oval vesicular nuclei, prominent nucleoli, and abundant eosinophilic cytoplasm with variable clearing Figure . Some inCurrently, complete surgical resection is the first-line treatment for ASPS, as it offers the greatest benefit ,10,15. ATargeted therapy of ASPS is showing increased success with tyrosine kinase inhibitors, specifically sunitinib and pazopanib, which are currently recommended by the National Comprehensive Cancer Network (NCCN) and the Chinese Society of Clinical Oncology (CSCO) ,4,16,17.ASPSCR1-TFE3 gene fusion along with a reciprocal fusion of TFE3-ASPSCR1 between TFE3 on exon 3 and ASPSCR1 on exon 8. The patient underwent complete surgical resection of the malignant tumor and has been in remission for 11 months. The current follow-up protocol includes yearly PET scans and clinical re-evaluation every six months for the first three years, then subsequent yearly evaluations to monitor for the presence of local recurrence or metastasis. As a consequence of the uncharacteristic location and age presentation that this exceptionally rare tumor demonstrated, increased clinical suspicion is warranted for a well-circumscribed mass of an unknown etiology presenting in an otherwise healthy patient. This case report and literature review demonstrate the importance of why surgeons need to be cognizant of malignancy when evaluating even the most seemingly benign masses.Alveolar soft part sarcoma (ASPS) is an exceedingly rare type of sarcoma that has less than 20 reported incidences in the buccal/oral region in the literature. Herein, we report a case of ASPS that presented in the left nasolabial fold in a 31-year-old female that exhibited the characteristic


Inflammation of the gingiva is one of the most common and routine findings in dental practice. These routine appearances of inflammatory gingivae can show peculiarity when associated with an underlying systemic condition or because of reactive, benign, or malignant pathologies. This case highlights minute clinical signs of the gingiva that deviate from the routine presentation and warrant further investigations. A 63-year-old woman presented with a chief complaint of severe pain in relation to the lower front teeth region for 1 month. Intraoral examination revealed a gingival lesion on the labial aspect of 41, 42, and 43, and an intraoral periapical radiograph showed mild bone loss. The lesion persisted despite oral prophylaxis, and a biopsy was advised. The final diagnosis was stage 1 gingival squamous cell carcinoma (GSCC). It is important to note that the non-descript presentation of GSCC in early stages often mimics benign traumatic or inflammatory lesions of the gingiva. Peculiar clinical features of GSCC of note include the lack of traditionally associated risk factors and localized red or ulcerative lesions with increased bleeding tendencies that do not respond to routine periodontal treatment within 2 weeks. Morphological changes associated with chronic gingivitis and periodontitis present as redness of the gingiva, enlargement, loss of stippling, bleeding on probing, etc. These routine appearances of inflammatory gingiva can show peculiarity when they are associated with an underlying systemic condition  or when there are local pathologies that are reactive, benign, or malignant in nature . Dentist2.A 63-year-old woman presented with a chief complaint of severe pain in the lower front teeth for 1 month . The patOn intraoral examination, there was a gingival lesion on the labial aspects of 41, 42, and 43, extending from the mesial aspect of 41 to the distal aspect of 43. The lesion involved marginal, interdental, and attached gingiva. The gingival lesion appeared to be erythematous, and the surface was irregular with erosions. The margins of the lesion were well-defined with raised edges. It was soft in consistency and tender on palpation. On periodontal examination, there was the presence of bleeding upon probing, with no exudation. There was a moderate deposition of calculi. There was an absence of mobility i.r.t 41, 42, and 43. There was no tenderness on lateral and vertical percussions on teeth i.r.t 41, 42, and 43. The rest of the oral mucosa had no significant findings. On extraoral palpation, submandibular lymph nodes on the right side were palpable, firm, non-tender, and mobile. An intraoral periapical radiograph  was take2.1.Considering the gingival lesion with a tendency for bleeding and the presence of interdental bone loss, chronic periodontitis exacerbated by an underlying systemic condition such as diabetes mellitus could be considered as a diagnosis in this case . The othLocalized lesions involving gingivae may occur because of chronic trauma. Additionally, toothbrush injury, the use of toothpicks, abrasive dentifrices, and rare self-inflicted injuries may cause gingival erosions and ulcerations . However2.2.Initially, a round of oral prophylaxis was carried out, and she was prescribed 0.2% chlorhexidine mouthwash. Additionally, she was advised to have a complete blood count and a random blood glucose test and recall after 2 weeks. The blood report was within normal range.As the lesion persisted along with bleeding tendency during the follow-up visit, an incisional biopsy was performed. A histopathological report revealed a squamous epithelium overlying the connective tissue with tumors irregularly proliferating in the form of sheets and islands in the connective tissue stroma. Additionally, keratin pearls were evident within the tumor islands. Squamous tumor islands showed dysplastic features such as hyperchromatism, pleomorphism, an altered nuclear-cytoplasmic ratio, individual cell keratinization, and a few mitoses. The connective tissue stroma comprised bundles of collagen fibers with spindle-shaped fibroblasts, chronic inflammatory infiltrate, and endothelial-lined blood vessels with RBCs . Thus, tThe patient was referred to a higher center for surgical intervention. Further investigations, such as contrast CT, were performed, and the patient was diagnosed with gingival squamous cell carcinoma (GSCC) Stage 1 . The patient underwent surgery and radiotherapy and is currently in follow-up. 3.Oral cancer is a broad term that includes various malignant conditions involving the oral tissues. It is the sixth most common cancer in the world and OSCC accounts for 90% of all oral cancers . South ATreponema pallidum (syphilis), Candida, and human papillomavirus (HPV), have been associated with an increased risk of malignancy , oral cytology (OC), and light-based detection (LBD) devices, such as Velscope, ViziLite plus , and ultThis case report highlights the non-descript presentation of GSCC at early stages, which often mimics benign traumatic or inflammatory lesions of the gingiva. Peculiar clinical features of GSCC of note include the lack of traditional risk factors and localized red or ulcerative lesions with increased bleeding tendencies that do not respond to routine periodontal treatment of oral prophylaxis within 2 weeks. The affinity of GSCC to invade the bone and spread at an early stage makes early diagnosis and prompt treatment critical for improving therapeutic outcomes for the patient.


The morphological characteristics of the nevi were evaluated by in vivo confocal microscopy, the pigmented nevus cells on the conjunctiva of the lacrimal caruncle were observed to be clustered in nests with irregular boundaries. The cells were round or irregular, with clear cell boundaries, hyper-reflective at the periphery, with low reflectivity in the center. Vascular crawling was observed in some regions. Histopathological analysis showed that nevus cells were roughly equal in size and distributed in a nodular pattern. Melanin granules were observed in the cytoplasm. No atypia or mitotic figures of the cells were found.The nevi of the four patients were all located at the conjunctiva of the lacrimal caruncle, with a slightly nodular surface, mixed black and brown color, and clear boundary. The nevi were round and highly protruded on the surface of the lacrimal caruncle, with an average diameter of 4.5 ± 1.29 mm. Under in vivo confocal microscopy.This study revealed that the microstructure of nevi growing on the conjunctiva of the lacrimal caruncle can be identified by  At present, IVCM imaging is mainly used for corneal diseases, and it has also been applied in the study of neoplasms of the ocular surface . WrIVCM examination was carried out using a HRT3/Rostock Cornea Module  equipped with a 670-nm laser . The resBefore IVCM examination, topical anesthesia was applied to the inferior conjunctival fornix of the eye with 0.5% proparacaine eye drops, administered three times at 5-min intervals. Carbomer eye gel was applied to the tip of the IVCM, which was then covered with a disposable sterile transparent shade. In order to display the detected image more clearly, the outer layer of the contact sleeve was evenly coated with carbomer eye gel. After sufficient ocular surface anesthesia, the chin and forehead of the subject were fixed in the corresponding positions of the IVCM machine. The ophthalmologist (C.X.) extended the upper and lower eyelids of the examined eye with the middle finger and thumb, respectively. The IVCM lens was then advanced by the other hand of the ophthalmologist so that it touched the edge of the pigmented nevus under examination. The scanning depth was adjusted, and the scan was performed gradually, moving from shallow to deep. Horizontal scanning was performed from the temporal side of lesion to the nasal side, and IVCM images were captured at any time during the scanning process. The five clearest images from each patient were selected for analysis.All operations were carried out by a single surgeon (J.C.). Before surgery, topical anesthesia was applied to the inferior conjunctival fornix of the eye with 0.5% proparacaine eye drops, administered three times at 5-min intervals. Local anesthetic was administered to the caruncle subconjunctival tissue by injection with 0.5 ml of 2% lidocaine. The conjunctival tissue was incised by 1 mm beyond the edge of the nevus. The nevus and a small amount of subconjunctival tissue were completely removed and sent for histopathological examination. The conjunctival incision of the lacrimal caruncle was released and closed intermittently with 10-0 nylon suture. Attention was paid to avoid injury of the lacrimal canaliculus during the operation.Histopathological examination was performed for all four specimens. The tissues of the caruncle conjunctival nevus were fixed in 10% paraformaldehyde, dehydrated, and embedded in paraffin according to the conventional procedure. The tissue sections (5 μm) were sliced, spread, baked, and stained with hematoxylin and eosin. Briefly, after deparaffinization at 60°C, the sections were incubated twice in xylene, then re-hydrated by passing them through decreasing concentrations of alcohol baths and water. The sections were stained for 8 min with Harris hematoxylin staining solution, followed by incubation with 1% hydrochloric acid in ethanol for 10 s. After washing, the blue-promoting solution appeared blue after 10 s. The sections were then washed with tap water, stained with 1% eosin iron-red, dehydrated in graded alcohol solutions increasing in concentration, and cleared in xylene. The HE-stained sections were imaged and analyzed via light microscopy by a pathologist to determine the morphological changes in the caruncle conjunctival nevus.Four patients, one male subject and three female subjects, were recruited. The ages of the four enrolled patients ranged from 14 to 24 years (mean: 17.75 ± 2.08). All lesions occurred only in one eye, with two occurring in the right eye and two in the left. The nevi of the four patients were all located at the conjunctiva of the lacrimal caruncle, with a slightly nodular surface, mixed black and brown color, and clear boundary . The nevThe four surgical specimens from the patients were all diagnosed as pigmented nevus in the histopathology analysis. Microscopically, the pigmented nevi were completely removed, and no nevus cells were seen at the edges of the specimens. Hematoxylin and eosin staining showed that nevus cells were located within the epidermis and dermis . The nevUnder IVCM, nevus cells on the conjunctiva of the lacrimal caruncle were observed to be clustered in nests with clear and irregular boundaries, and reflectivity was significantly increased as compared to that of normal lacrimal caruncle tissue . Each siA pigmented nevus, also known as a melanocyte nevus, is a benign hyperplastic growth composed of nevus cells. Its distribution covers the skin of the entire body, including the face and eyelid skin, as well as the conjunctiva. A Korean study has reported that 76.5% of conjunctival pigmented lesions are located on the bulbar conjunctiva, 8.2% on the caruncle, and 1.2% on the fornix. Compound nevus is the most common type (67.1%) of conjunctival melanocytic tumor and has a benign course. In contrast, conjunctival malignant melanoma is rare (7.1%) and carries serious consequences  for the publication of any potentially identifiable images or data included in this article.JC: conception and design, data collection and surgical operation, and drafting of the manuscript. CX: IVCM examination. JC, CX, and ZL: analysis and interpretation of data. TN: critical revision of the manuscript. All authors read and approved the final manuscript.


We identified 63 cases of conus medullaris teratoma over the past two decades by systematically analyzing the case reports. Findings demonstrated that most cases were diagnosed in the fourth decade of life, with the majority of cases (57.6%) being male. Lower back pain, radiating pain in the extremities, hypoesthesia, and urinary dysfunction are the most common clinical presentations among patients with teratoma of conus medullaris. Mature teratoma is the dominant pathologic subtype of teratomas in this region, comprising more than 95% of cases. Our case highlights the importance of considering spinal teratoma as a differential diagnosis in patients presenting with urinary incontinence and lumbar pain.In conus medullaris, mature teratomas are rare. We report a case of a 40‐year‐old man who presented with urinary incontinence, low back pain, and muscle weakness. Magnetic resonance imaging revealed a mass in conus medullaris  presenting with prolonged symptoms. While these tumors may manifest in various regions, teratomas constitute less than 1% of the central nervous system (CNS) tumors and are extremely rare in the spinal cord.2A 40‐year‐old man was referred to our center, the main referral neurosurgery center in Southeast Iran, complaining of progressive radicular pain. The patient had a history of urinary incontinence since the age of 10. Refractory lumbar pain radiating to both lower limbs developed about 1 year before the current admission. The pain intensified with activity and was relieved when the patient was relaxed. No history of neurogenic claudication was present. Four months before the admission, the patient developed a left foot drop. At the time of admission, hypoesthesia of both lower limbs and anesthesia of the left foot were present. Moreover, saddle hypoesthesia and urinary incontinence were noted.Grading of muscle strength revealed that the distal force of the left lower limb was significantly reduced, where the proximal and distal forces were 4/5 and 0/5, respectively. Examination of the right lower limb demonstrated that the proximal and distal force were 5/5 and 1/5, respectively. The straight leg raise (SLR) test and Patrick's test were negative. No signs of Hoffmann's reflex, Babinski reflex, or clonus were observed, and the proprioception was intact. However, the knee and ankle reflexes of both sides were absent.11–L1 (conus medullaris) causing spinal cord compression , even more prevalent than lower back/leg pain (59.0%).Generally, the most reliable diagnostic tool for spinal teratoma is MRI. The presence of inhomogeneous intensities on T1‐ and T2‐weighted images may indicate tissue heterogeneity, as seen in the solid and cystic components of the tumor, which is suggestive of teratoma. Other imaging techniques, such as plain X‐ray and computed tomography (CT) scans, can also be utilized to detect vertebral anomalies, erosions, calcifications, and increased interpeduncular space.Teratomas are generally classified into mature, immature, and malignant pathologic subtypes according to their degree of differentiation and the presence of benign or malignant components.Given the uncertain natural progression of teratomas, complete surgical excision is often considered the primary treatment approach.Adjuvant radiotherapy is advised for teratomas that include malignant components; however, there is no evidence of the effectiveness of adjuvant chemotherapy in such patients.In conclusion, although conus medullaris teratoma is a rare tumor, it can potentially affect patients of any age and cause progressive symptoms, thereby significantly affecting their quality of life. These tumors typically present with a variety of neurological symptoms, including back pain, motor and sensory deficits, and sphincter dysfunction. While the prognosis for these tumors is generally good, there is a risk of symptom progression if proper intervention does not apply. Moreover, in the case of immature or malignant teratoma, there might be cases of recurrence or metastasis.Masoud Eslami: Conceptualization; data curation; investigation; methodology; supervision; writing – review and editing. Mehran Ilaghi: Conceptualization; investigation; methodology; writing – original draft. Erfan Shahabinejad: Conceptualization; investigation; methodology; writing – original draft. Forouzande Khajepour: Conceptualization; data curation; investigation; methodology; supervision; writing – review and editing. Saeed Karamouzian: Conceptualization; investigation; methodology; supervision; writing – review and editing. Hamed Reihani‐Kermani: Conceptualization; investigation; methodology; project administration; supervision; writing – review and editing.None.The authors declare that no competing and financial interests exist.This study has been conducted according to the guidelines of the ethics committee of Kerman University of Medical Sciences.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Traumatic pericardi0-diaphragmatic rupture is very rare. It occurs due to high-velocity blunt trauma or penetrating injury to the abdomen or chest, which requires emergency intervention. The severity of injury varies, and it is very difficult to diagnose. Diaphragmatic ruptures are more common on the left side. Pericardial tears and diaphragmatic rupture are rare and often unrecognized in the acute phase. Computed Tomography is essential to diagnose and requires emergency surgery to avoid dreaded complications. A twenty-eight-year-old female reported to the emergency department with blunt injury to the abdomen following a road traffic accident. She was found to have diaphragmatic and a pericardial rupture with herniation of the bowel into the thoracic cavity. Emergency surgical repair was done. We report this case, as it is very rare to have a pericardial involvement along with diaphragmatic rupture, and to elaborate on the technical aspect of the surgical repair. Traumatic diaphragmatic rupture usually results from high-velocity blunt trauma to the abdomen. The incidence of pericardial rupture and diaphragmatic injury is 0.2-3.3% . PericarA twenty-eight-year-old female patient presented to the emergency department with a history of road traffic accidents. She had difficulty in breathing. The patient was conscious, oriented, and dyspneic, with a 110/60 mmHg blood pressure. Room air saturation was 90%, which improved with minimal oxygen supplementation. She had pain over the left side of the chest and abdomen, and there were reduced breath sounds on the left side of the chest. X-ray of the chest revealed herniation of the bowel in the left hemithorax and mediastinal shift to the right side  chest and abdomen showed diaphragmatic rupture with herniation of the stomach through the left hemidiaphragm Figure . The patDiaphragmatic ruptures following trauma are rare, accounting for less than 0.5% of all trauma and about 1.9% of all blunt abdominal trauma ,5. As inPatients usually present with breathing difficulty and abdominal pain. Few patients do not have any symptoms at the time of presentation, and they gradually worsen due to respiratory distress caused by bowel herniation into the thoracic cavity. Some patients have palpitations, chest discomfort, cardiac tamponade, or cardiogenic shock due to cardiac compression . The patDiaphragmatic hernia can be seen in chest X-ray as bowel in the thoracic cavity, loss of diaphragm contour with mediastinal shift to the contralateral side like in this case. The sensitivity of Multi-detector Computed Tomography (MDCT) in identifying diaphragmatic rupture is 100% and 83 % for the left side and right side diaphragmatic rupture, respectively . Though Surgical repair remains the mainstay of treatment for pericardio-diaphragmatic rupture. Surgery can be done through laparotomy, thoracotomy, or laparoscopy. It involves reducing herniated content in the abdomen and repairing the diaphragm with non-absorbable sutures . Other aDiaphragmatic rupture with pericardial involvement is rare and carries a poor prognosis. Pre-operative diagnosis of the pericardial injury is complicated, and CT is mandatory in diagnosing pericardial tear and excluding other visceral injuries. Care should be taken while closing the pericardium to avoid injuring the heart. Emergency surgical repair and close postoperative monitoring are always required to avoid severe complications.


Supratentorial extraventricular ependymomas (STEE) are very rare primary tumors of the central nervous system (CNS). A 19-year-old man complained of headache, hemiparesis and seizures and was admitted to our hospital. Magnetic resonance imaging (MRI) revealed a right frontal intra-axial lesion. The patient underwent surgical treatment, and the tumor was resected successfully. A diagnosis of World Health Organization (WHO) grade 3 STEE was based on microscopic examination and immunohistochemical analysis. The patient was discharged without a neurological deficit. Ependymomas are relatively uncommon glial tumors that account for 3% of primary central nervous system (CNS) tumors in adults . They caA 19-year-old male with no significant past medical history was admitted to the emergency department. He presented two events of 10 minutes duration of focal motor fits involving the right superior limb which became generalized with tonic-clonic seizures and somnolence in postictal status. He complained of episodes of frontal, oppressive and moderate-intensity headaches associated with nausea and vomiting over one month before admission. In the previous two weeks, the patient was referred to progressive left-sided weakness. His neurological examination revealed mild left-sided paresis without any other neurological deficit. A complete blood count, liver function test, basic blood chemistry test, and coagulation test were performed. The results of the serum analysis were normal.A cranial magnetic resonance imaging (MRI) showed a right fronto-parietal intra-axial and well-defined multilobulated lesion, measuring 42 x 47 x 55 mm with perilesional edema. The lesion had a cyst component with hyposignal on T1 and hypersignal on T2-weighted images and showed restricted diffusion. After gadolinium administration, it showed heterogeneous enhancement with intensely periferic enhancing of the cystic portion Figures -1C.Under general anesthesia in supine position with the head fixed with the Mayfield skull clamp and 45° grades rotated to left, a horse shoe incision and a right parasagittal craniotomy bone flap was created. The dura was opened in square-shaped and was based on the superior sagittal sinus. The tumor was found to be a solid-cystic lesion. The cystic portion was surfacing at a large parasagittal area and the deeper walls were found to be surrounded by gliotic brain tissue. An adequate line of cleavage was found and we proceed to dissection under surgical microscope. Gross total resection was achieved and hemostasis was secured Figure .Pathological analysis was performed, and macroscopic examination revealed a solid-cyst aspect, brownish and cerebriform shape neoplasm Figures , 2B. HisThe patient´s hemiparesis improved, and he was discharged in a stable condition after four days of hospital stay. At two months follow-up, he had resolution of all symptoms. On postoperative cranioespinal MRI there was no evidence of residual tumor or other lesions at spinal level Figures -3C. He wEpendymomas represent 3%-4% of all intracranial neuroepithelial neoplasms of CNS in adults ,5. The cIn adults, intracranial ependymomas represent 19% and have a predilection for supratentorial level and the majority are classified as WHO Grade 3 . The molThe pathogenesis remains unclear, it has been proposed supratentorial extraventricular ependymoma (STEE) develops from the rest of the ependymal cells. Vernet et al. proposed that the origin of STEE could be developed from 1) an ependymal cyst; 2) an outpouched ependymal cell lining; and 3) a primitive neuroectodermal tumor which would differentiate along the ependymal lineage .The STEE are frequently localized in frontal and temporal lobes. Clinical manifestations are unspecific and depend on the localization and tumor size. The common presenting signs and symptoms of intracranial ependymomas are headache, seizure, and motor weakness .The STEE usually show a heterogeneous appearance on T1-T2 weighted sequences and tends to be large lesions at presentation, especially of the high-grade variety. The majority of lesions show a solid cystic appearance that tends to compress rather than infiltrate the surrounding brain parenchyma. An important characteristic that differentiates other gliomas and STEE is a well-defined demarcation line between tumor and peripheral brain tissue, and it can be seen both radiologically and intraoperatively .STEE are tumors that generate controversy in their clinical management. In literature, reported factors of poor prognosis of STEE include age, histology, tumor size, extent of resection and adjuvant RT. Wang et al. identified EOR and tumor grade are both prognostic factors for overall survival (OS) and progression-free survival rates (PFS). Subtotal resection and WHO grade 3 ependymomas predicted worst OS and PFS . Goya etThe aim in the management of STEE is gross total resection and in cases of recurrence, reoperation should be considered. The local recurrence is the most common recurrence pattern. The role of adjuvant RT in treatment of STEE is controversial. It is widely accepted that postoperative RT should be administered especially in patients with WHO grade 3 and those with subtotal resection ,15.Ependymomas can spread through cerebrospinal fluid in 11.2% with STEE. Many authors consider all patients to undergo craniospinal screening with a magnetic resonance imaging study .STEE are infrequent glial tumors. The WHO grade 3 ependymomas tend to have a local recurrence and are worst prognostic compared with infratentorial or spinal lesions. The extension of resection and tumor grade are the major factors for prognosis. Gross total resection extension and adjuvant RT were the modalities of treatment in this case. A craniospinal MRI must be performed to exclude other lesions. Close follow-up is required to monitor the recurrence or progression of the disease.


Pyogenic granuloma (PG) is a reactive connective tissue disorder with female predilection, which exhibits a tumor-like mass with occasional bleeding and superficial ulceration. It most commonly occurs in the maxillary gingiva followed by the mandibular gingiva. It can also occur in extra gingival sites like buccal mucosa, labial mucosa, and palate. There are two histopathological types of PG, namely, a lobular capillary hemangioma (LCH) variant and a non-LCH variant.The various management methods include surgical resection or laser excision along with deep curettage, and there are various nonsurgical methods like local steroid injection, topical administration of various drugs, and sclerotherapy. During the surgical excision, there is a risk of bleeding, and the surgeon should be equipped for the same. The PG (both LCH and non-LCH variant) has an increased chance of recurrence because of which complete excision is mandatory along with the removal of the local irritants.In this case report, a 28-year-old female patient reported recurrent painless swelling in the lower front gums for the past nine months.The surgical excision was done in-toto along with the removal of local irritants . The swelling was sent for histopathological examination. The patient was kept on regular follow-ups.The patient was followed up continuously for nine months. The swelling did not recur after the excision.Hence, it was concluded that complete excision and removal of local irritants are extremely crucial to prevent a recurrence. Pyogenic granuloma (PG) is a reactive benign lesion of the mucosa. The name PG is a misnomer because there is no evident pus in the lesion. The lesion was described by Hartzell in 1904. This is the most commonly occurring growth in the oral cavity, with various predisposing factors such as trauma and local irritation .In 2003, Toida et al. described the two variants of the lesion, namely, the lobular capillary hemangioma (LCH), also called epulis gravidarum, and the non-LCH [Mahajan et al. reported that this lesion has increased female predilection with more prevalence in young adults and teenagers . This lesion (PG/LCH) may develop rapidly and reach full size. The etiology of this entity is still an enigma. The lesion is thought to arise from local factors such as recurrent trauma, calculus, and also hormonal changes during pregnancy, and the reproductive age group could predispose to the above lesion. This lesion is unique in a way that it can recur many times even after complete excision and can bleed intraoperatively. Lobular capillary hemangioma could be considered a separate entity from PG and would recur frequently if not managed properly in the first visit.The present case report describes a recurrent LCH variant of PG in a 28-year-old female patient along with its successful management.A 28-year-old female reported to the outpatient department with a chief complaint of recurrent swelling in her gums in the lower front teeth region for the past nine months. The swelling was insidious in onset and gradually increased to the present size with no pain or pus discharge or any bleeding points. The patient had reported similar swelling twice before, which was excised under local anesthesia by a private practitioner. Then the swelling recurred within a span of two months. No previous documents were provided by the patient. The patient opted for excision of the swelling due to esthetic issues.On inspection, there was a single, ovoid swelling in the mandibular anterior region between 32 and 33 with the same color as adjacent mucosa, approximately 2 cm x 1.5 cm in size, with well-defined margins and well-defined border, with no active pus discharge. On palpation, the swelling was soft in consistency, non-tender, and had no fixity to underlying tissues. There was no pus discharge, fluid discharge, or bleeding on palpation. The swelling was 2 cm x 1.5 cm x 0.5 cm in size on palpation. On hard tissue examination, the patient had calculus in all the mandibular anterior regions. Preoperative photographs are presented in Figure Figure The histopathological examination revealed LCH, which showed a lesion comprised of dilated congested thin-walled vessels in low-power view (20X) and ectatic blood vessels in high-power view with a single lining of endothelial cells and lumen filled with red blood cells. The histopathological picture is shown in Figure The patient was followed up for nine months, and no signs of recurrence were evident. Postoperative pictures are shown in Figure PG has slight female predilection, and it frequently occurs in the second and third decades. Literature reports pinkish or purplish colored nodular or globular mass with occasional superficial ulceration. This lesion can also occur in pregnancy and is named as a pregnancy tumor, which mostly resolves spontaneously post-childbirth . HemangiLCH is also a fast-growing lesion, with a mean diameter of 0.8 cm, making it relatively smaller ,7. In thWhile the pathogenesis of PG root tracks the effect of estrogen, with predisposing factors such as pregnancy and puberty, LCH has no known stimulus to stimulate the bone marrow stem cells to get differentiated into ovoid cells, endothelial cells, and pericytes. Ovoid cells interact with the pericyte, and it secretes tyrosine receptors to induce angiogenesis and neovascularization. As a result, there occurs a proliferation of endothelial cells, smooth muscle cells, and ovoid cells, thus giving rise to the lesion .The various differential diagnoses include peripheral giant cell granuloma, which shows multinucleated giant cells upon histological examination. Another differential diagnosis is Kaposi’s sarcoma, which has pathognomic features such as the proliferation of dysplastic spindle cells, extravasated erythrocytes, vascular clefts, and intracellular hyaline globules.Surgical excision along with the removal of local irritants is the treatment of choice as per the literature. Laser-assisted excision (Nd:YAG laser) is also a viable option for the excision of PG . The lesThe recurrence rate is 8%-15% with females having an increased recurrence rate ,7. GenerAs proposed by ISSVA, the LCH variant of PG could be considered a vascular tumor and a separate entity from PG. Complete excision of the tumor should be done and all the local irritants should be removed in order to prevent recurrence. During the surgery, precautions should be made to prevent bleeding, and the surgical team should be ready to tackle the emergency.


Postoperative entero-enteric intussusception is a rare complication in adult patients with Crohn’s disease (CD). The knowledge of this distinct complication and its timely diagnosis and therapy are of utmost importance to prevent fatal intestinal necrosis. There is no consensus about the optimal management of postoperative entero–enteric intussusception, although surgical exploration is widely advised.In this report we describe an unusual case of postoperative jejuno–jejunal intussusception following small bowel resection in a patient with stricturing CD. Furthermore, this report offers an overview of the available literature and summarizes the best approach and management strategies for adult intussusception associated with CD.Delay in diagnosis and therapy can lead to life-threatening complications. Early diagnosis and emergent surgical treatment prevent intestinal necrosis and reduce the risk of short bowel syndrome. Crohn’s disease (CD) is a chronic inflammatory disease of the gastrointestinal tract, assumed to result from genetic and environmental factors as well as altered gut microbiota, leading to dysregulated immune responses . It is aIntussusception is defined as the invagination of a proximal segment of the gastrointestinal tract, called intussusceptum, into the lumen of an adjacent one, called intussuscipiens. It can lead to impaired peristalsis and intestinal obstruction and bears the risk of ischemia, perforation, and peritonitis , 6. WhilSo far, cases describing intussusception as a postoperative complication in patients with CD have been rarely reported in the literature , 10], , , 12], , , 14]. H. H14]. HA 27-year-old male patient with CD was transferred to our tertiary referral center with acute mechanical ileus due to fibrostenosis in the ileum. The patient, who was cachectic on presentation, had been first diagnosed with CD at the age of 21 and had been under treatment with Azathioprine for many years. In the past, whenever he presented with symptoms referred to ileal stenosis, the therapy was temporarily supplemented with Prednisone. Follow-up examinations or colonoscopies were not offered to the patient before. Magnetic resonance tomography showed fibrostenosis in the ileum with pre-stenotic dilatation (8 cm in diameter) of the small bowel. We performed a laparoscopic ileal segment resection with side-to-side ileo–ileal isoperistaltic (Kono-S) anastomosis and protective ileostomy. Protective ileostomy was created because of the reduced nutritional status and prior therapy with high dose prednisone before transfer. On postoperative day two the patient presented with severe bleeding from the ileostomy, excessive vomiting, and abdominal pain. He was tachycardic and hypotonic and repeated blood gas analysis showed a decrease in hemoglobin. The clinical examination revealed a palpable periumbilical tender mass. Abdominal ultrasound showed an intussusception with the typical “target sign”  6, 15, , 15, 16.Intussusception is primarily a pediatric disease but can also occur on rare occasion in adults . CompareIntussusception in patients with CD is very uncommon and therefore represents a challenging clinical scenario , 12. DueIn the presented case the patient had a long-standing intestinal dilatation due to the chronic obstructive Crohn’s lesion. We assume that the intussusception occurred after resection of the stenosis when proper peristalsis resumed.He presented with abdominal pain, intestinal bleeding, and an abdominal tender mass. Also, in children the clinical presentation is a triad of abdominal pain, bloody diarrhea, and a palpable mass. However, adults do not necessarily present with this typical triad .In the literature symptoms ranged from light intermittent abdominal pain over a longer period of time to acute severe crampy abdominal pain, vomiting and intestinal bleeding , 10], , , 12], , , 14, 1919, 20],,20], 2121, 22]..22]. In In five cases intussusception was reported without prior surgery , 19, 2020, 21],,21], 2222. The tAs intussusception in adults presents considerable variability in the patient’s clinical presentation, it is recommended to use radiological examinations such as abdominal X-ray, barium enema, abdominal ultrasound, or abdominal computed tomography (CT) to make a correct diagnosis . In the Optimal treatment is still unclear as no consensus exists about the indications of intussusception reduction or the necessity of emergent primary resection , 18, 20.Concerning small bowel intussusception, resection may not be necessary in all cases since the underlying condition might be benign , 18. FurAs colonic intussusception in adults shows a high rate of malignancies, some authors argue that primary resection without attempting reduction represents the optimal management to avoid possible tumor dissemination , 17, 20.In the literature reviewed, five cases required laparotomy and the intussusception could be reduced  9, 10, , 10, 12.Postoperative intussusception is a very rare complication in adult patients with CD. The patients’ clinical presentation can often be nonspecific and make the diagnosis difficult. However, physicians should be familiar with this differential diagnosis since delay in diagnosis and therapy can lead to life-threatening complications. Intussusception due to malignancy plays a marginal role in patients with CD. Early diagnosis and emergent surgical treatment prevent intestinal necrosis and reduce the risk of short bowel syndrome. Surgical management should be individually evaluated based on the intraoperative findings, but a stepped approach should be preferred in patients with CD to minimize the resected bowel region.Supplementary MaterialClick here for additional data file.


Autism spectrum disorders (ASD) and psychotic disorders have historically considered to be related conditions with a long history of diagnostic confusion. Although DSM-III distinguishes ASD and Schizophrenia Spectrum Disorders as distinct clinical entities, they continue to share overlaps in their clinical symptom presentations leading to diagnostic challenges that may consequentially result in delayed treatment. Prompt diagnosis is crucial in the context of psychosis, where early intervention impacts recovery.To present the diagnostic challenges encountered in distinguishing ASD from Psychosis.We present a case report demonstrating the challenges of distinguishing ASD from Psychosis.This is a case of a gentleman who initially presented to psychiatric services at 18 years old for conflicts with his mother related to his inflexibility to change. Further psychological evaluation revealed that he had a history of restricted social interaction with his peers, difficulties in non-verbal communications and identifying emotional states, stereotyped interests and obsessions that isolated him from his peers. He was diagnosed with ASD.In subsequent presentations, there were symptoms of excessive preoccupation of his facial appearance, excessive concern over contracting HIV, obsessions with arranging objects in a particular order and avoiding words starting with the letter “S” out of fears of blasphemy. While these symptoms had qualities of cognitive inflexibility, they could not fully be explained by ASD. Additional diagnoses of Body Dysmorphic Disorder, Borderline Personality Disorder, Obsessive Compulsive Personality Disorder and At-Risk Mental State were considered.A psychiatric admission was necessitated at 21 years old, when he presented with a 2-year history of repetitive banging of furniture in the middle of the night to communicate his frustrations towards his parents for their perceived acts of blasphemy. He also began to isolate himself, fearing that his parents would be able to look into his soul and reveal his sins. This paranoia towards his parents worsened to the point of urinating and defecating in his room to avoid his parents. His school performance declined as well.A unifying diagnosis of psychosis was made. His previous diagnosis of ASD was challenged as a misdiagnosis, with the impression that he likely had attenuated psychotic symptoms in his adolescent years, disguised as autistic traits. The diagnosis of psychosis was confirmed when the patient’s symptoms were observed to respond to antipsychotic treatment.This case report illustrates the challenges in distinguishing ASD from psychosis. A prior diagnosis of ASD may result in diagnostic overshadowing and subsequent delays in diagnosing psychosis. Further research in diagnostic tools would be helpful for diagnostic precision, thereby enabling prompt treatment for better recovery outcomes.None Declared


MAML2-rearranged primary central mucoepidermoid carcinoma (MEC) of the mandible that was discovered as an incidental finding. Our review of the literature identified 36 cases of MAML2-rearranged intraosseous lesions of the jaw . Given the therapeutic indications for a diagnosis of MEC , MAML2 rearrangement should be confirmed in suspected cases of central MEC.This report presents an extremely rare case of  MAML2 rearrangement with fusion partners CRTC1(MECT1) and rarely CRTC3 (MECT3) has been found in over 75% of salivary gland MECs [MAML2 rearrangement in CMEC [Mucoepidermoid carcinoma (MEC) is the most common malignant primary salivary gland tumor and accounts for 5–10% of all salivary gland tumors . MEC typand MECs , 9. Few  in CMEC .MAML2 rearrangement, discrediting the etiologic relationship between GOC and CMEC [MAML2 rearrangement in a 75-year-old female, adding to the few reports of documented MAML2 rearrangement in CMEC.CMEC occurs more commonly in the mandible with the premolar–molar–angle region as the most common site of occurrence, and the majority of CMECs occur in the fifth to seventh decade of life with a predilection for females , 2, 19. and CMEC . We repoA 75-year-old female patient was initially admitted to the Brooke Army Medical Center (BAMC) emergency room, San Antonio, for a motor vehicle accident when a neck lymphadenopathy was identified. Because of the lymphadenopathy and evaluation/extraction of non-restorable teeth #14 and #30, she was referred to the Oral & Maxillofacial Surgery Unit of BAMC from the general surgery unit of BAMC and a private dental office, respectively. The patient stated that the right neck swelling had progressively increased in size, prompting her to seek care with the general surgery unit. Extraoral examination was negative for facial asymmetry, erythema, and tenderness on palpation. An appreciable enlarged cervical lymph node of the neck was fixed and non-tender on palpation. Panoramic radiographic imaging revealed an asymptomatic ill-defined radiolucent lesion distal to tooth #31, without association with the apices, and no evidence of root resorption . IntraorMAML2 rearrangement was confirmed by fluorescence in-situ hybridization . Given the therapeutic indication for a diagnosis of MEC , MAML2 rearrangement should be confirmed in suspected cases of CMEC. However, a negative MAML2 rearrangement should not rule out a CMEC.In summary, we report an extremely rare case of


In female patients, acute pelvic pain can be caused by gynaecological, gastrointestinal, and urinary tract pathologies. Due to the variety of diagnostic possibilities, the correct assessment of these patients may be challenging. The most frequent gynaecological causes of acute pelvic pain in non-pregnant women are pelvic inflammatory disease, ruptured ovarian cysts, ovarian torsion, and degeneration or torsion of uterine leiomyomas. On the other hand, spontaneous abortion, ectopic pregnancy, and placental disorders are the most frequent gynaecological entities to cause acute pelvic pain in pregnant patients. Ultrasound (US) is usually the first-line diagnostic technique because of its sensitivity across most common aetiologies and its lack of radiation exposure. Computed tomography (CT) may be performed if ultrasound findings are equivocal or if a gynaecologic disease is not initially suspected. Magnetic resonance imaging (MRI) is an extremely useful second-line technique for further characterisation after US or CT. This pictorial review aims to review the spectrum of gynaecological entities that may manifest as acute pelvic pain in the emergency department and to describe the imaging findings of these gynaecological conditions obtained with different imaging techniques. Acute pelvic pain (APP) is defined as lower abdominal or pelvic pain of less than three months’ duration . In femaAnother common clinical manifestation of gynaecological and obstetrical pathologies that is often associated with APP is vaginal bleeding. It can have a variety of causes, ranging from benign conditions to severe medical disorders. From a clinical point of view, vaginal bleeding can be divided into menstrual, postmenopausal, and intermenstrual bleeding . Each ofIn the case of patients presenting with APP, the diagnosis is based on anamnesis, clinical and laboratory findings, and diagnostic imaging. Determining patients’ pregnancy status is essential to aid the diagnosis. Ultrasound (US) is usually the first-line diagnostic technique because of its sensibility across most common aetiologies and its lack of radiation exposure ,16. CompOn these bases, this pictorial review aims (1) to summarise the spectrum of gynaecological entities that may manifest as acute pelvic pain both in pregnant and non-pregnant women; (2) to identify and describe the most characteristic imaging findings of these gynaecological conditions obtained with different imaging techniques; (3) to outline the most appropriate management of patients with acute pelvic pain underlying the differences between pregnant and non-pregnant patients; and (4) to propose a flowchart of acute pelvic pain imaging management in the emergency department (ED).Ovarian torsion (OT), also known as adnexal torsion or tubo-ovarian torsion, is an emergency condition that occurs when the ovary twists around its vascular pedicle, frequently with a portion of fallopian tubes . It is cUS combined with colour Doppler is the first-line imaging of choice, and the findings depend on the duration and severity of the torsion. Typical findings are an enlarged (>4 cm), oedematous, and heterogeneous ovary found in an unusual location, for instance, shifted medially or cranially to the uterine fundus. The ovary usually shows a hyperechoic central stroma with peripherally displaced follicles (follicular ring sign) . An undeAlthough CT is not indicated as a first-line technique when OT is suspected, it is usually performed in female patients with aching nonspecific pelvic pain and vomiting. Moreover, it can be helpful for ruling out OT if US does not show ovarian abnormalities or if it is limited due to patient pain. CT scans usually show a large pelvic mass abnormally located at the midline, anteriorly to the uterus. During no-contrast scans, the ovary may appear hyperdense (>50 Hounsfield Unit) due to internal haemorrhage. In contrast-enhanced images, the ovarian twisted pedicle may be detected ,28. It cMRI is usually not available in emergency settings. However, it can be useful for further evaluating equivocal findings seen with other techniques and for characterising an underlying ovarian mass . If haemAcute bleeding or rupture of functional (follicles and corpus luteum) ovarian cysts is one of the most common causes of APP in young women . In sevePelvic inflammatory disease (PID) is one of the most common causes of APP and typically occurs in young and sexually active women ,33. PID Normal fallopian tubes cannot usually be distinguished upon imaging. In the case of salpingitis, lumen occlusion leads to the retention of purulent secretion and tubes swelling . During a US, a tubular structure with hyperechoic content is usually seen in the adnexal area. CT and MRI allow for a better visualisation of the dilated tube. Pyosalpinx is observed as a contrast-enhancing parauterine tubular structure with a thickened wall and incomplete septa (“cogwheel sign”) ,39,40,41When the inflammatory process evolves from the fallopian tubes to the ovaries, it produces a condition known as tubo-ovarian abscess (TOA) . AlthougOn the contrary, MRI is rarely needed to diagnose PID and is more likely to be used for a better delineation of uterus and adnexal structures, the differential diagnosis of unclear adnexal lesions, and the differentiation of PID from other pathologic processes. During MRI, TOA usually presents with a hypointense signal on T1-weighted sequences and a hyperintense signal on T2-weighted sequences. A T1 hyperintense rim along the inner wall of the abscess cavity, because of the presence of haemorrhage or granulation tissue, is often detected. However, the MRI findings depend on the presence of blood and the protein content of the mass. MRI is also a useful tool for distinguishing pyosalpinx from haematoalpinx because the latter usually does not demonstrate wall thickening and has a higher signal intensity on T1-weighted images due to the presence of blood products . In approximately 4% of cases during PID, right upper quadrant abdominal pain may occur due to inflammation of the hepatic capsule and overlying peritoneum with adhesion formation (perihepatitis). This condition is known as Fitz–Hugh–Curtis syndrome, and during CT imaging, it manifests as a thickened and enhanced liver capsule, transient hepatic perfusion abnormalities in arterial phases, periportal oedema, and inflammatory stranding in the right paracolic gutter ,45.Uterine leiomyomas are extremely common benign and usually asymptomatic gynaecological tumours. However, they can undergo several complications and cause APP ,47.Red degeneration, also referred to as carneous degeneration, is one of four main types of degeneration that can involve uterine fibroids and is the most frequently occurring type during pregnancy, particularly during the second and third trimesters, and in the case of large fibroids (>5 cm) .Red degeneration primarily occurs secondary to the rupture of intralesional arteries or venous thrombosis, leading to haemorrhagic infarction of leiomyomas. This condition usually manifests with APP, fever, and nausea. Upon US and CT imaging, red degenerated fibroids may appear as large, inhomogeneous, and well-circumscribed intramural masses, with cystic areas and an absence of Doppler signal/flow in infarction areas. MRI examinations may demonstrate a peripheral high-intensity rim on T1-weighted images due to the T1 shortening effects of the methaemoglobin of blood products confined to the thrombosed and dilated vascular structures surrounding the leiomyoma. In gadolinium-enhanced fat-suppressed T1-weighted sequences, red degenerated leiomyomas do not show contrast enhancement  47,49].,49.47,49The degeneration or torsion of uterine leiomyomas usually occurs in subserosa and pedunculated fibroids, and it is a rare but potentially life-threatening cause of APP. The severity of symptoms depends mainly on the degree of rotation: if pedicle torsion is partial and spontaneously untwisting, symptoms are usually mild; nevertheless, a complete torsion leads to venous stasis, with oedema and congestion, and then causes compression of the arterial blood supply. Obstruction of the arterial network produces haemorrhagic necrosis. If not treated, massive bleeding or peritonitis may occur . US, CT,Infection of leiomyomas (pyomyoma) is an infrequent complication of uterine fibroid but is associated with high morbidity and mortality. It may occur in postmenopausal women, during pregnancy, in the postpartum period, or as a complication of uterine artery embolisation for treating leiomyomas ,53. Its Endometriosis, defined as the presence of functional endometrial tissue outside the uterine cavity, is a frequent cause of chronic and cyclic pelvic pain ,56. NeveIn the case of gastrointestinal or urinary tract complications in an emergency setting, endometriosis is rarely identified as an aetiologic factor on imaging, even if it should be suspected in the context of known endometriosis with intestinal or urinary tract involvement. The presence of stellar, mildly enhanced, infiltrative, and fibrotic lesions in suggestive areas in female patients of reproductive age may help doctors reach the correct diagnosis ,58. DuriThe rupture of an endometrioma is an infrequent complication. CT signs are similar to those of a corpus luteal cyst rupture, with spontaneously dense ovarian masses and ascites. MRI usually shows a distorted endometrioma and free peritoneal fluid with a high T1 signal. In the case of endometrioma superinfection, CT usually shows a nonspecific hypodense cystic adnexal with adjacent fat stranding. During the MRI, the superinfection of an endometrioma is suggested by the presence of thickened and enhancing walls of the lesion, an increase in size of an already known endometrioma, the loss of the characteristic high signal in T1 and the shading sign in T2, and a marked restriction of diffusion in DWI .Mature ovarian teratoma, also known as a dermoid cyst, is the most common benign tumour in premenopausal females . AlthougOvarian hyperstimulation syndrome (OHSS) is a side effect of ovarian stimulation therapy used for in vitro fertilisation. Rarely, it may also occur spontaneously during pregnancy . OHSS isHyperreactio luteinalis (HS) is a condition that shares many clinical and pathogenetic characteristics with OHSS. Both entities are characterised by bilateral clusters of luteinised ovarian cysts that show a characteristic “spoke-wheel” appearance during an US, accompanied by a physiologic flow on colour Doppler velocimetry . HoweverPelvic malignancies, most commonly ovarian, cervical, and endometrial uterine cancers, can induce pain of different intensities and durations. Gynaecological cancer may present with sudden onset in cases of advanced stages, with the invasion of adjacent structures that lead to several complications, such as intestinal perforation, thrombosis, and intestinal or ureteral obstruction  71,72,7,772,73. Ectopic pregnancy (EP) is the implantation of a fertilised ovum outside the uterine cavity and, due to the risk of massive bleeding, is a potentially life-threatening gynaecological emergency, representing the leading cause of maternal mortality in the first trimester, with an incidence of 5–10% of all pregnancy-related deaths ,75. PredTorsion of a pregnant uterus is an infrequent condition, defined as a rotation of more than 45 degrees around the uterine long axis, most frequently occurring at the level of the uterine isthmus, the transition between the corpus and cervix. Uterine torsion is observed in all age groups during the fertile period and at all stages of pregnancy. Abnormal foetal presentation, large pre-existing leiomyomas, and uterine malformations are considered risk factors . An accuUterine sacculation is a rare complication of pregnancy that is defined as a transitory sac-like structure or outpouching of the uterus caused by an abnormal forward or backward rotation of the uterine fundus . WithoutFull-thickness uterine ruptures usually occur during pregnancy, especially in the presence of a previous Caesarean scar. Patients present with APP and haemodynamic instability . US and Placental disorders include various entities, such as location, vascular, and implantation abnormalities. US evaluation is the first-line technique for placental evaluation. However, when US findings are equivocal, MRI is an efficient technique to evaluate placental disorders ,87. PlacMoreover, MRI can be useful for assessing abnormal placental villous adherences  . PreviouThe prominent role of imaging is to distinguish conservatively treatable APP causes from potentially life-threatening causes  or emergencies requiring surgery . US is the imaging modality of first choice, as it permits driving through the diagnosis to the urinary tract , gastrointestinal , or gynaecological pathologies. Nevertheless, US is an operator-dependent technique and often suffers from technical limitations such as obesity and meteorism. When US findings are equivocal, or US cannot be performed due to patients’ discomfort, CT plays a vital role in evaluating female patients with APP. Depending on its availability, MRI is also a valuable diagnostic option. However, in acute situations, it is routinely used mainly in pregnant women or young patients, because it offers excellent spatial and contrast resolution without exposing patients to ionising radiations. For these reasons, in the case of female patients during childbirth age, evaluating serum beta-hCG levels is mandatory ,2,3,7,95Many gynaecological pathologies may manifest with acute pelvic pain, including pelvic inflammatory disease, uterine and ovarian disorders, endometriosis, and ectopic pregnancies. Diagnostic imaging plays a crucial role in the diagnosing aetiology of APP and distinguishing potentially life- and fertility-threatening conditions from those that can be treated conservatively. Knowledge of the most common imaging findings, obtained through US, CT, and MRI, allows for early and correct diagnosis and assists clinicians in proper treatment planning.


Schwannoma is a tumor that originates from the Schwann cells that surround a neuron’s axon. This tumor is very rare in the gastrointestinal tract and develops submucosally from intestinal nerve plexuses. The most common location for gastrointestinal schwannomas is the stomach, where they account for only 0.2% of gastric tumors. We present the case of a 56-year-old asymptomatic patient who was diagnosed, following a routine ultrasound examination, with an abdominal tumor. An abdominal MRI confirmed the gastric origin of the tumor. Although a subsequent upper-digestive endoscopic ultrasound was performed, a definitive diagnosis could not be established. Thus, a laparoscopic wedge resection of the stomach was performed. The immunohistochemical examination of the tumor established the diagnosis of benign schwannoma. Despite the availability of advanced endoscopy and imaging techniques, the diagnosis of gastric schwannoma is very rarely preoperative. The immunohistochemical identification of S-100 on the surgical specimen confirmed the diagnosis.