Auto-transplantation of third molars is frequently undertaken in order to restore a perfect occlusion and to improve mastication following a substantial loss of molars. However, little is known about the precise role of the periodontal membrane during this procedure. Therefore, we investigated if the epithelial rests of Malassez persist in the periodontal ligament of auto-transplanted teeth and, if so, whether these may show signs of a neuro-epithelial relationship.We report a case of a 21-year-old Caucasian woman who underwent an auto-transplantation of two third molars. After two years, renewed progressive caries of the auto-transplanted teeth led to the removal of the auto-transplanted elements. The periodontal ligament was removed and studied with a light and transmission electron microscope.In this report we examined the ultrastructure of the periodontal ligament after auto-transplantation in order to see if the periodontal ligament recovers completely from this intervention. We observed fully developed blood vessels and a re-innervation of the epithelial rests of Malassez which were proliferating following auto-transplantation. This proliferation might be critical in the remodelling of the alveolar socket in order to provide a perfect fit for the transplanted tooth. In order to minimalise the damage to the epithelial rests of Malassez, the extraction of the tooth should be as atraumatic as possible in order to provide an optimal conservation of the periodontal ligament which will be beneficial to the healing-process. The periodontal ligament (PDL) is the dense fibrous connective tissue which connects the cementum-covered surface of the root with the alveolar bone . Its maiA 21-year-old Caucasian woman presented to our clinic with multiple caries and inflammatory paradental cysts (IPCs). One of the IPCs was located in the lower jaw near molar 37. A histopathological examination revealed that the cyst was predominantly surrounded by granulation tissue although the local presence of Malpighian epithelium could be found. On the periphery it was surrounded by an inflammatory infiltrate which consisted mainly of lymphocytes, plasmocytes and neutrophilic polymorphonuclear cells. The outermost lining consisted of a dense compact connective tissue and no signs of malignant degeneration could be detected.Two weeks later, the IPCs were enucleated after incision and trepanation of the bone. We decided to extract teeth 15, 37, 45 and 47 because of multiple and severe carious lesions. As the patient had a substantial loss of molars, the intra-osseous teeth 18 and 48 were extracted carefully and transplanted into position 36 and 47, respectively. The procedure was done as atraumatically as possible with no visible damage to the periodontal ligament of the extracted teeth. No problems were encountered during surgery and the auto-transplantation was a success. After four months, an X-ray was taken of the upper and lower jaw . The fixative was gently aspirated with a glass pipette and the specimens were post-fixed in 2% osmium tetroxide, put through a dehydrating series of graded concentrations of acetone and embedded in araldite according to the conventional method. Semi-thin sections (0.5 μm) were stained with a solution of thionin and methylene blue (0.1 aqueous solution) for light microscopy. Ultra-thin sections (0.06μm) were mounted on 0.7% formvar-coated grids, stained with uranyl acetate and lead citrate and examined in a Philips EM 208 transmission electron microscope operated at 80 kV.From a light microscopic examination of the semi-thin sections, we concluded that the ERM of the transplanted teeth were slightly larger than in normal PDL. A mean value of 20 cells was counted in the transplanted tissue in contrast to a mean value of 10 cells in normal/control PDL Figure .From transmission electron microscope (TEM) analysis we concluded that the auto-transplantation was successful because fully developed blood vessels appeared in the PDL Figure . The lumThe specific morphological features which could be detected on the ultrastructural level can be regarded as typical for ERM and are confirmed in the recent literature -9. ERM cIn auto-transplantation, the alveolar bone around the implantation-site normally has to be remodeled to provide a good fit for the implanted tooth. Bone breakdown is a process involved in this remodeling and it can be stimulated by increased prostaglandin E2 secretion by the ERM. This could explain why the ERM in the PDL of transplanted teeth are enlarged. It is also possible that the ERM in PDL of transplanted teeth remain enlarged when the remodeling process has finished. This implies that transplanted teeth will always have more mobility in the jaw than normal teeth because of the increased prostaglandin E2 secretion.In addition to the expected bone remodeling, the PDL also needs to be remodeled. The compartmentalization of the collagen bundles can be seen as a consequence of this process. Furthermore, following auto-transplantation, the need for re-innervation of the PDL is of significant value. As ERM play an important role in the distribution of the fibrous and neural elements in the PDL, the enlOne of the key elements necessary for a successful auto-transplantation is the conservation of the periodontal ligament. These results suggest that the extraction should be as atraumatic as possible in order to conserve the periodontal ligament and minimalise the damage brought to the ERM.ERM: epithelial rests of Malassez; ERSH, epithelial root sheath of Hertwig; IPC, inflammatory paradental cyst; PDL, peridontal ligament; TEM, transmission electron microscope.The authors declare that they have no competing interests.SJ, PC, SS and VL performed the surgical procedures, collected, analyzed and interpreted the patient data in order to determine the surgical follow-up. ST and LI performed the histological and ultrastructural examination of the PDL and wrote the manuscript. CL and JR revised the manuscript and contributed to the overall discussion. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


We report the case of a 4-year-old girl presenting with the retroperitoneal epidermoid cyst. The lesion presented as an intra-abdominal cyst on physical examination and was followed up with more specific investigations by ultrasound and computed tomographic scanning. The final diagnosis was obtained only after laparotomy where the cystic mass was completely excised and pathological examination was done. The patient is well at 3-year follow-up. epidermoid cyst of the reteroperitoneal space, although rare, should be considered in the differential diagnosis of incidentally discovered intra-abdominal cysts during investigation of irrelevant illnesses or during routine abdominal ultrasound scan. Retroperitoneal cysts are the least common of abdominal lymphatic malformations and they can be located anywhere in the retroperitoneum. Retroperitoneal cysts should be considered a different entity from mesenteric, omental, splenic and enteric duplication cysts even though they present clinically in a similar fashion . EpidermHistopathologic examination of a retroperitoneal epidermoid cyst showed a cyst to be lined with squamous stratified epithelium. The wall of the cyst consisted of dense fibrous tissue . SurgicaWe report the case of a 4-year-old girl, Kosovo Albanian nationality, with a 4-month history of recurrent abdominal pain and abdominal distension without vomiting. At about the same time his parents became aware of an enlargement of the right side of his abdomen. Examination disclosed a soft, non-tender a palpable abdominal mass in the right upper quadrant of the abdomen that was dull to percussion. Laboratory tests were within the normal limits , platelets , except for the erythrocyte sedimentation rate (78 mm/h). The CRP was elevated with a mean count of 104 mg/l. Serological test for hydatid was negative. Alpha-fetoprotein (αFP) level was normal. In an abdominal ultrasound scan revealing a large mass with a thin-walled cystic mass, with fine internal septa, measuring 8 × 7 × 4 cm and was located in the abdomen (Figure 00 ml, plThe presence of a retroperitoneal cystic mass in children presents a diagnostic problem which frequently remains undiagnosed until surgery reveals the true nature of the mass. Cysts of the mesentery, retroperitoneum and omentum are uncommon and present with similar incidence, varying between, and 1 per 100.000 hospital admissions in most series . MesenteRetroperitoneal cysts should be considered a different entity from mesenteric cysts even though they present clinically in a similar fashion. Epidermoid cysts are slow growing, formed by desquamation of epithelial cells . EpidermFakhir et al. , and MidTo our knowledge, retroperitoneal epidermoid cysts, in this unusual location in children have not been reported in the literature. In our patient, a huge retroperitoneal mass - 11 × 9 × 7 cm in diameter was -closely connected with transverse and ascending colon to the inferior vena cava, and homolateral kidney. In addition to epidermoid retroperitoneal cysts, differential considerations include cystic lesions such as abdominal cystic lymphangioma that occur most commonly in the mesentery of the small bowel, with the retroperitoneum being the second most frequent site , retropeSymptoms are most frequently caused by the compressive effect of the cyst on surrounding structures and rarely by complications of the cyst: inflammation, abscess, and rupture.Our patient become last 4 months symptomatic, resulting from local mass effect causing flank pain, and enlargement of the right side of his abdomen. In our cases surgical approach was successful in removing the completely cyst tissue mass without recurrence. The incidence of recurrence for retroperitoneal cysts is higher than with other forms of cysts because their proximity to major blood vessels and vital structures sometimes makes them difficult to completely excise . In our One case of large retroperitoneal epidermoid cyst an unusual location is presented; the finding of a right upper quadrant retroperitoneal mass in a child should lead the physician to a prompt assessment and diagnosis of possible retroperitoneal epidermoid cyst. Successful treatment dependent upon early diagnosis, careful operative technique through abdominal incision, and adequate preoperative and postoperative management. Management of a retroperitoneal cystic lesion is determined by the underlying pathology. Retroperitoneal cystic lesions, although are benign, can be technically difficult to excise because of the proximity to major vessels or other organs.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.The authors declare that they have no competing interests.NSH carried out design of the study, drafted the manuscript, and was a major contributor in writing the manuscript. SSL participated in design of the study and in drafting the manuscript. HJJ performed the literature review, and was involved in writing the manuscript. DHK and BZK were involved in literature and image collection. All authors read and approved the final manuscript.


Leiomyosarcomas are rare tumours, predominantly localized in the stomach, small intestine and retroperitoneum. Only one case of primary leiomyosarcoma of the spleen is described in human beings in literature.We report a case of locally advanced primary leiomyosarcoma of the spleen in a 54 year-old woman, diagnosed only after splenectomy, performed with the suspicion of splenic haematoma.Due to the lack of cases, no specific chemotherapy regimen has been tested to provide a longer survival. Leiomyosarcomas are rare tumours, predominantly localized in the stomach, small intestine and retroperitoneum. Only one case of primary leiomyosarcoma of the spleen is described in human beings in literature.A 54-year-old Caucasian woman was referred to our department with a history of left-sided abdominal pain, lasting about 8 months. No other signs or symptoms were present at the moment of observation. Past medical history revealed no significant medical problems. Hysterectomy for endometriosis had been performed ten years before admission. No history of carcinogenic exposure was reported. At admission physical examination revealed a palpable spleen 4 cm below the left costal margin. No hepatomegaly was noted. Laboratory exams showed no alterations, except for mildly elevated lactic acide dehydrogenase (LDH). Chest X-ray showed a normal mediastinum and lung parenchyma. Abdominal US revealed, in the superior portion of the spleen, multiple target-shaped focal lesions, one of these with a large anechoic fluid-filled area. CT scan showed a large, inhomogeneous mass of the spleen, of 10 × 7 cm in diameter. This mass was isodense, without enhancement after contrast injection, and had low density fluid-filled areas. The liver parenchyma was normal and no evidence of retroperitoneal lymphadenopathy was found. Emergency laparotomy was performed, due to the suspicion of splenic haematoma. Neither obvious metastases nor hepatic lesions or abdominal fluid were found at laparotomy. An enormous mass of superior portion of the spleen was found, with infiltration of left suprarenal gland and of a portion of diaphragm. Due to the local dissemination a splenectomy and left surrenalectomy were performed, along with a partial diaphragm resection, with a free resection margin of about two centimetres. Splenic vessel lymphadenectomy was also performed. There were no postoperative problems and the patient was discharged on 7th postoperative day. Two different Institution was necessary to obtain the definitive diagnosis. Histological examination showed a spleen of 11 × 5 × 5 cm, with a soft dark lesion, of 10 cm diameter, in the upper pole. Gross examination showed no haemorrhage or necrosis. Microscopic examination revealed a non capsulated spindle and polyhedral cell proliferation along with multiple foci of cellular necrosis. Tumor cells, with pleomorphic and atypic vesicular nuclei, showed marked pleomorphism and rare mitotic figures Figure . ImmunohThe patient underwent specific chemotherapic regimen (5 cycles) with epirubicin 90 mg (days 1 and 2) and ifosfamide 2700 mg (days 1 – 5) every 21 days, with no significant adverse reactions.Actually, 21 months after operation, the patient is alive and totally disease-free.Leiomyosarcoma is a rare tumour, predominantly localized in stomach, small intestine and retroperitoneum . It is aLeiomyosarcoma is a rare neoplasm, with a poor prognosis. Along with this case we have described, only one case of splenic localization is reported in literature. The diagnosis can be made only at laparotomy, after pathological examination of the removed specimen; US, CT scan and MRI can be useful in suspecting diagnosis. Splenectomy performed in early stage, without rupture, seems to improve survival. No specific chemotherapy regimen has been tested for this neoplasm, but adjuvant therapy should be offered to these patients, even if only for palliation.The author(s) declare that they have no competing interests.PP, preperation of the draft manuscript, VV, GC, MC, AC, Searching of the literature and helped in preperation of draft FT, RI, GC, AS, FR, LF, MAM, Helped in preperation of manuscript GB final revision of the manuscript.All authors read and approved the final manuscript.


Teratomas are thought to arise from totipotent primordial germ cells (PGCs) Dehner (1983) which may miss their target destination Moore and Persaud (1984). Teratomas can occur anywhere from the brain to the coccygeal area but are usually in the midline close to the embryological position of the gonadal ridges Bale (1984), Nguyen and Laberge (2000). We report a case of a bipartite anterior extraperitoneal teratoma. This is an unusual position for a teratoma, but one which may support the “missed target” theory of embryology. A 4-year-old girl was referred with an 18-month history of a lower abdominal swelling . She hadMagnetic resonance imaging demonstrated a 16 × 15 × 12 cm mass with cystic and solid components . The cysAt surgery a bipartite mass was found. Extraperitoneal and anterior to the bladder was a cystic bowel-like structure which was not continuous with true bowel . SeparatHistological examination of the cystic bowel-like component  demonstrThe calcified component had appearances consistent with teratoma fat, bone, cartilage, ciliated epithelium, smooth and skeletal muscle, and a cyst containing epidermal appendages lined by giant cells. X-rays showed irregular areas of well-formed bone in a circular formation but no true skeletal formation .Eighteen months after resection, the child remains well and is asymptomatic. Repeat imaging and tumour markers have not shown any sign of recurrence.Teratomas are defined as having three embryonic layers, although recent classifications include monodermal types . In our This case report identifies a bipartite teratoma in an unusual position. There are 3 theories for the origin of teratomas . The firPrimordial germ cells lose their potency, as gastrulation progresses, which is associated with spatial restriction . SacrocoIn mammals, the PGCs are observed in an extraembryonic region near the yolk sac, they translocate to the endodermal epithelium of the hindgut, separate from the gut epithelium to enter the dorsal mesentery, and finally migrate to form the gonadal ridge . There aThe histology in this case showed teratomatous features some of which are present in fetus in fetu. For a diagnosis of fetus in fetu, the mass should include vertebrae or notochord and a high degree of structural organisation –14. PlaiThis case report questions the validity of the gastrulation theory of teratoma formation. The bipartite nature of the tumour and position along the migratory pathway of primordial germ cells, support the missed target theory for teratoma formation.


Acute compartment syndrome (CS) of the paravertebral muscles without external trauma is rarely reported in literature. Not all of clinical symptoms for CS are applicable to the paravertebral region.A 30-year-old amateur rugby player was suffering from increasing back pain following exertional training specially targeting back muscles. He presented with hardly treatable pain of the lumbar spine, dysaesthesia of the left paravertebral lumbar region as well as elevated muscle enzymes. Magnetic resonance imaging (MRI) showed an edema of the paravertebral muscles. Compartment pressure measurement revealed increased values of 47 mmHg on the left side. Seventy-two hours after onset of back pain a fasciotomy of the superficial thoracolumbar fascia was performed. Immediately postoperatively the clinical condition improved and enzyme levels significantly decreased. The patient started with light training exercises 3 weeks after the operation.We present a rare case of an exercise-induced compartment syndrome of the paravertebral muscles and set it in the context of existing literature comparing various treatment options and outcomes. Where there is evidence of paravertebral compartment syndrome we recommend immediate fasciotomy to prevent rhabdomyolysis and further consequential diseases. Compartment syndrome (CS) was initially described by Volkmann in 1881, and can have various etiologies. Pathophysiologically, CS is a multifactorial condition caused by increased tissue pressure in a closed fibro-osseous space, which may develop after trauma in the presence of certain cofactors. The local microcirculation is altered because of endothelial destruction, capillary leak, protein loss, and fluid accumulation in interstitial and intracellular third spaces [CS of the extremities presents with the classical symptom of severe intractable pain, typically not relieved by non-narcotic pain medication, and the classical signs of pain on passive stretch, pallor, paresis and paresthesiae. These symptoms are not all applicable to the paravertebral region. Patients with CS may be at risk of multi-organ failure due to intravascular volume loss and rhabdomyolysis with myoglobinuric renal failure, and adequate treatment is required to prevent complications. Treatment involves surgical decompression and rehydration to restore fluid deficits and induce diuresis .Exercise-induced CS has been described in the hand, forearm, leg and thigh, generally developing 24 to 48 hours after exercise . Acute CLumbar paravertebral CS was first described in a 1985 case report of a young man with postexertional back pain . The diaA 30-year-old amateur rugby player participated in weightlifting training mainly targeting the muscles of the lumbar spine. An hour after the end of training, he started to feel left-sided lumbar pain, which gradually developed into severe back pain. The patient did not take regular medications, was a non-smoker and denied using anabolic or illegal substances. He denied any trauma, major impacts during recent rugby games, or previous back pain. Five hours after the end of training, he presented to the emergency room of another hospital and received non-steroidal anti-inflammatory drug treatment. As his vital signs were unremarkable and no neurological symptoms were observed, he was discharged from hospital.His pain worsened after discharge, and he re-presented to the hospital a few hours later. As he had severe pain unresponsive to non-steroidal anti-inflammatory drug treatment, he was admitted to the ward for further investigation and intravenous therapy including opioids. Physical examination revealed tenderness to palpation over the lumbar muscles and altered sensation over a 10 × 15 cm area to the left of the lumbar spine. There was no abdominal tenderness, and the remainder of the physical examination was unremarkable. At 24 hours after the end of training, laboratory testing showed a high serum CPK level of 33 000 U/l . Magnetic resonance imaging (MRI) of the lumbar spine showed edema of the multifidus and longissimus muscles  revealed pressures of 3–10 mmHg on the right side and up to 47 mmHg on the left side. The patient’s blood pressure was 110/70 mmHg. Elevation of the left leg in the supine position resulted in increased back pain and was interpreted as a positive stretch sign. The left leg had normal muscle function and no sensory deficits. At 72 hours after the training session, surgical decompression was performed to prevent further muscle necrosis. Under general anesthesia, a left paravertebral incision was made using the Wiltse approach . The thoBased on the results of studies of peripheral CS, various pressures have been suggested as critical limits for surgical intervention. Whitesides et al. proposed that fasciotomy should be performed when the compartment pressure has increased to within 10–30 mmHg of diastolic pressure, or approximately 50–70 mmHg in a normotensive individual ,12. MatsSongcharoen studied 20 volunteers to evaluate normal compartment pressures at rest and during weight-lifting exercise . They reKonno et al. studied the relationships between intramuscular pressure of the lumbar back muscles, and pain and degenerative spine disease, in 102 patients with lower back pain with or without neurological deficits . IntramuParavertebral CS has previously been reported in downhill skiers, surfboarders and weight lifters, as well as in reperfusion injury after surgery of the abdominal aorta ,15,17-21The diagnosis of CS is confirmed by detection of high levels of myoglobin in the serum and urine, a high serum CPK level, and computed tomography findings suggestive of ischemia and necrosis. In all reported cases of paravertebral CS, the main symptom was steadily increasing pain which started within 12 hours of exercise. None of the patients had radicular irritation in the lower extremity. Paravertebral loss of sensation has previously been reported to be a potentially useful sign for early detection of CS. The loss of sensation is thought to result from dysfunction of the lateral branches of the posterior primary rami at multiple levels . Our patLaboratory findings showed a high serum CPK level and high serum and urine myoglobin levels. Rhabdomyolysis is suspected when the serum CPK level is > 5000 U/l and there are high levels of myoglobin in the serum and urine. In our patient, CS of the paravertebral muscles was indicated by these abnormal laboratory values.MRI is the preferred radiological examination in patients with suspected CS. Typical MRI findings include muscle edema and hyperintense areas on T2-weighted images. Decreased gadolinium uptake suggests muscle necrosis. In our patient, T2-weighted MRI findings suggested paravertebral muscle edema.Most previously reported patients with lumbar paravertebral CS were managed by conservative treatment. Careful attention to pain control is very important. Conservative treatment includes administration of analgesics and crystalloid fluid, urine alkalinization and bed rest. In our patient, conservative treatment was not feasible because of the severe pain and increasing serum CPK level. Patients who were managed conservatively experienced only mild back pain on vigorous exertion, and the sequelae of such a condition may be unimportant, making operative decompression unnecessary. Nevertheless, Styf and Lysell reported that fasciotomy relieved the pain in a patient with chronic unilateral lumbar paravertebral CS .In our case, surgery was performed using the Wiltse approach. Wiltse described a modified transmuscular paravertebral approach consisting of longitudinal separation of the sacrospinalis muscle between its multifidus and longissimus parts .To date, only 11 cases of acute paravertebral CS have been reported. Three of these were treated with fasciotomy, resulting in full recovery. We therefore conclude that surgical therapy has good outcomes for both acute and chronic CS.Two further points should be discussed regarding this case. First, the fascia was left open, but the skin was closed. The decision to close the skin was based on the lack of noticeable tension at the wound margins. Second, none of the gray, non-contractile muscle tissue was removed, except for the biopsy specimen. There was intraoperative discussion regarding the need for total resection of the abnormal muscle tissue. In our opinion, the potential for regeneration of the muscle cannot be determined at the time of decompression, and we therefore did not resect the muscle. Intramuscular scar tissue was assumed to be more beneficial for functional regeneration of this long muscle bundle than the potential muscle defect caused by resection.In conclusion, acute paravertebral CS should be considered in the differential diagnosis of patients with acute exertional back pain, especially if the pain seems out of proportion to the exertion. We experienced good results after performing surgical decompression in a patient with acute lumbar paravertebral CS after excessive training.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.CS: Compartment syndrome; CPK: Creatine phosphokinase; MRI: Magnetic resonance imaging; ODI: Oswestry disability index.The authors declare that they have no competing interests.GM drafted the manuscript. LL made substantial contributions to the conception of the manuscript. ML, ET, GW and HS gave final approval of the version to be published. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/259/prepub


The authors report a rare case of 17-year-old lady with late presentation of congenital diaphragmatic hernia. She presented with vague abdominal pain and was thought to have urinary tract infection, ruptured ovarian cyst, and appendicitis by different medical teams in the first few days. She eventually underwent a diagnostic laparoscopy with no significant findings. In the early postoperative recovery period, she suffered from severe cardiorespiratory distress and a large intestinal left diaphragmatic hernia was diagnosed subsequently. At further operation a strangulated loop of large bowel herniating through a left antero-lateral congenital diaphragmatic hernia was discovered, which was reduced and repaired with a prolene mesh through thoracotomy. She made an excellent recovery and was discharged a few days after the operation. The authors postulate a mechanism of positive pressure from laparoscopic surgery causing herniation of large bowel through a pre-existing diaphragmatic defect. This case highlights the diagnostic challenge of this disease due to its diverse clinical presentation, the importance of prompt diagnosis and intervention. CDH usuity rate .Late presentation of CDH is uncommon, accounting for 5-30% of all CDH cases in several studies [We report a case of a 17-year-old girl who presented with non-specific lower abdominal pain, underwent negative laparoscopy, and deteriorated post operatively. A diagnosis of left diaphragmatic hernia was made, confirmed at operation and successfully treated.A 17-year-old lady presented to the Accident and Emergency Department with a 5-day-history of constant, sharp, localized left sided abdominal pain, urinary frequency and vomiting. Her bowel habits were normal. There were no respiratory symptoms and cardiorespiratory examination was unremarkable. Her abdominal examination revealed mild tenderness in the supra-pubic region with normal bowel sounds. She was diagnosed with urinary tract infection and was sent home with trimethoprim.She returned the next day with no improvement of symptoms. A urinary pregnancy test was performed and showed positive results. Her chest examination remained normal and chest-x-ray (CXR) was not performed. After consulting with an obstetrician, a diagnostic laparoscopy was carried out because of suspected ruptured ovarian cyst. At laparoscopy, normal uterus and ovaries were noted and general surgical opinion was sought. Minor bowel adhesions were noted and appendicectomy was performed.Her recovery was slow postoperatively. One day after operation, she developed cardiorespiratory distress with respiratory rate of 40/minute, a documented tachycardia of 200 beats per minute and mild hypoxia. Clinical examination revealed reduced left sided air entry. A CXR was performed Figure  and showShe was transferred to a Cardiothoracic Surgical Unit for urgent surgical intervention. A left postero-lateral thoracotomy approach was used. Copious clear serous fluid was present in the chest, and there was a strangulated loop of large intestines herniated through a small left antero-lateral congenital diaphragmatic defect approximately 3cm X 5cm. The defect was expanded through an incision on the diaphragm to facilitate the reduction of the bowel into the abdominal cavity which was then repaired with a prolene mesh. Her left lung was noticed to be normal.She was discharged to the ward after 24-hour care in critical care unit. Figure Beyond infancy diaphragmatic hernia is an unusual finding. There are different causes other than CDH, for example, trauma, phrenic nerve palsy, and longstanding acquired hiatus hernia.The Congenital Diaphragmatic Hernia Study Group conducted a 10-year study across 30 centers to review the demographics, clinical manifestation and outcomes of late onset CDH . Of 3098Presenting symptoms of late onset CDH could be classified as respiratory , gastrointestinal , both or asymptomatic . GastroiThe group speculates that partial liver herniation in right CDH impedes further herniation of hollow organs into the chest, thereby obviating gastrointestinal symptoms ,4. InterThe CDH Study Group also concluded that the prognosis of late-onset CDH is excellent once the correct diagnosis is made. However, making the correct diagnosis is challenging because of its diverse clinical presentations. Clinical suspicion and CXR remain key. Nevertheless, the variety of organs and the size of herniation may make CXR interpretation difficult and late presenting CDH may mimic pneumonia, tumor and diaphragmatic eventration. The hernia may be intermittent and the presence of a normal CXR does not exclude the diagnosis . FurtherIt was difficult to make the correct diagnosis at the initial stage of this patient because of the paucity of respiratory symptoms and absent chest signs. Imaging was complicated by the early pregnancy. The cause of her initial vague lower abdominal pain was difficult to ascertain leading to laparoscopy. It is possible that the initial diagnostic laparoscopy missed either the early stage or an established herniation of large bowel through the defect. We believe, however, that the positive pressure of the diagnostic laparoscopy might have pushed the hollow organs through the diaphragmatic defect hence allowing it to present itself. This has only once been reported in the past .Following diagnosis the management of acute presentation of CDH aims to achieve urgent bowel decompression. This is critical to prevent complications such as gastric volvulus, bowel strangulation or respiratory complications. In this case the herniated large bowel was strangulated with profound venous engorgement, which could have led to infarction.The timing of surgery, different types of surgical approach and repair techniques have been greatly studied but this will not be discussed any further in this report.This case highlights the diagnostic difficulties that clinicians face when dealing with late-onset CDH due to its rarity and diverse presentations. It emphasizes the importance of the sound clinical evaluation, correct interpretation of imaging, and consideration of CDH in all age groups when clinical suspicion is raised. Extensive search of the literature demonstrates that this as the first reported case of late presenting strangulated CDH, due to positive pressure from laparoscopic surgery.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CDH: Congenital Diaphragmatic Hernia; CT: Computerized Tomography; CXR: Chest-X-Ray.The authors declare that they have no competing interests.KHY contributed in pre-operative, intraoperative and post-operative care. He also collected data and prepared the first draft. MTJ contributed in pre-operative, intraoperative and post-operative care. He also revised the article thoroughly and critically. Both authors approved the final version to be published.


Echinococcus granulosus in an isolated primary subcutaneous hydatid cyst has been reported only once before. In this report, we are describing a 53-year-old male who developed a slowly growing subcutaneous thigh mass. Light microscopy confirmed the presence of hydatid cyst. Further radiological workup for liver and lung has not shown any visceral hydatid focus.Palisading granulomatous reactions are prominent microscopic characteristics that are seen in many diseases. Isolated subcutaneous cystic echinococcosis is rarely documented. Palisading granuloma as a host immune reaction to  Echinococcus granulosus, usually locating in liver or lungs, and subcutaneous location or extension is rare.Cystic echinococcosis is an important tapeworm disease caused by Palisading granulomatous reactions have been documented in several diseases. Furthermore, rare cases of echinococcosis that show palisading granulomatous reaction have been documented. Herein, we report an unusual clinical presentation with an uncommon microscopic feature of isolated subcutaneous cystic echinococcosis that shows prominent palisading granuloma.A 53-year-old male presented with a right thigh mass slowly growing over 10 years. Physical examination revealed a rounded, firm mass in the right upper thigh with no skin changes. Magnetic resonance imaging revealed a cystic well-circumscribed heterogenous soft tissue mass involving the mid-upper right thigh just inferior to the right inguinal ligament Figures . The masMacroscopic examination of the received excisional biopsy showed a well-circumscribed subcutaneous cystic mass that measures 13.5 cm in maximum dimension covered by skeletal muscle tissue. The outer surface is intact and the section surface revealed multiloculated cystic mass containing thick yellow gelatinous material.Echinococcus cyst walls better appreciated on high magnification , followed by the lungs (10%–40%). The hydatid disease, as in our case, can remain asymptomatic for years or may develop serious complications as rupture, infection, anaphylaxis, and death.Subcutaneous cystic echinococcosis is rarely reported and due to the diagnostic difficulties and mimicry of various subcutaneous cystic lesions, cystic echinococcosis should be considered in the differential diagnosis of any cystic mass . DiagnosTreatment is total surgical excision without opening the cyst. If the cyst cannot be excised without opening, the fluid contents should be aspirated, the laminated membrane should be totally excised, and the cyst pouch should be irrigated. The reported case had undergone wide excision. Identifying postoperative recurrence of the cyst in endemic regions is very difficult because the probability of formation of a new cyst is high .Echinococcus coexisting with palisading granuloma reaction all of which had a primary lesion elsewhere [Palisading granuloma is seen in various diseases such as granuloma annulare, necrobiosis lipoidica, and rheumatoid nodules. In the English literature, there is only one documentation of seven cases of subcutaneous cystic lsewhere .There are several reports of primary subcutaneous/soft tissue hydatid cyst –10, but


The spacer placement is a prevalent procedure to separate the surrounding normal tissues from locally recurrent rectal tumor before the application of radiotherapy. However, complications could occur due to the foreign nature of the spacer. This report describes a case of 60-year-old man who had undergone radiotherapy two years earlier for a recurrent rectal tumor and presented with small bowel obstruction. A spacer was used before radiotherapy. Radiological assessment and laparotomy revealed the presence of the spacer inside the small bowel lumen. It is possible that the spacer established contact with the intestine, elicited local inflammatory reaction that facilitated the complete penetration of the intestinal wall without causing any clinical symptoms. Radiotherapy is effective for locally recurrent rectal cancer. The risk of bowel radiation injury depends on the radiation dose. Basic radiation protection principles include increasing the distance between normal tissue and site of radiation, to reduce overall radiation exposure . For thiThe patient was a 60-year-old man with a negative past medical history. In June 2005, he was diagnosed with advanced rectal cancer with bladder invasion and underwent abdominoperineal resection with partial cystectomy and vesicoureteral anastomosis. The final TNM stage was stage IIIB (T4N3M0). Two years after the first surgery, follow-up positron emission tomography/computed tomography (PET-CT) scan showed locally recurrent rectal cancer in front of the sacrum. He opted to receive radiotherapy, but this proved difficult due to the close proximity of the recurrent tumor to the small bowel in the pelvic cavity. To prevent exposure of the small bowel to the irradiation, a polytetrafluoroethylene spacer measuring 15 × 10 cm was placed between the tumor and small bowel. The spacer was secured in place with 3-0 Vicryl suture. A CT scan showed the spacer was positioned appropriately in the desired location (Figure Two years after the second surgery, he presented to the emergency department with left abdominal pain, nausea and vomiting. A CT scan of the abdomen showed dilated small bowel and spacer migration to the abdominal cavity Figure . He was Although surgical resection is considered the most effective therapy for locally recurrent rectal cancer, surgical stress and sacral nerve damage accompanied by high sacral resection often yield dismal results . The useIntraluminal migration of artificial materials has been described previously, such as the migration of mesh after hernioplasty -8. AgrawTwo published case reports have described complete migration of artificial materials into the small bowel ,10. MajeWhile migration of artificial material is quite uncommon, it is possible for mesh to translocate into the hollow abdominal viscus, although the exact mechanism involved in this process is not clear at present. Robinson and Levin  suggesteThe above proposed mechanisms do not provide a reasonable explanation for the present case. Our patient was in good nutritional status and was not on long-term steroid use. How did the spacer pass from the outside of the small bowel into the lumen? A huge defect in the intestinal wall is required for the spacer to migrate into the lumen. However, this patient never developed sepsis-like symptoms that would be expected during the course. Based on the presence of dense adhesions in the pelvic cavity, we propose that the contact between the spacer and intestinal wall elicited local inflammatory reaction without systemic symptoms, during which the spacer eroded the bowel and ultimately penetrated the entire wall. However, the small intestine site containing the spacer was not near the pelvic cavity. This suggests that the spacer traveled within the lumen from the penetration site retrogradely to the site of small bowel obstruction. This case presents extremely uncommon complication of surgery using spacer. Such complication could be perhaps avoided by leaving non-viscus tissue between the spacer and intestinal wall, leaving no direct contact between the two.We experienced a very rare complication of intraluminal spacer migration with small bowel obstruction.Written informed consent was obtained from the patient for publication of this report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.TO wrote the main manuscript and MS performed the operation, revised the manuscript for important intellectual content, and gave the final approval for the version to be submitted for publication. All authors read and approve the final manuscript.


Spigelian hernias are a rare type of hernia through the Spigelian aponeurosis. Spigelian hernias are very uncommon and constitute only 0.12% of all abdominal wall hernias. These hernias are located in the aponeurosis of the internal oblique muscle and transverse abdominal muscle.A 30-year-old woman at 28 weeks’ gestation was admitted to the obstetrics department due to pain and swelling in the anterior abdominal right region. On inspection, we suspected either a lipoma, a spontaneous hematoma, a tumor of the abdominal wall, or a Spigelian hernia. A Doppler USG and abdominal and pelvic Magnetic Resonance Imaging revealed necrobiotic fibroma of the uterus in Spigelian hernia. The patient was started on dual analgesic and corticotherapy. Overall, the patient improved one week after the acute episode and had no further pain during her gynecologic follow-up.We have reported a first case of Spigelian hernia that was complicated by uterine fibroid. The clinical presentation varies, depending on the contents of the hernial sac and the degree of herniation. MRI is the preferred method for accurately identifying masses of the abdominal wall. Our treatment options were based on the extent of the acute-phase reaction and the venous thrombosis.It is important to differentiate this rare Spigelian hernia from other hernias as the treatment for this hernia is medical rather than surgical. Before the final choice of treatment is made, digestive surgeons should bear this rare hernia in mind. Spigelian hernias occur due to a slit-like defect in the anterior abdominal wall adjacent to the semilunar line. Diagnosis of Spigelian hernias is difficult. In the absence of incarceration or strangulation. Smooth muscle tumors are the most common type of uterine neoplasm. We will present below a first case of Spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman.22) and she had no personal or family medical or surgical history. She had no history of medical drug use.A 30-year-old woman (gravida 1 para 0) at 28 weeks’ gestation was admitted to the department of gynecology and obstetrics due to pain and swelling in the anterior abdominal right region. This mass had suddenly appeared two months before. Her pregnancy was progressing well (body mass index of 16 kg/mOn admission, she had no fever, vomiting or transit disorder. On inspection, we suspected a lipoma, a spontaneous hematoma, a tumor of the abdominal wall or a Spigelian hernia. Physical examination revealed a Spigelian hernia that was rather painful because the mass had developed on the linea arcuata . This maUltrasound assessment of the anterior abdominal area revealed a mass on the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally. The mass appeared well-defined, solid, with a whorled appearance and of similar echogenicity to the myometrium. The Doppler USG showed circumferential vascularity and absence of flow . TypicalThe patient was started on dual analgesic and corticotherapy. Overall, the patient improved one week after the acute episode and had no further pain during her gynecologic follow up.3We have reported a first case of Spigelian hernia that was complicated by uterine fibroid. Spigelian hernias are very uncommon and constitute only 0.12% of all abdominal wall hernias.The clinical presentation varies, depending on the contents of the hernial sac and the degree of herniation. Because of its varied presentation, clinical examination is often inconclusive. In this case, the diagnosis was apparent because the patient had a palpable lump along the Spigelian aponeurosis.Only 50% of cases are diagnosed preoperatively.The clinical was resolved entirely with analgesics and corticotherapy. Our treatment options were based on the extent of the acute-phase reaction and the venous thrombosis.Smooth muscle tumors are the most common type of uterine neoplasm. The vast majority of such tumors are benign leiomyomas. Leiomyomas are by far the most frequent mesenchymal uterine neoplasms. The leiomyoma, by far the most common of all the neoplasms, is generally hormone sensitive, with rates of growth semi-quantitatively related to estrogen and progesterone receptor levels. Ischemic or infarct type necrosis is not considered a criterion for malignancy. The diagnosis of fibroids on USG is usually reasonably straightforward. When there is doubt about the origin of a mass at USG, further evaluation by means of MRI should be performed. MRI is the preferred method for accurately identifying masses of the abdominal wall. The risk of strangulation of uterine fibroid and necrobiotic is higher because of the sharp fascial margin around the defect.Before the final choice of treatment is made, digestive surgeons should bear this rare hernia of uterine fibroid in mind for the differential diagnosis of an intestinal incarceration. It is important to differentiate this rare Spigelian hernia from other hernias, as the treatment is medical rather than surgical. Indeed, this mass has a remarkably favorable prognosis.None declared.None.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Radwan Kassir and Enrico Tarantino contributed in writing the paper. Robert Lachez and Aurelie Di Bartolomeo collected the data. Amine Brek and Olivier Tiffet reviewed and revised the paper.


Benign fibrous overgrowths are often found in the oral cavity, almost always being reactive/irritational in nature. However, benign mesenchymal neoplasms of the fibroblasts are extremely uncommon. Here we report a case of “True Fibroma of Alveolar Mucosa” for its rarity. Fibroma is a benign neoplasm of fibroblastic origin, rare in the oral cavity . It is sStout said that “it is exceedingly difficult to decide whether or not there is true benign neoplasm composed of fibroblasts” . Since tThe histologic criteria of a true fibroma were first described by Barker and Lucas. Three more cases of true gingival fibroma have been reported in literature since then . We descA 60-year-old male was examined for a two-month-old solitary swelling measuring approximately 2.5 × 2.5 cm in the right middle third of the face. Intraorally, on palpation it was ovoid and firm in consistency with respect to 16 and 17 region . RadiogrA soft tissue specimen, pinkish white in colour, irregular in shape, and firm in consistency, that measured approximately 3.5 × 3 × 3 cm was received . The cutHistopathology revealed a flattened hyperparakeratotic stratified squamous epithelium overlying a well circumscribed encapsulated mass of dense collagenous stroma. The stroma was composed of numerous spindle shaped plump fibroblasts, collagen arranged in parallel or interlacing dense bundles with areas of hyalinization, sparse inflammatory cells, and minimal vascularity Figures . The tisThus, a diagnosis of “True Fibroma” was arrived at, eliminating lesions like irritation fibroma, peripheral giant cell granuloma, peripheral ossifying fibroma, giant cell fibroma, neurofibroma, and pyogenic granuloma.Localized fibrous tissue overgrowths are very common in the oral mucosa. As far as the nature of these lesions goes, most pathologists believe that both hyperplasias and neoplasms can occur. However, it is very difficult to differentiate between the two and decide whether a benign neoplasm exists or not. The extremely low frequency of occurrence of true fibromas (benign neoplasms) was highlighted by Barker et al. in 1967 when they reported two true fibromas among 171 specimens of localized fibrous growths , 5.A reactive or irritational fibroma usually has an etiology, that is, a source of irritation, while benign fibrous neoplasms do not have that. Also, the character of these lesions tells a story. According to Barker and Lucas, irritational fibromas exhibit a pattern of collagen arrangement depending on the amount of irritation and the site of the lesion. There are two types of patterns: (a) radiating pattern and (b) circular pattern.In the radiating type, the fibres radiate towards the epithelium from the base of the lesion. While the circular type shows a central mass of disoriented fibres surrounded by a peripheral layer of collagen fibres running beneath and parallel to the overlying epithelium. Thus, they hypothesized that the former appears when there is a greater degree of trauma and in sites which are immobile in nature , while lesser trauma induces the latter and it occurs in sites that are flexible in nature  .the character of the collagen fibres of the lesion (does not have either of the patterns),the sharp demarcation of the tissue from the surrounding normal tissue,the presence of a capsule.True fibromas can be differentiated from their irritational counterparts on the basis ofThe present case also showed histopathological features suiting the above mentioned criteria, which pointed towards the diagnosis of a true fibroma.


Purpose. Extrapulmonary small cell carcinoma affecting the anal canal is a rare and poorly understood entity which can, in its early stages, masquerade as benign anorectal disease such as hemorrhoids. Methods. We report a case of this rare malignancy which initially presented with hematochezia and anal pain. We also review the literature with regard to previously described cases and management strategies including the role of surgery. Results. Despite aggressive multidisciplinary treatment consisting of chemotherapy and radiation, the disease progressed rapidly with dissemination occurring only three months after completion of treatment. Because of the aggressive nature of this tumor, the treatment options for this almost universally fatal malignancy are often palliative in nature. Conclusion. Chemoradiotherapy is likely the most reasonable approach to extrapulmonary small cell carcinoma of the anal canal given its aggressiveness. Anal carcinomas represent approximately 4% of all gastrointestinal cancers diagnosed annually in the United States with an estimated 5260 new cases to be found in 2010 [A 63-year-old female developed episodic hematochezia and anal pain. Initial anorectal exam revealed only small internal hemorrhoids and colonoscopy demonstrated no proximal pathology. Weeks later she developed an enlarged, symptomatic right inguinal lymph node which was excised and revealed metastatic small cell carcinoma. She was then referred to us for evaluation. At this time digital exam revealed a 2 cm fixed mass in the anal canal at the level of the dentate line. Biopsy of the anal canal mass demonstrated small cell carcinoma which was histologically similar to that seen in the inguinal node .Staging CT of the chest, abdomen, and pelvis, and MRI of the brain did not reveal distant metastatic disease nor a primary lung tumor. 18F-FDG PET scan demonstrated uptake in the anal canal and right inguinal region . RoutineHer anal symptoms improved markedly during the first few weeks of treatment. Clinical examination four weeks after completion of chemoradiotherapy revealed complete regression of the anal tumor and no palpable recurrence in the inguinal regions. However, three months after the completion of chemoradiotherapy, she developed new onset arm weakness. Imaging revealed the development of extensive brain and intra-abdominal metastasis. Pancreas, adrenal gland, liver, breast, lung, brain, and lymph nodes all showed evidence of disease on imaging . At thisSmall cell lung carcinoma comprises about 13% of all lung cancers . ApproxiSmall cell carcinoma of the anal canal is extremely rare and its true incidence is not entirely known; most of the literature on this topic is in the form of isolated case reports. Additionally, the existing literature may be misleading because some reports detailing cases of small cell carcinoma affecting the rectum might have actually been describing lesions that arose in the anal canal if strict definitions of the surgical anal canal were used. The largest number of cases was reported by Boman et al.; their retrospective review of 188 cases of anal canal carcinomas seen over a 27-year period found that only 13 of them were actually small cell carcinoma [Because of the rarity of EPSCC, not much is known about its origin. Some reports refer to these carcinomas as “neuroendocrine,” but others feel that this terminology implies an embryologic origin that, as of yet, is still unproven . NonetheIt is not known if any acquired or life-style-related factors predispose to the development of EPSCC. Although our patient was a long-time smoker and smoking is frequently associated with SCLC, approximately 30% of patients with EPSCC are nonsmokers . While rAs highlighted by our case, the initial staging workup for suspected EPSCC consists of imaging the brain, chest, abdomen, and pelvis to rule out the lung as the primary and assess for distant or locoregional disease. Given the lymphatic drainage of the anal canal, if this is the primary location special attention must be paid to the inguinal lymph nodes. Suspicious lymphadenopathy not amenable to biopsy should be further investigated via PET scan as they are typically PET avid. Since our case presented with locoregional disease only, we proceeded with treatment similar to that which is done for limited stage SCLC where the typical regimen is concurrent chemoradiotherapy using cisplatin and etoposide. Although the patient's anal symptoms improved drastically and the primary tumor appeared to have completely regressed by 4 weeks after chemoradiotherapy, significant distant disease arose shortly thereafter.Unfortunately, no well-studied treatment guidelines exist for anal EPSCC; thus our current strategy relies on how it is treated when it occurs in other anatomic locations. For example, Hoskins et al. found that of 34 patients with EPSCC of the cervix treated with chemoradiotherapy, 55% were long-term survivors . AlthougSurgery has been employed in cases of anal EPSCC but the results have been equally disappointing. It did not significantly impact the progression of disease in the case reported by Nakahara et al. . MoreoveEPSCC of the anal canal is rare, and in its early stages may have a clinical presentation similar to other routine anorectal problems. It continues to be associated with a very poor prognosis, and at this point, treatment with chemoradiotherapy seems to be the most reasonable. The rapid distant dissemination occurring in our patient despite treatment highlights the fact that this disease is very aggressive and further investigation must be done to define novel therapeutic options.


EBV-positive diffuse large B-cell lymphoma of the elderly is a newly described aggressive lymphoma predominantly affecting patients >50 years of age. Patients may present with nodal and/or extranodal involvement. The lung is one of the more common extranodal sites. The incidence of pleural fluid involvement is less well described. In one study by Oyama et al., pleural effusions were noted in nine percent of cases. Identification of pleural fluid involvement could be important as it may carry prognostic importance in staging , and it could be a relatively easy means of establishing a diagnosis in newly presenting cases. We report the first description of the pleural fluid cytology in a case of EBV-positive diffuse large B-cell lymphoma of the elderly. EBV-positive diffuse large cell lymphoma (EBV+ DLBCL) of the elderly is a newly recognized aggressive B-cell lymphoproliferative disorder. Initially characterized by Oyama et al. in 2003 , this enA 64-year-old man presented to an outside hospital with fatigue, fever, chills, nights sweats, and a 65 pound weight loss over a 2.5 month period. A CT scan demonstrated hilar and mediastinal lymphadenopathy and splenomegaly. An extensive workup was performed including lymph node and skin biopsies and cytologic evaluation of pleural effusion. All sites showed a polymorphic population of T and B-cells with occasional rare atypical CD20 positive B-cells. IgH and kappa and lambda studies on the skin biopsy failed to identify a clonal population. While the findings were worrisome for lymphoma, a definitive diagnosis could not be made. The decision was made to transfer the patient to our institution.On admission to our hospital, the outside histopathology was reviewed and the diagnoses confirmed. Given the strong clinical suspicion of lymphoma, a second lymph node was biopsied. The lymph node contained a polymorphous population of medium-to-large-sized lymphocytes with clumped chromatin, multiple nucleoli, a scant-to-moderate amount of cytoplasm, and frequent mitotic figures . There wThe patient started therapy and developed sepsis complicated by worsening dyspnea. A pleural effusion and pulmonary infiltrate were noted. Pneumonia was suspected clinically, and a thoracentesis was performed. Cytologic and immunohistochemical evaluation of the fluid demonstrated a polymorphous population of B and T cells Figures . Hidden EBV+ DLBCL of the elderly is a relatively newly described entity with an aggressive course. By definition, it arises predominantly in immunocompetent adults older than 50 years of age, although younger patients have been described , 4. PatiSince its initial recognition, the morphologic overlap between EBV+ DLBCL of the elderly and reactive EBV lymphoproliferative disorders, classic Hodgkin lymphoma (cHL), and T cell-rich B-cell lymphoma has been recognized –8. CliniIn summary, we report the first description of the cytologic findings of EBV+ diffuse large B-cell lymphoma involving the pleural fluid. Diagnosis of lymphomas by cytologic examination of fluid is well recognized and accepted. However, pitfalls remain due to cytologic overlap among lymphoma subtypes. EBV+ DLBCL of the elderly has just recently been added to WHO classification of diffuse large B-cell lymphomas. In at least a subset of cases, pleural effusions are present either at the time of presentation or subsequently. Pleural fluid analysis may be a comparatively easy target for initial diagnosis. The polymorphous infiltrate, common to other EBV driven processes, can be misleading and lead to a diagnosis of a reactive process. A high index of suspicion is important to make the diagnosis. Therefore, this case also demonstrates the importance of adding EBV in situ hybridization to the list of ancillary studies performed in the evaluation of polymorphic pleural effusion cytology specimens. In our case, the initial review revealed rare, partially obscured atypical lymphoid cells in a polymorphic background, initially interpreted as being reactive. Clinically, the patient was believed to have therapy-induced pneumonia, and the cytology supported this. Cytomorphology alone was not diagnostic. The correct diagnosis required EBER-ISH with careful clinical correlation.


Lumbar hernias are very rare posterolateral abdominal wall hernias, and they are spontaneous in most adult patients. Here we report two cases of spontaneous lumbar hernias associated with chronic obstructive pulmonary disease (COPD). Some factors such as chronic cough, poor nutritional status and old age in patients with COPD would contribute to lumbar hernia. The majority of patients either are asymptomatic or complain of a posterior lump, flank discomfort or chronic backache. Some factors including raised intra-abdominal pressure and muscle atrophy are believed to predispose to primary lumbar hernias.2 Here we present two cases of primary lumbar hernias associated with chronic obstructive pulmonary disease (COPD) to detect some relationship between these two diseases.Lumbar hernias are very rare posterolateral abdominal wall hernias which are located in the thoracolumbar region. Until now, there have been fewer than 300 cases reported in the world literature.Case-1:A 67-year-old male with repeated cough and shortness of breath for seven years presented to our pulmonary center. He was diagnosed with chronic bronchitis and treated with intermittent oral cefaclor and salbutamol in the local clinic in the past three years. The patient was a truck farmer and had a history of smoking for forty years.There was no previous history of surgery or injury. Due to lack of response from prescribed medications, he was referred to our center for further investigations. On physical examination, the patient’s chest was symmetrical and barrel shaped, with diminished breath sounds heard. Pulmonary function tests showed forced vital capacity (FVC) and forced expiratory volume in 1s (FEV1) was below lower limit of normal (FEV1/FVC was 60% and FEV1 was 55%). Chest CT scan showed significant emphysematous changes in his lung. The diagnosis of COPD was established. On abdominal examination, there was a 6x4cm soft, non-tender, smooth-surface swelling in the right lumbar region. . The masCase – 2: The patient was a 61- year- old male, presenting with gradually increasing painless and reducible left flank mass for the past two years , admitted to our hospital for operation. He was a non-smoker and had a medical history of COPD. He had been working as a cargador for 20 years. In the past ten years, He had always been coughing and mild breathless intermittently, especially in winter and spring .There was no history of trauma, surgery. On admission, his pulmonary function tests revealed FEV1/FVC was 63% and FEV1 was 70%. On abdominal examination, there was a 6x5cm soft, non-tender, smooth-surface and reducible swelling in the left lumbar region. Computed tomography (CT) scan of the abdomen was carried out which confirmed the presence of left lumbar hernia containing fatty tissue , chronic cough, poor nutritional status and old age could be the risk factors. More studies should be performed to make it clear.TX: Conceived, designed and did editing of manuscript.SZ and HW: Did data collection and manuscript writing.WY: Did review and final approval of manuscript.


Migration is a rare complication of venticuloperitoneal shunts and is thought to be associated with the "memory" of the plastic tubing and the windlass effect of neck flexion and extension. The purpose of this case report is to detail a very rare case of complete distal to proximal shunt migration. An 11-month-old female with a history of multiloculated, complex intracranial cysts with shunt-dependent hydrocephalus and seizure disorder presented to the emergency department with a 2-day history of lethargy, sleepiness, nausea and vomiting. The patient was 3 days status post insertion of a left ventriculoperitoneal shunt insertion. Vital signs were stable, and physical exam revealed a large subgaleal mass at the left occipital area. Figures  and headSignificant proximal shunt migration is an extremely rare complication that has only been reported in the literature on six occasions -5, with The authors declare that they have no competing interests.BK oversaw and edited the case report and the organization of the images as published. DH researched the current literature and wrote the body of the paper. LS oversaw patient care in the ED and obtained verbal and written consent for publication. All authors read and approved the final manuscript.


We suggest that the markedly high serum CA 19-9 level could be indicative of carcinoma in polyp at the very least.Here we report the first case of carbohydrate antigen (CA) 19-9-producing early gastric adenocarcinoma arising in polyp. A solitary pedunculated polyp lesion of the stomach, measuring 26 × 20 × 20 mm, was noticed in a 76-year-old Japanese woman due to an abdominal disorder, associated with a markedly high serum CA19-9 level . After endoscopic mucosal resection was performed, the CA19-9 level was drastically decreased and normalized. The scanning view of immunohistochemical staining of CA19-9 exhibited a focal, not diffuse, positive-expression in the hyperplastic epithelium and, especially, in the irregular and fused tubular glands and the mucinous material secreted into the dilated glands. In particular, microscopic examination of the strongly CA19-9-positive areas showed structurally atypical epithelium containing mildly to focal moderately enlarged nuclei and prominent nucleoli with loss of cellular polarity, estimated as adenocarcinoma. No stromal invasion was evident. Immunohistochemically, distinct nuclear stainings for p53 and Ki-67 were seen, occasionally conforming to the CA19-9-positive atypical cells, respectively, confirmed by double immunostaining. These hyperplastic and atypical cells were classified into the pure gastric phenotype by mucin histochemical methods. Based on these features, we finally made a conclusive diagnosis of CA19-9-producing http://www.diagnosticpathology.diagnomx.eu/vs/1692254825554310The virtual slides for this article can be found here:  CA19-9 genicity ,3. Monoclβ1-4Glc . The exilβ1-4Glc . At leaslβ1-4Glc . Here weThe patient was a 76-year-old woman, who had only hypertension with long-term administration of depressors in her past medical history. She had never taken Sucralfate, a drug for protection against gastric mucosa. She complained about abdominal disorder at the rt. lower portion, but nothing remarkable was found in her laboratory data except for a markedly high serum CA19-9 level  by electrochemiluminescence detection method for development of immunoassays . The other tumor markers, such as carcino-embryonic antigen (CEA) or CA125, were within normal limits. No remarkable change was seen in the abdominal and chest CT. Gastrointestinal endoscopy was performed for further investigation, revealing a solitary pedunculated polyp lesion measuring approximately 25 mm in the posterior wall of the lower gastric body  than that after it. In addition, CA19-9 immunohistochemical expression was detected focally in this specimen. These features are consistent with CA19-9-producing gastric neoplasms, characteristics of which also are well differentiated and gastric foveolar phenotypes, but often poor prognosis with invasion depth beyond the submucosal layer . There arent one . By contrent one ,15. ThesOn the other hand, the rate of high serum CA19-9 levels before surgery among all patients with gastric cancer is not remarkable, only 25% to 30%, and thus, the serum CA19-9 levels are not clinically important for a tumor marker, but only for a prognosis indicator ,14. In tWe herein reported the first case of a CA19-9-producing early well differentiated adenocarcinoma arising in gastric hyperplastic foveolar polyp. We should be aware that gastric polyp lesions might rarely produce markedly high CA19-9 antigens, possibly associated with malignant transformation.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.XG and SY participated in conception of the idea and writing of the manuscript. XG, SY, HO, KYW, TT, AN, KK and YS performed the histopathological interpretation of the tumor tissue.All authors have read and approved the final manuscript.


Background. Rosai-Dorfman Disease (RDD) is rare benign hematologic disorder of histiocytes, which usually manifests as painless lymphadenopathy, fever, leukocytosis and hypergammaglobulinemia. Extranodal RDD has been reported in 43% of cases, with skin as commonly involved site followed by head and neck region. However, soft tissue cheek mass is rare presentation of extra-nodal RDD. Case Presentation. A 26-year-old Saudi man presented with a six-month history of right cheek swelling and left upper eyelid swelling. Physical examination revealed right cheek mass of size 3 × 3 cm and left upper eyelid mass of size 1 × 2 cm and no palpable cervical lymphadenopathy. Incisional biopsy of cheek mass showed positivity for S100 and negativity for CD1a, consistent with extra-nodal RDD. Patient did not respond to systemic steroids and was given radiation therapy to left orbit with minimal response. Then, he was started on chemotherapy Rituximab, cyclophosphamide, vincristine, and prednisolone (RCVP) 8 cycles followed by reirradiation 10 Gy in 10 fractions with 6 MeV electron with complete response. After 12 months of followup, patient had recurrence in right cheek and was started on radiotherapy to the cheek mass. Conclusion. Extra-nodal RDD with involvement of cheek is a rare presentation. Incorporation of S100 and CD1a is helpful in diagnoses of RDD and differentiating it from other benign histiocytosis. Treatment consists of surgery, steroids, chemotherapy, and radiation therapy. Rosai-Dorfman Disease (RDD) is also referred to as sinus histiocytosis with massive lymphadenopathy (SHML), which is rare, benign, and self-limited and is a non-Langerhans proliferative disorder of histiocytes . It is cExtranodal RDD has been reported in 43% of cases, and the skin is the most common extranodal site .Herein we presented 26-year-old Saudi man, who present with RDD of right cheek and left upper eyelid treated with steroids, systemic chemotherapy, and radiation therapy. A 26-year-old Saudi man presented with a six-month duration of right cheek swelling and left upper eyelid swelling. Physical examination revealed right cheek erythematous mass of size 3 × 3 cm and a similar erythematous mass over left upper eyelid of size 1 × 2 cm ; howeverIncisional biopsy from left eyelid mass and excisional biopsy from right cheek mass were taken, which showed a nodular inflammatory infiltrate within the dermis consisting of histiocytes with plasma cells and lymphocytes aggregates. Large histiocytes were found with vesicular nuclei and emperipolesis. Immunohistochemistry demonstrated the positivity for S-100, CD68, and CD45 and negativity for CD1a, which confirmed the diagnosis of extra-nodal RDD . PatientAfter discussing the case in multidisciplinary meeting, patient was given 30 Gy in 15 fractions radiation therapy with 6 MV photons to left eyelid mass . MagnetiRDD is rare benign hematologic disorder of histiocytes, and its variant extra-nodal RDD is seen in 43% cases of RDD. The histological findings in extra-nodal RDD are characterized by dense infiltrate of histiocytes with scattered lymphocytes, plasma cells, and neutrophils in the dermis or subcutaneous tissue. The histiocytes are larger in size with large vesicular nuclei, small nucleoli, and abundant pale pink cytoplasm. Emperipolesis  within histiocytes is the pathognomic feature . ImmunohThe exact pathogenesis is not well known; however, abnormal responses of histiocytes to a viral stimuli and polyclonal expression have been postulated by different studies , 9. TreaNo ideal treatment guidelines exist for the RDD. Many RDD lesions remain asymptomatic and heal spontaneously without any intervention . SurgicaRadiation therapy was known to have limited efficacy in most cases of RDD, although recent reports have shown benefit in a refractory extra-nodal RDD with higher radiation doses , 13. HowIn conclusion, steroid-resistant extra-nodal RDD of cheek is rare manifestation, and multidisciplinary approach can achieve durable symptoms control. Radiation therapy can be considered as part of of RDD to enhance local control.


Rosai–Dorfman disease (RDD) is rare and characterized by histiocytic proliferation and massive cervical lymphadenopathy. About 40% of patients have extra-nodal involvement. Opthalmic involvement is seen in 10% of cases. A case of orbital Rosai Dorfman disease in a 58 years old woman is presented here, who was misdiagnosed as orbital inflammatory disease initially. The patient did not respond to a course of oral prednisolone. Then complete surgical excision of the mass was performed and the histopathological examination was consistent with a diagnosis of RDD. The diagnosis depends on the histopathology and immunohistochemitry. We report a case of orbital Rosai Dorfman disease in a 58 years old woman, who was misdiagnosed as orbital inflammatory disease initially.Rosai-Dorfman disease is a non-neoplastic disease of unknown etiology observed mainly in children and adolescents, affecting mainly the lymph nodes.The patient was a 58-year old woman, who complained of exophthalmos for 30 years and developed a swollen mass of right lower-eyelid for two years. Her visual acuity was 20/20 in both eyes. Ocular pressure was 20mmHg in right eye and 22mmHg in left eye. The measurement of exophthalmos was 18mm in right eye and 14mm in left eye. Examination revealed a large, tough, non-tender mass in right lower eyelid measured 2.0cm by 1.5cm by 0.8cm and that in upper eyelid measured 1.0cm by 0.5cm by 0.5cm. Anterior segment examination, fundoscopy and systemic examination were essentially normal. A computerized tomography (CT) scan of the orbits done at that time diagnosed inflammatory pseudotumor, shown a homogenous mass in right orbit .A preoperative diagnosis of inflammatory pseudotumor was made. But she gave no response to a course of oral prednisolone. Then complete surgical excision of the mass was performed under general anaesthesia. Histopathological examination revealed infiltrates composed of histiocytes, lymphocytes and plasma cells. Histiocytes with indecisive outlines were large. A characteristic finding was the presence of lymphocytes engulfed within the histiocytic cytoplasm, a feature called emperipolesis. Immunohistochemically, the large histiocytes reacted strongly and positively to S-100 protein and CD68, but negative to CD1a . So the This study was approved by the institutional ethics committee of The First Affiliated Hospital, School of Medicine, Zhejiang University. Informed consent was obtained from the patient and her family.5 Typically, it involves the intraconal space in the orbit and runs a slow infiltrative and cicatricial course.6 The exact pathogenesis of RDD is unknown. However, some studies suggest that human herpes virus type 6 (HHV-6) and Epstein-Barr virus may play a role.7Rosai-Dorfman disease is a rare and non-hereditary histiocytic proliferative disorder, recognized by Rosai and Dorfman. They described four cases called “sinus histiocytosis with massive lymphadenopathy” initially. It usually presents with massive painless bilateral cervical lymphadenopathy. Opthalmic involvement is seen in 10% of cases.8,9 RDD is relatively benign and may take years to develop. Only tumors affecting organ functions are considered for treatment. The diagnosis of RDD depends on the histopathological and immunohistochemical confirmation. The tissue consist of numerous histiocytes, lymphocytes, plasma cells and neutrophile granulocytes. The polygon or elliptic histiocytes are rich of cytoplasma, which usually swallow some whole lymphocytes, plasma cells and neutrophile granulocytes. Furthermore, the tissue shows immunoreactivity for CD68 and S100, but negative for CD1a which is often present in Langerhans’cell histiocytosis.The differential diagnosis of RDD includes Langerhans’cell histiocytosis, inflammatory pseudotumor and lymphoma.10 As for therapeutic options, such as surgical excision, radiation therapy, corticosteroid and other immunosuppressive therapies should be considered.11 When the patients are treated with corticosteroids, long-term follow-up is required because of the potentially vision-threatening complications and the probable recurrence. Our patient did not respond to corticosteroids and surgical excision was curative without recurrence by two years follow-up. Hence at present the surgical resection is the first choice for treatment of orbital rosai-dorfman disease.Our patient was an elderly woman, and preoperative CT scan presented an inflammatory tumor, the preoperative diagnosis was not definite. A definite diagnosis of RDD requires histopathological and immunohistochemical confirmation. Therefore when patient is suspected of idiopathic orbital inflammation,a biopsy is considerd. Bijlsma demonstrated biopsy to be safe in not delaying diagnosis of malignancies and efficient in providing a rapid diagnosis.


Endocervicosis in the urinary bladder is a rare benign condition. We present a case in a 37-year-old woman with classical clinical and pathological features of endocervicosis. The unusual observation of endocervical-like mucinous epithelium in continuity with the urothelium in addition to fully developed endocervicosis prompted immunohistochemical profiling of the case using antibodies to cytokeratins , HBME-1, estrogen receptor (ER) and progesterone receptor (PR) to assess the relationship of the surface mucinous and endocervicosis glandular epithelia. The surface mucinous epithelium, urothelium and endocervicosis glands were immunopositive for AE1/AE3, CK7 and CK19 while CK20 was only expressed by few urothelial umbrella cells. The surface mucinous epithelium was CK5/6 and HBME-1 immunonegative but showed presence of ER and PR. This was in contrast to the urothelium's expression of CK5/6 but not ER and PR. In comparison, endocervicosis glands expressed HBME-1, unlike the surface mucinous epithelium. The endocervicosis epithelium also demonstrated the expected presence of ER and PR and CK5/6 immunonegativity. The slightly differing immunohistochemical phenotypes of the surface mucinous and morphologically similar endocervicosis glandular epithelium is interesting and requires further clarification to its actual nature. The patient has remained well and without evidence of disease 18-months following transurethral resection of the lesion. Endocervicosis in the urinary bladder is a rare benign condition, first recognised by Steele and Byrne in 1982 in their report of endocervical-like glands deep in the urinary bladder wall -5. To thA 37-year-old woman presented with complaint of an episode of macroscopic, painless hematuria. She had a similar episode 3-months previously and was seen at another hospital and told to have a small bladder lesion detected by ultrasonography. There was no history of catamenial exacerbation or association for either episode. She defaulted follow-up till this current episode. Apart from laparoscopic removal of an ovarian cyst (5 × 4 × 2 cm) six years ago at a different hospital, the patient was otherwise well. Review of the hematoxylin and eosin stained sections confirmed that the ovarian cyst was a benign mucinous cystadenoma lined by single-layered endocervical-like epithelium. The patient also gave a history of two caesarean sections, thirteen and eleven years earlier. Physical examination revealed no significant findings. The patient underwent cystoscopic examination and transurethral resection of the lesion at the posterior dome of the bladder under spinal anesthesia.Multiple rubbery, whitish-grey tissue fragments of varying sizes and shapes, measuring 1.5 × 1.2 × 0.5 cm in aggregate were resected. The fragments of bladder tissue revealed glands lined by a single-layered mucinous columnar epithelium with basal nuclei reminiscent of endocervical epithelium in the lamina propia and extending into the muscularis propia. These endocervicosis glands ranged from round to branched Figure . Occasios20.8, 1:100), HBME-1 , estrogen receptor (ER)  and progesterone receptor (PR)  via the EnVision™+ (DakoCytomation) system.4-μm sections of the formalin-fixed, paraffin-embedded tissue were subjected to immunohistochemical staining using monoclonal antibodies to pancytokeratin AE1/AE3 , CK7 , CK19 , CK5/6 , CK20 (DakoCytomation KSouthgate's mucicarmine clearly delineated the mucinous epithelium from the adjacent urothelium in this case Figure . Table 1Endocervicosis in the urinary bladder is an uncommon benign entity but causes sufficient clinical anxiety with presentation as a lesion in the bladder frequently associated with hematuria. To the best of our knowledge, there are less than 40 cases reported in the English literature to date. Table The patient has remained asymptomatic and without evidence of disease recurrence 18-months after transurethral resection of the lesion as would be expected by the currently known natural history of the condition ,15.Endocervicosis in the urinary bladder is a rare but clinically significant entity. The observation in this case, of endocervical-like mucinous epithelium in continuity with urothelium and the slightly differing immunophenotype of this epithelium with that of the endocervicosis glands, is interesting and may provide clues to the pathogenesis of this rare entity.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journalThe authors declare that they have no competing interests.PLC was a major contributor in writing the manuscript. LML, KHT, KSM, ARN participated in the pathological examination of the case. GEGL provided the clinical information and correlation. All authors read and approved the final manuscript.


In 2006, while admitted in our hospital for surgical treatment of recurrent diverticulitis, a 54-year-old man was found to have an adenocarcinoma arising within a colonic diverticulum. Computed tomography, during this episode of diverticulitis, showed a thickened wall of the sigmoid and inflammatory induration of the pericolonic fat. Colonoscopy could be performed up to no more then 25 cm from the anus due to mucosal edema. A sigmoid resection was performed. Histopathological examination of the resected specimen showed an inflamed diverticulum with a submucosal adenocarcinoma of the intestinal type within its wall. The surrounding flat colonic mucosa was not involved by the cancerous process. Due to lymph node involvement the patient received adjuvant chemotherapy and remained disease free during follow up. Chronic and recurrent diverticulitis are often treated by resection of the affected bowel part. Malignant tumor development within a diverticulum is distinctly rare and difficult to diagnose. We report a case of adenocarcinoma arising in a diverticulum in a patient with recurrent diverticulitis.Diverticulitis is common, though most patients remain asymptomatic. Only one-third of the patients who experience an attack of diverticulitis will have chronic or recurrent symptoms.A 54-year-old man presented with recurrent diverticulitis since 1993. From January to August 2006 he suffered from chronic diverticulitis. Computed tomography (CT), during an acute episode in 2006, showed a severely thickened wall of the sigmoid and inflammatory induration of the pericolonic fat tissue, consistent with a diagnosis of diverticulitis. Colonoscopy could only be performed up to 25 cm from the anus due to mucosal edema. A sigmoid resection with side-to-end anastomosis was electively performed. Peroperatively, an obvious diverticulitis was noticed with severe induration of the surrounding tissue. Because the inflamed tissue was fixed to the retroperitoneum, peri- and paracolic lymph nodes were also dissected.2 was administered eight times in a 3-week cycle; Capecitabin 1000 mg/m2 was administered twice a day at day 1 and 14 of each cycle. During one year follow-up there were no signs of metastases or recurrent disease.Macroscopic examination of the resected specimen showed a 16 cm long specimen, with a diameter of 5 cm and mesenterial fat tissue of 7 cm width. At the outer surface several hemorrhagic areas were observed. On transverse slides multiple diverticula were seen and a number of fibrous strands within the fatty subserosal tissue . The mucAlthough colonic diverticulitis and cancer are common diseases in Western countries, cancer arising within a diverticulum is rare. In the present report, histopathological examination of the colonic specimen showed a carcinoma within a diverticulum without involvement of the colonic mucosa. Only eight such cases have previously been reported in the literature.–5 A thickened wall of the sigmoid is a characteristic sign for as well diverticulitis as colon carcinoma. A previous study to distinguish diverticulitis from carcinoma demonstrated that mesenteric inflammation (fluid at the root of the mesentery and vascular engorgement) had a positive predictive value for diverticulitis. Furthermore, the presence of pericolic lymph nodes may suggest a diagnosis of colon cancer rather than diverticulitis. In the current report, we retrospectively were not able to detect any of these specific CT signs.Because the occurrence of a carcinoma within a diverticulum is an uncommon phenomenon, this diagnosis can be easily missed. Nowadays CT scan is the technique of choice for assessment of diverticulitis and colon cancer. However, difficulties in distinguishing between these two diseases are well recognized.Although colonoscopy is the standard diagnostic method to detect colon carcinoma, it is not the option of choice in acute diverticulitis. In our patient colonoscopy was performed up to 25 cm from the anus without detecting any signs of carcinoma. And, as the 16 cm long resection included the proximal rectum, we can assume that the colonoscope passed the affected area. Since the surrounding flat mucosa was not involved in the cancerous process this carcinoma was not visible during colonoscopy. Fortunately, we performed a resection with oncological margin due to severe inflammation.This report demonstrates that a malignancy in a diverticulum can easily be missed during diagnostic work-up for diverticulitis. And, since specific markers to distinguish between diverticulitis and malignant disease are lacking, it remains important to consider the possibility of a cancerous process masquerading as diverticular bowel thickening or phlegmon, especially when surgical intervention is not warranted.


The gastrointestinal tract is the most common extranodal site involved with lymphoma accounting for 5–20% of all cases. Lymphoma can occur at any site of the body, but diffuse and extensive involvement of the peritoneal cavity is unusual and rare. We report a case of diffuse large B-cell lymphoma in a 57-year-old female infiltrating the peritoneum and omentum and presenting with ascites and pleural effusion. The performed examinations did not discover any pathological findings affecting the digestive tract or parenchymal organs, except for diffuse thickening of the peritoneum and omentum. Peripheral, mediastinal, or retroperitoneal lymphadenopathy was not registered. The blood count revealed only elevated leukocytes and on examination there were no immature blood cells in the peripheral blood. The cytology from the ascites and pleural effusion did not detect any malignant cells. Due to the rapid disease progression the patient died after twenty-two days of admission. The diagnosis was discovered postmortem with the histological examination and immunohistochemical study of the material taken during the surgical laparoscopy performed four days before the lethal outcome. Although cytology is diagnostic in most cases, laparoscopy with peritoneal biopsy is the only procedure which can establish the definitive diagnosis of peritoneal lymphomatosis. Extranodal lymphoma occurs in about 40% of all patients with lymphoma and has been described in virtually every organ and tissue . ExtranoDLBCL is the most common histological NHL subtype in adults accounting for approximately 25% of all NHL cases , 13. An Although lymphoma can occur at any site of the body, diffuse and extensive involvement of the peritoneal cavity is rare. Multiple intra-abdominal organ infiltration or disseminated peritoneal lymphoma, called peritoneal “lymphomatosis” (PL), receives much less attention in the literature than peritoneal carcinomatosis, probably due to its relative infrequency , 25. The12/L, white blood cells count 9.8 × 109/L, and platelet count 197 × 109/L). During the stay the leukocyte count raised up to 16.7 × 109/L with granulocytic predominance. The peripheral blood smear showed no immature cells . The routine laboratory tests showed no specific abnormalities, except for the remarkable LDH values of 3194 U/L  and uric acid of 1068 μmol/L . The total plasma protein level was 58 g/L, albumin level 35 g/L, globulin level 23 g/L, and CRP level 37 mg/L. Renal and liver functional tests, bilirubin, and electrolytes were normal. The serological screening for B and C hepatitis (HBsAg and anti-HCV) was negative. The abdominal ultrasound showed large amount of ascites without findings of liver cirrhosis or portal hypertension  and specific (97%) nonculture method of detecting tuberculous peritonitis especially when using cut-off values from 36 to 40 IU/L . ConsideThere are only few cases in the literature where the lymphomatous involvement of the peritoneum and omentum is the only localization of lymphoma. Mostly, the peritoneal lymphomatous affection is secondary to continuous spread from some other part of the gastrointestinal tract , 37, 38 In our case, gastroscopy with biopsy excluded primary lymphoma affecting the proximal GI tract. In order to evaluate the large bowel, colonoscopy was also planned, but this was prevented by the patient's general condition and the tendency for further deterioration. It should be emphasized that in all of the reported cases of intestinal lymphoma with diffuse peritoneal infiltration and massive ascites, the CT scans suggested some form of bowel affection , 38, 40.Primary effusion lymphoma (PEL), formerly known as “body cavity-based lymphoma,” is a rare NHL type limited to body cavities without detectable tumor formation. According to the WHO classification of hematopoietic malignancies , PEL is Peritoneal lymphomatosis is considered a rare manifestation of aggressive histological types of high-grade lymphomas, characterized by systemic involvement and rapid clinical deterioration often rapidly leading to death. Therefore, it is extremely important to provide correct and early diagnosis in order to provide treatment and prolong survival.In lymphoma cases surgical intervention can contribute to disease progression and additional clinical deterioration. Image-guided needle biopsy or laparoscopic peritoneal and omental biopsy appears to be the gold standard method for diagnosing PL. Therefore, they should be used in order to make the diagnosis preoperatively and every effort should be made to avoid unnecessary laparotomy or massive surgery whenever possible.Gastrointestinal lymphoma and PL have a variable and nonspecific presentation and can resemble other neoplastic or inflammatory conditions. Clinical presentation, imaging spectrum, or laboratory data alone can be inconclusive and misinterpretations of the findings could initially presume incorrect diagnosis, extend the diagnostic process, and delay the diagnosis which reduces the possibility for optimal treatment. Therefore, only focused clinical awareness, high level of suspicion, and complementary approach can lead towards accurate diagnosis.