Acute abdomen during pregnancy is rare. Despite advances in diagnostic imaging, preoperative diagnosis in the pregnant population due to anatomical and physiological changes can pose difficulties. Diagnosis and surgery delays increase the risk of adverse outcomes for both maternal and fetal health. In symptomatic cases, explorative surgery might be essential for correct diagnosis and patient treatment. Here, we present Meckel’s diverticulum as an unusual cause of small bowel obstruction complicated with gangrene in a 34-week pregnant patient. The diagnosis was only apparent during explorative surgical laparotomy. Acute abdomen during pregnancy is rare and diagnosed in approximately 1 in 500 pregnant women . ComplicAcute abdomen diagnosis in the pregnant population can pose diagnostic challenges due to changes in anatomy and physiology during pregnancy, such as nausea, vomiting, physiological anemia, and leukocytosis . HoweverWhile asymptomatic Meckel’s diverticulum may be left untreated, all uncertain cases or inconclusive radiological assessments should prompt surgical exploration and treatment . An inteIn this case report, we present Meckel’s diverticulum as a cause of small bowel obstruction and gangrene in the third trimester of pregnancy. The case was managed by performing laparotomy, which included necrotic bowel resection, an end-to-end ileoanastomosis, and an emergency Cesarean section at 34 weeks of gestation.A 36-year-old primigravida woman who was 34 weeks pregnant was admitted to the Emergency Department due to severe  abdominal pain and vomiting. The abdomen was tight on palpation during the general and special examination, painful throughout, and without signs of peritonitis. One of the symptoms the patient had was trapped gas and no defecation for 24 h.The cause of the pain was unclear. The vital signs were without any concern—the pulse was 80 beats per minute, the blood pressure was 112/76 mmHg, and no fever was detected. Complete blood count and comprehensive metabolic panel laboratory tests showed no anemia or significant changes in inflammatory and biochemical parameters. The c-reactive protein was only 0.87 mg/L (0–5), and the lactate was 2.1 mmol/L (0.5–2.2). The only symptom that has led to suspicion of ileus was trapped gas and no defecation for 24 h. The gravid uterus made it difficult to perform a detailed abdominal ultrasound. An interdisciplinary team decided to do an abdominal and pelvic CT scan in order to clarify the possible etiology of acute abdominal pain. In this case, the CT scan was the first-choice diagnostic tool due to the ability to perform it urgently and obtain the results as quickly as possible. The clinical condition and pain level of the pregnant patient were evaluated as critical, so the diagnosis needed to be made immediately. The multidisciplinary team had to make a difficult decision in this particular situation whether to perform a CT scan immediately or wait for the MRI scan, but the choice was made according to the deteriorating condition of the patient.The abdominal CT revealed an obstruction in the small intestine due to a probable small bowel (ileo-pelvic) reversal. Two main symptoms, a dilated diameter of the small intestine  and air–Based on the patient’s complaints, clinical features, diagnostic tests, and preliminary diagnosis, the interdisciplinary team decided that urgent surgery for the patient’s treatment was necessary. It was decided to perform a laparotomy first to treat the ileus. In case of intestinal necrosis, a treatment plan was put in place to resect the necrotic bowels, form an end-to-end ileoanastomosis and, only if necessary, perform an emergency Cesarean section. The patient consented to the intended treatment plan.The surgery was performed by an experienced surgeon team—an abdominal surgeon and obstetrician-gynecologist. The surgery was started by the professor of abdominal surgery. A midline laparotomy incision under general anesthesia was performed. The laparotomy incision revealed 500 mL of hemorrhagic fluid and Meckel’s diverticulum on the left side of the abdomen, which was inflamed and “adherent” to the gravid 34-week-sized uterus. A 50 cm necrotic ileum was trapped in the “window”, which was determined by adhesions between the uterus fundus and bowels, especially Meckel’s diverticulum. Therefore, the main reason for the dynamic ileus was thought to be the adherent Meckel’s diverticulum to the uterus, which created a “window” for the obstruction of the ileum .During surgery, the diverticulum was transected, and the bowel was released. The necrotic bowel was resected. As the blood supply to the distal ileum had not fully recovered and the gravid uterus made it technically impossible to inspect the remaining ileum and cecum, the decision to perform an emergency Cesarean section was made.After an emergency Cesarean section, which was performed by an experienced senior obstetrician-gynecologist, the size of the uterus decreased, and the remaining small bowel was inspected. Its blood flow was restored, and an end-to-end ileoanastomosis was performed by the abdominal surgeon.The newborn was delivered 51 min after the beginning of the surgery, and the Apgar scores were 3, 6, and 7 after 1, 5, and 10 min, respectively. The pH value of the umbilical artery was 7.22. During the neonatal examination hypotonus, areflexion and apnea were found. Therefore, the initial steps of newborn resuscitation were performed, and mechanical lung ventilation was started. However, it was not effective; therefore, the newborn was intubated. The newborn was immediately transported to the Neonatal Intensive Care Unit (NICU), where continuous positive airway pressure therapy (CPAP) was continued for 4 days.The mother was treated and monitored in the Intensive Care Unit (ICU) for 2 days. Two days after the surgery, the patient had an episode of dynamic ileus, which occurred as vomiting and gastrostasis. The nasogastric probe was inserted, and 150 mL of greenish fluid was evacuated. The intravenous crystalloid infusions and parenteral nutrition were applied for four days after the surgery until the bowel function was restored and the patient started defecating. No hematochezia was noticed before the surgery or after. The mother and the newborn were discharged from the hospital after 9 days.Afterward, histological examination revealed necrotic Meckel’s diverticulum of the small (ileum) bowel, as well as local peritonitis and segmental hemorrhagic infarction.Meckel’s diverticulum is present in 2% to 4% of the population, accounting for one of the most commonly diagnosed congenital malformations of the gastrointestinal tract. Its frequency is similar in both sexes, but the incidence of complications is more significant in males. Meckel’s diverticulum forms when the obliteration of the vitelline duct is incomplete. This leads to the formation of a true diverticulum of the small bowel . Meckel’Most patients with Meckel’s diverticulum remain asymptomatic, particularly adults . In the During pregnancy, physiological leukocytosis can mimic an acute intra-abdominal inflammatory process. According to the literature, the white blood cell counts usually revert to the pre-pregnancy levels by the sixth postpartum day. The physiological anemia during pregnancy is also observed due to increased plasma volume in proportion to the red cell volume. Physiological anemia, together with a physiological increase in heart rate, can pose difficulties in case of hemorrhage ,12. In tDiagnostic imaging tools for Meckel’s diverticulum and its associated complications include abdominal ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), abdominal X-ray, and endoscopy . In our Regarding the imaging diagnostic tools, the correct diagnosis of Meckel’s diverticulum is made during laparoscopy or laparotomy . In our Symptomatic Meckel’s diverticulum treatment is always a surgical resection. A pregnant patient should be managed the same as the general population. However, attention must also be paid to the well-being of the fetus. Laparoscopic treatment is considered the first choice of treatment because of its safety and effectiveness. The advantages of minimally invasive surgery include better intraoperative visualization, less pain after surgery, faster recovery, and shorter duration of hospitalization . HoweverIn our case, the laparotomy approach was chosen due to the large size of the uterus in the late third trimester, almost reaching the costal margin. Despite the considerable gestational age, a Cesarean section was delayed and performed only after it was clear that the gravid uterus interfered with the removal of the twisted and gangrenous part of the intestine. According to the literature, during emergency situations, fetus delivery decisions and modes should be decided based on obstetric indications. However, delivery is indicated in every case if the continuation of the pregnancy is expected to lead to maternal morbidity or mortality. The patient should be treated with the fetus in utero if improvement of the maternal condition cannot be expected with delivery . In a prIn order to compare our case with others, we performed a selection of clinical cases in Pubmed advanced search using keywords “Meckel” and “pregnant” or “pregnancy”. A total of 10 clinical cases were included for comparison. The main characteristics of the case descriptions are presented in All cases were diagnosed in the second or third trimester of pregnancy; there were none in the first. The most frequently used instrumental diagnostic tool was ultrasound. MRI was chosen as a primary diagnostic tool in only one case. A CT scan as a primary diagnostic tool was chosen in one case and two cases to clarify the diagnosis after a non-informative ultrasound examination. In our case, a CT scan was also chosen after an ultrasound examination, which was not informative enough. However, we can see a trend toward a CT scan being performed less frequently due to potential radiation-related harm to the fetus. Of all these cases, Meckel’s diverticulum diagnosis was suspected preoperatively only in one case. In our case, the diagnosis was also established only during surgery. Preoperative diagnoses included a variety of reasons causing acute abdomen, including gastroenteritis, appendicitis, intestinal obstruction, intussusception, perforated ulcer, inflammatory bowel disease, and diverticulitis. In our clinical case, bowel obstruction was suspected first. In most cases, including ours, the chosen management was exploratory surgery—laparoscopy or laparotomy. Conservative treatment tactics were chosen in only three cases. One case had diagnosed Meckel’s diverticulitis; in two cases, the final diagnosis was a perforated Meckel’s diverticulum. In the presence of symptomatic Meckel’s diverticulum, even in the pregnant population, the preferred case management is surgical treatment .During pregnancy, the best possible outcome must be sought not only for the mother, but also for the fetus, and every intervention must be considered and performed only when necessary and as safely as possible. Non-obstetric surgery is associated with adverse fetal outcomes such as a higher risk of prematurity, low birth weight, low Apgar scores (<7), neonatal and infant death, longer admission in the hospital, and higher medical expenses. Surgical treatment is associated with a significantly higher rate of prematurity but lower stillbirth rates in the third trimester of pregnancy than in the first one . In thisMeckel’s diverticulum and its associated complications are rare causes of acute abdomen during pregnancy. In order to achieve the best outcome for both the mother and the fetus, it is crucial to manage acute abdomen cases during pregnancy with an interdisciplinary team. Despite the pregnancy, faster imaging methods and larger-scale surgery can be chosen for diagnosis and treatment. In this case, CT and laparotomy were chosen despite the higher risks for the fetus. Timely and correctly chosen diagnostic and treatment tactics led to a successful outcome for both the mother and the fetus, regardless of prematurity.


Neoplasms of the urachus are an extremely rare entity consisting of incompletely obliterated tissue of the urachal canal during embryonic development, which sometimes remains into adulthood in the urinary bladder. The treatment of choice for these entities is surgical excision, which maximizes patient survival should the lesion prove to be malignant. In this case, we describe a 57-year-old female who presented with a one-year history of left lower quadrant pain. The patient underwent robot-assisted surgery to remove the mass, bladder dome, and median longitudinal ligament en bloc without evidence of recurrence to date. Urachal neoplasms are exceedingly rare tumors of urachal remnants within the anterior abdominal wall. Typically, these occur along the length of the median umbilical ligament, which exists as the obliterated fibromuscular canal that bridges the allantois and urinary bladder during embryonic development . UrachalThese tend to fall within two morphologic categories: non-cystic and invasive versus predominantly cystic and low-grade . Most urDiagnostic workup typically involves cystoscopy to demonstrate mass and identify gross invasion of the bladder, which should be followed by radiographic imaging (ultrasound (US) plus computed tomography (CT) or magnetic resonance imaging (MRI)) for mass evaluation, staging, and search for metastasis -7. CalciA 57-year-old female with a family history of ovarian, colon, and breast cancer as well as melanoma who was status post open hysterectomy for benign uterine fibroids presented to the clinic for evaluation of a one-year history of left lower quadrant pain. Initial evaluation included a pelvic ultrasound that demonstrated a 3.8 x 3.1 x 3.9 centimeter (cm) cystic lesion in the central pelvis without vascularity on Doppler imaging  and specificity (21%) for urachal carcinoma 3% and sp,17. AlthCurrently, there are no consensus guidelines for the staging of urachal neoplasms. Urachal carcinomas historically were staged using the Sheldon Staging System, though more recently the novel Mayo Clinic Staging System has gained popularity and is being utilized as a staging system . UrachalPatients with suspected urachal carcinoma require wide surgical excision of the lesion and the remainder of the median umbilical ligament, partial or radical cystectomy, and sometimes bilateral pelvic lymphadenectomy . PartialThis case report demonstrates an extremely rare pathology that has only been described within other case reports. Urachal masses require careful evaluation because the ability to distinguish urachal adenocarcinomas from those of primary bladder origin greatly impacts care, surgical approaches for treatment, and quality of life. Our case emphasizes the importance of proper radiologic and surgical management to mitigate any progression of a potential malignancy.


Hemobilia is an uncommon diagnosis and is often not suspected in the absence of recent hepatobiliary intervention or trauma. Hemobilia in the setting of cystic artery pseudoaneurysm secondary to type I Mirizzi syndrome is a rare occurrence. We report the case of a 61-year-old male who presented with epigastric pain and vomiting. Blood tests demonstrated hyperbilirubinemia with elevated inflammatory markers. Magnetic resonance cholangiopancreatography revealed type I Mirizzi syndrome in the presence of a 21 mm cystic duct stone. During endoscopic retrograde cholangiopancreatography, hemobilia was identified. Subsequent triple phase computed tomography imaging identified a 12 mm cystic artery pseudoaneurysm. Angiography with successful coiling of the cystic artery was accomplished. Cholecystectomy was performed, confirming type I Mirizzi syndrome. This case demonstrates the importance of considering ruptured pseudoaneurysm in patients presenting with evidence of upper gastrointestinal bleeding in the setting of biliary stone disease. Transarterial embolization, followed by surgical management, is effective in both the diagnosis and management of ruptured cystic artery pseudoaneurysm with associated hemobilia. Hemobilia is an uncommon diagnosis defined by the extravasation of blood within the hepatobiliary tree . The expMirizzi syndrome involves the compression of the bile duct secondary to an impacted stone at the gallbladder neck or cystic duct . This coHere we present the case of a 61-year-old male with hemobilia in the setting of a cystic artery pseudoaneurysm that developed secondary to type I Mirizzi syndrome. This is a rare finding, however, should be considered when there is evidence of hemobilia or upper gastrointestinal bleeding in the presence of biliary stones.2) male presented to the emergency department with acute onset epigastric pain and vomiting. His medical history included a previous episode of cholecystitis one year prior, treated with antibiotic therapy with the patient declining a cholecystectomy at this time. There was no evidence of pseudoaneurysm on intravenous iodinated Contrast Enhanced Computed Tomography performed during this presentation. He did not have any other medical comorbidities, nor any previous surgical history.A 61-year-old, obese  demonstrated a thick-walled gallbladder with numerous cholelithiasis. A 21 mm stone was observed in the cystic duct, with associated oedema  was advanced to the bulb of the duodenum and a significant volume of clotted blood was encountered. The duodenoscope was exchanged to a forward viewing endoscope  to facilitate diagnostic assessment. There was a significant volume of clotted blood throughout the duodenum Fig. a which w.The papilla was cannulated with a wire  and sphincterotome  was advanced. Contrast was injected and demonstrated a narrow common bile duct, with dilated intrahepatic ducts with extrinsic compression of the common hepatic duct, consistent with Mirizzi Syndrome type I  was initially inserted to achieve hemostasis, however, was unable to be advanced proximal to the obstruction due to the severity of the extrinsic compression Fig. b. It wasAn urgent triple-phase liver computed tomography was arranged. This demonstrated a 12 mm focus of arterial hyperenhancement within the region of the medial gallbladder in close proximity to the cystic artery Fig. a. Gross Cholecystectomy was arranged 48 h following embolization. The procedure was converted to open cholecystectomy to enable removal of multiple impacted gallstones within the gallbladder. A further stone impacted at the cystic duct and common bile duct junction was removed. Histopathological assessment of the gallbladder confirmed acute on chronic cholecystitis with no evidence of dysplasia or malignancy.Following surgery, the patient continued to have improvement in their bilirubin and inflammatory markers. A repeat ERCP was performed which demonstrated an improved but persistent biliary stenosis in the main duct Fig. . This waWe report a rare case of type I Mirizzi syndrome leading to the formation of a cystic artery pseudoaneurysm with associated hemobilia. Pseudoaneurysm formation occurs secondary to injury to the blood vessel wall with subsequent extravasation and containment in surrounding tissue. This may occur following trauma, medical intervention, infection, malignancy, or inflammation that damages the vessel wall .Pseudoaneurysm is an uncommon cause for hemobilia, which is most commonly the result of prior hepatobiliary intervention, trauma or malignancy . Within Mirizzi syndrome is present in up to 5.7% of cholecystectomy cases , with tyOur patient was diagnosed with a gallstone impacted within the cystic duct on MRCP with associated hepatic duct obstruction and no cholecystobiliary fistula. Prior to ERCP, there was no clinical symptoms or signs of upper gastrointestinal bleeding or change in hemoglobin. Direct mechanical injury, in addition to inflammation from the impacted stone and the associated cholecystitis, likely resulted in disruption to the cystic artery wall with extravasation into the hepatobiliary tract. While the source of hemobilia can originate at different locations within the biliary tree, it is felt that the cystic artery pseudoaneurysm was the source of hemobilia within this patient. This is suggested from the persistent hemobilia despite placement of the covered metal stent and cessation following angiography and coiling of the pseudoaneurysm.Prior to operative management of Mirizzi syndrome and cholecystitis, transarterial embolization (TAE) is useful for the definitive diagnosis and treatment of pseudoaneurysm , 7, 12. At repeat ERCP, the cholangiogram demonstrated persistent narrowing of the bile duct following removal of the covered metal stent. This did not require intervention and the patient had improvement in liver enzyme tests. This stricture of the bile duct may have been associated with the embolization procedure performed for management of the pseudoaneurysm.This case describes a ruptured cystic artery pseudoaneurysm associated with type I Mirizzi syndrome and hemobilia evident at ERCP. Successful endovascular coiling of the cystic artery pseudoaneurysm followed by operative management enabled effective treatment in the absence of acute postoperative complications. While rare, ruptured pseudoaneurysm is important to consider in the presence of symptoms and signs of upper gastrointestinal bleeding and gallstone disease.


Dear Editor,To date, several cases of multiple lentigines in resolved psoriasis lesions have been reported. Herein, we describe a rare case of psoriasis that resolved leaving multiple small lentiginous patches in the lesions after successful treatment with a Tumor Necrosis Factor (TNF) inhibitor. Moreover, a recurrence of psoriasis was observed in the pigmentary patches.A 55-year-old male was diagnosed with psoriasis vulgaris 6 years previously and had been treated with topical corticosteroid ointment. Joint pain appeared on the bilateral fingers, wrists, and ankles 3 years previously, and he received systemic therapy with adalimumab . Both cutaneous and joint manifestations responded well to adalimumab. Psoriasis Activity and Severity Index (PASI) score was reduced from 6.0 to 0 (PASI clear), and also, he was relieved from joint pain. After the complete disappearance of psoriasis, pigmentation emerged. However, during maintenance therapy with adalimumab, cutaneous psoriasis relapsed 7 months later, but without recurrence of joint pain. Physical examination showed multiple brownish plaques on the lower extremities. A few psoriatic plaques were observed in some, but not all, of the resolved lesions A‒C. In o+ tissue Resident Memory T-cells (TRM) enriched in the resolved lesion preferentially produced IL-17 and IL-22 upon restimulation.RM on the non-lesional skin, improved skin with pigmentation, recurred psoriasis lesion in the resolved area, and recurred psoriasis lesion in the previously non-lesional area, because the patient refused biopsy. Further studies are necessary to elucidate the mechanism of lentiginous pigmentation after the improvement of psoriasis and the role of TRM in such conditions.There are several cases of psoriatic plaques that were treated with biologics such as TNF inhibitors, Interleukin-17 (IL-17) inhibitors, IL-12/23 inhibitors, T-cell inhibitors, and phosphodiesterase 4 inhibitors, and left lentiginous lesions in the resolved area.None declared.Toshiyuki Yamamoto: Study conception and planning; data collection, analysis and interpretation; management of studied cases; preparation and writing of the manuscript; approval of the final version of the manuscript.None declared.


Seromucinous hamartoma is a rare benign glandular proliferation arising from the respiratory epithelium of the sinonasal tract and nasopharynx. It was described for the first time in 1974 by Baillie and Batsakis. Since then, few cases have been reported in the literature with most of them occurring in the posterior nasal septum. We report the case of a 52-year-old woman that presented to our department with left periorbital edema, pain, and dacryorrhea due to seromucinous hamartoma arising from the left inferior turbinate and extending through the lateral nasal wall into the maxilla, the nasolacrimal duct, and the orbit. Endoscopic medial maxillectomy and endoscopic transnasal orbital tumor resection were performed. The patient remains symptom-free for 16 months, till her most recent follow-up. Seromucinous hamartoma of the nasal cavity is an exceedingly rare diagnosis, especially in the lateral nasal wall. It should be included in the differential diagnosis of nasal tumors. According to the literature review, this is the first case report of seromucinous hamartoma with orbit infiltration. Endonasal endoscopic resection is the treatment of choice. Hamartomas of the sinonasal region can have an epithelial, mesenchymal, or mixed origin, and they include nasal chondromesenchymal hamartoma, respiratory epithelial adenomatoid hamartoma (REAH), seromucinous hamartoma (SH), and mixed chondroosseous respiratory epithelial hamartoma –3. AlthoA 52-year-old woman presented to our clinic with a two-month history of dacryorrhea, mild nasal obstruction, periorbital pain, and slowly progressive periorbital edema. There was no history of epistaxis and no signs of ophthalmoplegia. Also, there was no history of fever nor mucopurulent discharge. The nasal endoscopy that was performed showed the presence of hyperplastic tissue arising from the inferior turbinate and the lateral nasal wall . The CT Endoscopic medial maxillextomy with transnasal resection of the orbital lesion, which was in vicinity but did not invade the medial and inferior rectus, was performed. At the anterior border of resection, a cut was made from the anterior attachment of the middle turbinate to the lateral nasal wall downward to include the maxillary crest containing the nasolacrimal canal and duct. A mucosal flap was elevated with a Freer elevator, and an anterior osteotomy was made anteriorly to the nasolacrimal canal. Following osteotomy, the nasolacrimal duct, as it descends from the lacrimal sac, was sharply dissected with endoscopic scissors and included in the specimen. The lateral nasal wall was mobilized medially with progressive dissection allowing entry into the maxillary sinus. At this point, the infraorbital nerve canal was recognized and preserved. Posterior cuts were made posteriorly to the maxillary ostium at its junction with the orbit. The sphenopalatine artery was cauterized. The posterior attachment of the remaining part of the inferior turbinate was cut, and the specimen including the lateral wall with the tumor was removed. In the following surgical steps, the lamina papyracea and the adjacent periorbita were removed. The pathological tissue inside the orbit was removed, preserving the medial and inferior rectus muscles. The result of the biopsy from all the specimens was seromucinous hamartoma with no signs of malignancy. There were no postoperative complications, and the patient was discharged after 3 days with no signs of edema or pain. Sixteen months after the surgery during her regular follow up the patient is symptom-free with no signs of recurrence .The sinonasal tract encompasses a wide range of reactive and neoplastic lesions, and their differential diagnosis can be challenging, especially in small biopsy samples . Differeth decade of life. Although factors such as neoplastic proliferation, chronic mechanical irritation, inflammation, and embryological tissue misplacement are considered as possible mechanisms of its development, the exact pathogenesis remains still unclear [SH is considered a rare lesion of the sinonasal tract . To date unclear . In 80%  unclear , 13. It  unclear . In our  unclear , mucopur unclear . In our Pathological findings of SH, include an epithelial proliferation of small glands, serous acini, and tubules that can grow in clusters, lobules, or haphazardly. Larger glands or cysts covered by ciliated respiratory epithelium are frequently admixed with these small glands. The surrounding stroma is usually fibrous and often contains a lymphoplasmacytic inflammatory infiltrate lacking eosinophils. Periglandular hyalinisation and the absence of the myoepithelial layer have also been reported in some cases , 8–10. TThe differential diagnosis includes REAH, low-grade sinonasal adenocarcinoma (LGSNA), juvenile nasopharyngeal angiofibroma (JNA), olfactory neuroblastoma (ON), and inflammatory nasal polyps , 10, 16.Differential diagnosis from low-grade sinonasal adenocarcinoma (LGSNA) is important because it can impact therapeutical choice in terms of surgery extent and adjuvant radiotherapy. LGSNA exhibits an infiltrative exophytic pattern which usually grows in a papillary or cribriform shape that can invade nearby normal structures. Microscopically, it is characterized by the configuration of back-to-back glands with pleomorphisms, mitoses, anisocytosis, and cell hyperchromasia, without a rich stroma , 12. SH The treatment of choice for this rare neoplasm is transnasal endoscopic resection, and with complete excision, recurrence is extremely rare .Seromucinous hamartoma is a rare benign lesion of the sinonasal tract that should be included in the differential diagnosis of polypoid nasal lesions. Location in the lateral nasal wall is rare, to our knowledge, after a literature review, this is the first case with orbital involvement. Excision via transnasal endoscopic surgery is the treatment of choice today, and it can be combined with a transnasal approach of the orbit. Otorhinolaryngologists should be aware of this pathologic entity when dealing with nasal neoplasms.


Malignant tumors of the foot are rare pathologies that can involve the skin, soft tissue, or bone. Due to their rarity, they are often misdiagnosed, resulting in inadequate excision and poor outcomes. A correct approach with a careful examination and radiological study, followed by a properly performed biopsy, is thus mandatory to avoid these pitfalls. The present article reviews the most common malignant bone and soft tissue lesions of the foot region, discussing their clinicopathological presentation, imaging features, and current concepts in treatment. Malignant foot and ankle tumors are rare lesions, contributing to approximately 3% of all cases of bone tumors and 5% of malignant soft-tissue tumors ,7,8,9. TIn this paper, the most common malignant bone and soft-tissue tumors of the foot are presented, discussing their epidemiology and presentation, their clinical and instrumental diagnosis, and principles of treatment in order to enhance the knowledge of these pathologies and favor the correct diagnostic and therapeutic strategy.The first approach includes a careful history, to obtain information about a patient’s age, how the lesion developed and was noted, the rate of growth in terms of aggressiveness, and other symptoms such as pain, numbness, fever, or weight loss. Pain characteristics, i.e., type, severity, and worsening during activity or during rest, need to be investigated. Any history of exposure to sun, radiation, chemicals, or pollutants should be recorded. Concomitant or previous diseases, particularly malignancies, should be investigated. Any data about prior biopsies or surgery should be examined .A careful physical examination is mandatory. Inspection should exclude any skin lesions, discolorations, or visible lumps. On palpation, any mass should be characterized in terms of location, size, shape, consistency, mobility, and tenderness. Any palpable lymph nodes should be recorded. A thorough neurovascular examination should be included.Laboratory tests can be helpful in guiding the diagnostic algorithm: in some tumor histotypes, an increase in the erythrocyte sedimentation rate can be observed (Ewing’s sarcoma or hematologic neoplasms), while others specifically modify alkaline phosphatase (osteosarcoma).Whereas there are no doubts that radiographs and ultrasound represent the first imaging approach for bone and soft tissue lesions, respectively, there is no international uniform method of staging. X-rays represent an essential first step. In bone tumors, they show the location of the lesion , its aspect , the pattern of bone destruction, i.e., geographical vs moth-eaten appearance, and the presence of any calcifications, cortical thinning or destruction, or periosteal reaction. The risk for pathological fractures can also be estimated from X-rays . In softIn cases in which malignancy is highly suspected, or after a histologic confirmation of a malignant tumor, a chest CT scan and a bone scan should be performed to assess any metastatic spread. Other exams such as whole-body PET-CT and abdominal/pelvic CT scans should be considered in specific settings and histotypes ,15.Biopsy is an important step of staging, but not necessarily the last. Performing a biopsy before completing the staging avoids unnecessary second-level systemic imaging tests in benign tumors (which are 200 times more frequent). Staging prior to receiving histopathological findings is indicated if there is almost no doubt of malignancy and there is no time to waste to start neoadjuvant therapy . An adequate biopsy provides representative and viable tissue to make a correct diagnosis. The type of biopsy performed depends on the clinical situation , the surgeon’s skills, and the pathologist’s interpretive experience. A core needle biopsy is the gold standard for sampling that maintains tissue architecture, with a low rate of contamination and a minimally invasive approach ,17. It cOsteosarcoma is rarely observed in the foot  and is well described in small series or reports, with an incidence ranging from 0.5 to 1.3% of all osteosarcomas . In the In the family of osteosarcomas, some subcategories may present osteolytic behavior , predisposing pathological fracture as an onset symptom. In osteoblastic variants, the osteoid deposition may calcify, causing the typical intralesional hyperdensity changes and periosteal reaction with Codman’s triangle on imaging. MRI allows for the easy identification of bony and intramedullary extension and the invasion of surrounding soft tissue .Neoadjuvant chemotherapy regimens and surgery for systemic and local control, respectively, are the standard management for osteosarcoma. Four drugs are classically used in each cycle of chemotherapy , dividing the treatment into administrations before and after surgery. Surgery involves the removal of the primary tumor and the subsequent reconstruction procedure if limb salvage is possible. Enneking et al. clearly classified resection margins as intralesional, marginal, wide, and radical , but somChondrosarcomas (CHS) are the second most common primary bone tumors, characterized by the ability of tumor cells to produce a cartilage matrix. More than 90% of cases are conventional CHS . VariantWhereas the pelvic bones, humerus, femur, and chest wall are the most common sites involved, the small bones of the feet are rarely affected . The involvement of toes is extremely rare . These tUnlike other chondrosarcomas, which tend to be confined in the metadiaphysis, in the feet, these lesions involve the majority of the length of the bone. Characteristic features include endosteal scalloping greater than two-thirds of the cortex or soft tissue involvement. MRI shows intermediate to high signal intensity on T1-weighted imaging and hyperintensity on fluid-sensitive sequences. In the small tubular bones of the hands and feet, the histologic threshold for the diagnosis of CHS is much higher than that for lesions elsewhere in the body . CHS areWith regard to grade 1 chondrosarcomas, the current literature has drastically changed the approach compared to the past. This tumor type is also referred to as an atypical chondromatous tumor (ACT) to avoid rigorous overtreatment. Although the histological appearance is similar to benign cartilage lesions, a multidisciplinary evaluation and the interpretation of clinical, imaging, and histological features are required to combine radiographic interpretation and clinical evaluation with histological findings to obtain an accurate preoperative diagnosis of grade 1 central chondrosarcoma.The histological grade represents an independent prognostic factor for the survival of patients with CHS. However, the differentiation between enchondroma and ACT is the focus of extensive discussion in the literature . SurgeryEwing sarcoma (ES) is usually observed in males (O.R. of 1.5) in the first two decades of life. ES is the third most frequent primary bone tumor affecting long bones , the pelvis, the chest wall, and the spine, even if it can rarely originate from soft tissue. The small bones of the foot are rarely involved, ranging from 3% to 5% of the reported cases . PatientOn macroscopic evaluation, the tumor appears as a multilobulated mass with extensive necrotic and hemorrhagic areas, while on microscopic evaluation, the typical carpet of small, round monomorphic cells with vesicular nuclei with finely dispersed chromatin is present and scant cytoplasm. Staging and response to chemotherapy are the most important prognostic factors for ES . SynchroThe ES treatment strategy includes a multidrug chemotherapy approach and local control, which can be performed with surgery, radiotherapy, or both. Despite the anatomical difficulties, local control is of primary importance, considering the reduced survival rates in case of metastatic spread or local recurrence of the disease .Metastases affecting the bones distally to the bone or elbow are called “acrometastases” and are rare, with an incidence of 7% and a median age of presentation of about 60 years old . Moving Although it is not yet clearly understood, hematogenous dissemination through the microcirculation of the extremities seems to be the most accredited hypothesis. In fact, it would explain the higher prevalence of lung tumors because tumor cells have immediate access to the systemic circulation through the left atrium and ventricle. Symptoms include tenderness, pain, functional impairment, erythema, heat, and swelling . Often, Radical surgery is the treatment of choice for acrometastases depending on prognosis and the risk of tumor ulceration, and amputation is the preferred option in more distal lesions. In all patients affected by bone metastases from carcinoma, systemic chemotherapy represents the only valid weapon for prognostic purposes, but surgery and radiotherapy can be useful in maintaining a good quality of life and limb function . The proSoft-tissue sarcomas (STSs) of the distal extremities account for less than 5% of sarcomas. Synovial sarcoma, epithelioid sarcoma, and clear-cell sarcoma are the most frequently reported malignancies in the foot and hand ,53,54. MBecause of its rarity, the management of STS in the hand and foot is not well established, with a 5-year survival rate ranging from 67% to 80% . The so-Melanoma represents 4% of skin cancers but is extremely lethal, causing 80% of total skin cancer deaths. Approximately 15% of melanomas are located on the foot . Acral mAM is the most frequent subtype in populations with darker skin phototypes , in the Chronic or intermittent sun exposure associated with sunburn are the main factors implicated in the genesis of the disease. However, for lesions arising in unexposed areas such as the nail unit and soles of the feet, additional factors may contribute. The role of trauma has been much debated but remains unresolved. Pre-existing plantar lesions can be a risk factor, as suggested by the presence of higher percentages of nevi  in less sun-exposed sites. Some authors have analyzed exposure to agricultural and industrial chemicals as possible factors associated with tumor development .Melanoma typically presents as a darkly pigmented macule or nodule on the skin, with variegated, blue–black pigment and irregular borders . These lFactors linked to poor prognosis in subungual melanomas are similar to those seen in other sites: tumor stage at diagnosis, ulceration, Breslow depth, and a positive sentinel lymph node biopsy . ExcisioSurgery represents the standard of care. International guidelines recommend a wide excision with a safety margin of 2 cm in melanomas with Breslow thickness > 2 mm, while one cm is sufficient in thinner ones. Complete lymphadenectomy should be performed in the case of sentinel positive nodes, as it appears to offer improved survival outcomes. Systemic and local treatments other than surgery  can be used with contradictory results .Epithelioid sarcoma is an uncommon malignancy, representing less than 1% of STS . The claSurgery is the main treatment if the tumor can be adequately removed with wide, clear margins at first approach. Conventional adjuvant chemotherapy appears to have a limited effect on epithelioid sarcoma. Pazopanib, a multi-tyrosine-kinase inhibitor, has been recently approved in advanced STSs, but its efficacy in epithelioid sarcoma is still unknown .Synovial sarcoma is one of the most frequent malignant soft-tissue tumors, accounting for 10% of all soft-tissue sarcomas. It is the most common malignant soft-tissue sarcoma of the foot, accounting for 8% of all primary malignant soft-tissue tumors. Although both sexes are affected, males tend to be affected more often . It can MRI has the advantages of better contrast resolution and soft tissue specificity. The tumor appears heterogeneous and isointense with respect to the muscle on T1-weighted images, with greater signal intensity on T2  Figure .Synovial sarcomas may calcify in up to 30% of cases, thus mimicking a benign entity ,76. BiopClear-cell sarcoma is a malignant ectoblast tumor that originates from the latent melanin-producing cells that had wandered from the neural crest in the embryonic period . The tumRhabdomyosarcomas are a rare STS in adults, but relatively common among patients under 20 years of age . Three pathological subtypes may be identified: embryonal rhabdomyosarcoma, alveolar rhabdomyosarcoma, and pleomorphic rhabdomyosarcoma . About 1Multi-drug chemotherapy regimens significantly improved the survival rates in patients with localized rhabdomyosarcoma over the last decades. When function can be preserved, surgical resection should be considered for local control, but amputation is still used in selected cases. Adjuvant RT can be a very effective treatment modality without resulting in significant morbidity .Leiomyosarcoma affects mostly adults and males, with a peak between 40 and 60 years of age. The lower extremities are frequently affected (about 45%), but these STSs can occur almost anywhere because they may originate from cutaneous tissue, soft tissue, and major vessels ,91. The The 2013 World Health Organization (WHO) identified four main liposarcoma subtypes: myxoid liposarcoma, atypical lipomatous tumor/well-differentiated liposarcoma, dedifferentiated liposarcoma, and pleomorphic liposarcoma. Myxoid liposarcoma represents the most frequent subtype, approximately 5% of all STSs, and about one-third to one-half of all liposarcomas. It primarily affects adults (fifth decade), but is also the most common subtype in the growing ages . PatientThis is a narrative review with the aim of summarizing the literature on malignant tumors of the foot and describing its current state. The paper is a thorough and critical overview of previously published research on key clinical imaging features and the management of key histologic entities.This narrative review is based on a selective English and non-English language literature search carried out in PubMed and in the ISI Web of Knowledge database in 2023 using the principal search string ((“bone neoplasms”[MeSH Terms]) OR (“soft tissue neoplasms”[MeSH Terms])) AND (“foot”[MeSH Terms]). Overall, our search string identified 959 articles. Two authors (M.C. and V.L.) independently reviewed the abstracts, while a third author (A.A.) was consulted in case of discrepancies. Articles were divided into different groups according to histologic diagnosis and large case series were separately analyzed. Inclusion criteria were: original articles, English and non-English language, and systemic and narrative reviews. Exclusion criteria were editorials, letters, and case reports. One hundred and twenty-four articles were excluded after reviewing the abstracts, and a further forty-five were excluded following a full examination.Although the compact anatomy should facilitate the early detection of tumors of the foot and ankle, early diagnosis is often missed by a lack of awareness on this subject. Vigilance and prudence are key in investigating foot masses, including those with low aggressiveness characteristics. To keep the “diagnostic window” as short as possible, even the experienced orthopedic surgeon and foot specialist needs special training in musculoskeletal oncology and tumor orthopedics. Major oncologic mistakes can be avoided if clinicians take into account all possible differential diagnoses. If a suspicious lump or bump of the foot or ankle cannot be further distinguished by imaging diagnostics, histopathological analysis through image-guided biopsy must be pursued. In the interest of the patient and due to the complexity of this heterogeneous pathology, the expertise of a center for foot and ankle surgery with a specialized tumor surgeon should be consulted or referral to a designated tumor center must be initiated.


Myxoglobulosis is a rare form of appendiceal mucocele characterized by mucoid material inside the appendix that resembles fish eggs. It is usually asymptomatic and diagnosed incidentally, but it can also present as a surgical abdomen, which can create a diagnostic dilemma. This case report presents a 37-year-old male patient with features suggestive of acute appendicitis. A computed tomography scan of the abdomen showed features of appendiceal mucocele. The patient underwent appendicectomy through a lower midline incision. The macroscopic finding was myxoglobulosis, and the patient had an uneventful postoperative course. The histopathology report of the appendix confirmed the diagnosis.  Appendiceal mucocele is a rare disease in which the appendix fills with mucus. It may be associated with neoplastic or non-neoplastic pathologies. There are four histological groups of appendiceal mucocele: mucosal hyperplasia, simple or retention cysts, mucinous cystadenomas, and mucinous cystadenocarcinomas . In appeA 37-year-old male shepherd presented with features suggestive of acute appendicitis. He had one day of lower quadrant abdominal pain, which was dull aching in nature, started peri umbilically, and then shifted to the right iliac fossa. The pain was associated with nausea, loss of appetite, and two episodes of vomiting. He had no fever or change in bowel habits. He had a previous history of recurrent right iliac fossa pain, mild in nature, one year ago. Abdominal examination revealed deep right iliac fossa tenderness with negative rebound tenderness. Blood tests were unremarkable, apart from a high leukocyte count of 13 000.Abdominal ultrasound reported a mass with a cystic component at the right iliac fossa with unclear margins, suggestive of an appendicular abscess. Consequently, a computed tomography (CT) abdomen with oral and IV contrast was requested. It showed an oblong, fluid-filled structure originating from the medial side of the caecum, 14 cm long and 3 cm wide, with a wall thickness of 5.3 mm, extending down to the pelvis . This reLaparotomy exploration took place under general anaesthesia through a lower midline incision. The operative finding was a mobile appendiceal mucocele, soft adhesion, and a mobile caecum . An appeOn gross examination, the removed appendix contained small, rounded white globules a few millimetres in diameter . PostopeHistopathology reports showed acute appendicitis and the white globules as mucinous material, with the final diagnosis of acute appendicitis with myxoglobulosis of the appendix.Appendiceal myxoglobulosis, a subtype of appendiceal mucocele, is characterized by mucinous, often calcified, pearl-shaped globules in the lumen , 7. It wIn various hypotheses, the formation of a core, which is a nidus for mucin deposition, is thought to initiate the pathogenesis of the globules. Some authors suggest that small mucinous masses might develop in dilated glandular crypts from bacterial and necrotic epithelial debris , 9. In LThe diagnosis of myxoglobulosis cannot be made based on specific laboratory findings. Radiology studies, especially CT scans, can suggest a diagnosis, but pathologic confirmation of mucin globules is required . When foAll appendiceal mucoceles should undergo early surgical resection to exclude mucinous neoplasms and prevent spontaneous rupture . PreventThe suitability of open surgery over laparoscopic surgery is continuously debated. Due to more meticulous handling, an open approach reduces the chances of rupture. Palpating the tumour during surgery and determining the optimal resection is possible. Furthermore, if detected during a diagnostic laparoscopy, the procedure is better converted to an open procedure . Fewer t


Intracranial parameningeal rhabdomyosarcomas are rare, aggressive, rapidly progressive paediatric malignancies that carry a poor prognosis. The authors report a case of a 2-year-old boy who initially presented with a left facial palsy, ataxia and, shortly after, bloody otorrhoea. MRI imaging was initially suggestive of a vestibular schwannoma. However, there was rapid progression of symptoms and further MRI imaging showed very rapid increase in tumour size with mass effect and development of a similar tumour on the contralateral side. A histological diagnosis of bilateral parameningeal embryonal rhabdomyosarcoma was made. Despite treatment, progression led to hydrocephalus and diffuse leptomeningeal disease, from which the patient did not survive. Few intracranial parameningeal rhabdomyosarcomas have previously been reported and these report similar presenting symptoms and rapid disease progression. However, this is the first reported case of a bilateral intracranial parameningeal embryonal rhabdomyosarcoma which, on initial presentation and imaging, appeared to mimic a vestibular schwannoma. Rhabdomyosarcoma is the most common type of paediatric soft tissue tumour, accounting for approximately 6% of all childhood malignancies . They tyPresentation of parameningeal rhabdomyosarcomas can be non-specific and mimic other more common conditions, delaying diagnosis and therefore management , 5. SympHere, we describe a rare presentation of a bilateral primary intracranial parameningeal embryonal rhabdomyosarcoma which initially mimicked a vestibular schwannoma.A 2-year-old boy with no significant past medical history or family history initially presented with a three week history of left infranuclear facial palsy and two day history of ataxia and vomiting. Initial imaging was suggestive of a vestibular schwannoma. Six weeks following this he represented with new onset blood stained otorrhoea and organic white debris in his left ear, at which point he was treated for otitis interna. Two weeks later, there was ongoing otorrhoea with new otalgia, cough, swallowing difficulties, drooling and hoarseness. The white debris noted in the left ear had increased in size to fully obstruct the ear canal. His ataxia at this time was persistent but not progressive and the facial palsy remained.Initial MRI imaging following the first presentation showed a lesion in the left internal acoustic meatus measuring 7 mm × 11 mm (Fig. Repeat MRI imaging was carried out at the time of representation with progression of symptoms, six weeks following initial imaging Fig. b. This sA retromastoid approach on the left side was carried out with an aim to resect the lesion. Frozen section intraoperatively revealed elongated spindle cells and plump eosinophilic cells with a rhabdoid morphology contrary to the initial working diagnosis of vestibular schwannoma. Immunohistochemical staining was strongly positive for desmin and the rhabdoid cells were strongly positive for myogenin Fig. . FOX01 FOne week post operatively, the child developed new onset seizures. Further MRI imaging revealed new hydrocephalus due to cerebral aqueduct occlusion which was managed with surgical insertion of a ventriculoperitoneal shunt. MRI imaging at this time also revealed low grade osteomyelitis and cranial nerve palsies involving cranial nerves IV, VI and VII. There was progression of the right sided mass into the cerebellopontine angle and growth of the residual left-sided mass. There was enhancement of Meckel’s cave bilaterally Fig. a.Fig. 3aDespite chemotherapy, the tumour progressed to diffuse leptomeningeal disease with compression of the lateral, third and fourth ventricles Fig. b. ClinicTo date, we are not aware of any previously documented bilateral intracranial parameningeal embryonal rhabdomyosarcoma cases in the literature. However, several studies and case reports of rhabdomyosarcoma have been noted. Symptoms reported in these cases are reminiscent of those presented here, including facial nerve palsies, otorrhoea, ataxia and swallowing difficulties , 6, 9–11Previous reports suggest symptoms and imaging were often initially indicative of another diagnosis such as vestibular schwannoma , 12 or oThe case discussed here echoes the rapid progression described in the literature. Over a period of weeks, the tumour had rapidly increased in size and caused mass effect on several intracranial structures. It invaded the local bone and cranial nerves and led to hydrocephalus secondary to ventricular obstruction. Other reports have shown a similar progression from parameningeal rhabdomyosarcomas , 15, 16.This is the first reported case of bilateral intracranial parameningeal embryonal rhabdomyosarcoma; an aggressive tumour with a poor prognosis. Presenting symptoms can easily mimic other more common, less rapidly progressive conditions such as vestibular schwannoma or otitis media. A high level of clinical suspicion is required to make a timely diagnosis and initiate treatment. Unfortunately, in this case, treatment was not successful in inducing remission and the bilateral tumours progressed rapidly to diffuse leptomeningeal disease.


Teaching Point: Calcified intervertebral disc herniation in children is rare, and spontaneous resolution is the rule. The complaints started with fever, decreased appetite and vomiting. The pain increased gradually over the next few days and did initially not respond to analgesics. Clinical examination revealed limited range of motion (ROM). Neurological examination was normal. Laboratory examination was unremarkable except for mild leucocytosis (13.8 × 10On computed tomography (CT), there was calcification of the intervertebral disc (IVD) of C2-C3, with a significant herniation to the anterior epidural space with inferior migration underneath the posterior longitudinal ligament (Subsequent magnetic resonance imaging (MRI) showed peripheral epidural enhancement surrounding the calcified disc with a tail-like extension superiorly and inferiorly  calcification is a common finding at imaging in adults, it is rare in children.It can be asymptomatic or symptomatic. Seventy per cent of the symptomatic cases occurs in the cervical spine . The meaPatients present with insidious cervical pain and stiffness, sometimes with mild inflammatory signs. Radiographs or CT reveal a calcified nucleus pulposus, with or without disc herniation On MRI imaging, the calcified disc is hypointense on both T1 and T2-WI. Sometimes adjacent edema and enhancement due to inflammation can be seen, like in our case.Follow-up imaging shows complete resolution in most cases, with resorption of the calcifications. Residual changes that have been observed radiographically in some patients include vertebral body flattening, residual disk space calcification, and osteophytes.The prognosis of this condition is favourable, and therefore most cases can be treated conservatively without surgical intervention.Very rarely, symptomatic compression of the neural element requires surgery.The radiologist should be aware of this paediatric condition because it has a favourable prognosis. Invasive diagnostic or therapeutic intervention should be avoided.


Histopathology examination further confirmed mucormycosis. Glycemic control was done by infusing Insulin (both Lantus and regular). The case was managed with aggressive debridement and interpositional arthroplasty with a buccal fat pad. Liposomal amphotericin infusion was also started pre-operatively and continued in the post-operative phase. After 4 years of follow-up, the patient is well and had adequate mouth opening.Temporomandibular joint ankylosis is caused by trauma, infection, autoimmune, inflammatory joint diseases, and several other minor causes. Mucormycosis causing temporomandibular joint ankylosis has not been reported. We report two cases of temporomandibular joint ankylosis caused by mucormycosis from 2018 to 2022. In both cases, the infection started in the maxilla, then progressed to orbit. After that, involvement of the mastoid process, styloid process, and base of the skull was observed in the first case, while in the second case, there was the involvement of the base of the skull and mandibular ramus. As the temporomandibular joint (TMJ) components are contiguous to the base of the skull, it got affected causing temporomandibular joint ankylosis. Mucormycosis was diagnosed by KOH mount. The smear examination showed aseptate hyphae at 90Mucormycosis infection affecting the TMJ has been reported in the literature. However, this is the first report of a mucormycosis infection resulting in TMJ ankylosis in the literature. The infection should be aggressively managed. Reversals of an immunocompromised state, aggressive surgical management, and antifungal medication are the key factors for the success of the deadly fungal infection. Mucormycosis is highly prevalent in India due to the presence of a humid climate and the high endemicity of diabetes. In the Indian population, the incidence is 80 times higher than in developed countries . RhinoceThe involvement of the skull base occurs during the last stage of the disease. There are case reports in the English language literature discussing the involvement of TMJ in mucormycosis but mucormycosis causing TMJ ankylosis has not been reported. To our knowledge, this is the first case of mucormycosis of the maxilla with extensive involvement of the adjacent area and causing temporomandibular joint ankylosis.Case 1A 26-year-old patient presented with the chief complaint of inability to open the mouth widely for 2 years Figure .He had a history of uncontrolled diabetes. His random blood sugar and Hb1Ac were 535 mg/dl and 14% respectively. An endocrinology consultation was taken and Insulin (both Lantus and regular) was started to control the elevated blood sugar levels. He had a previous history of trauma 5 years ago, after which he developed protrusion of the right eyeball. The history revealed a dilated pupil, restricted eye movement, and chemosis of the conjunctiva. Blackish necrotic tissue was seen on the right infraorbital region and orbital apex region. A smear sent from the periorbita revealed aseptate hypha. Orbital exenteration of the right side was performed Figure .He had also undergone endoscopic debridement of the right paranasal sinus. Black necrotic tissue was seen. The histopathological report showed a case of invasive mucormycosis. A computed tomography scan showed osteomyelitis of the right-side base of the skull, condyle of the mandible, ramus region, and styloid process Figure .The diagnosis of TMJ ankylosis due to infective etiology was made. As there were chances of involvement of the brain, exploration of the area was planned and Neurosurgery was consulted The area was explored with a preauricular incision with temporal extension Figure .We found necrotic tissue in the temporomandibular joint region. Additionally, a fibrous band was seen between the osteolytic TMJ region and the glenoid fossa. Osteolytic changes were also seen in the styloid process and mastoid bone. The ankylotic region was released. Additionally, the involved styloid process, mastoid process, and all necrotic bone were removed Figure .Abdominal fat was used as interpositional material. Around 40 mm of mouth opening was achieved. The histopathology report showed aseptate hyphae consistent with mucormycosis. Liposomal amphotericin B was started. A total of 3 grams of intravenous amphotericin was given in 6 weeks. The daily dose was adjusted according to the renal status of the patient. The patient was kept on regular follow-up, and random blood sugar and Hb1Ac were monitored. Hb1Ac gradually improved from 15% to 6% in nine months. After four years of follow-up, the patient had adequate mouth opening with no recurrence.Case 2A 29-year-old male reported to the dental OPD with the chief complaint of inability to open his mouth widely. Eight months ago, he underwent endoscopic debridement of the right maxilla with right-side orbital exenteration for rhino cerebral mucormycosis. He also had a previous history of COVID-19 six months before developing rhinocerebral mucormycosis. He had cone beam computed tomography (CBCT), which showed an osteolytic area involving the right side condylar region and squamous temporal bone and skull base Figure , 7.Magnetic resonance imaging (MRI) was done to rule out an intracranial extension. The patient was planned for interpositional arthroplasty with debridement of the skull base, but the patient was lost to follow-up.The etiology of TMJ ankylosis can be broadly subdivided into major categories: post-traumatic and post-infective. Septic arthritis, rheumatoid arthritis, osteoarthritis, and various systemic infections are the main cause of TMJ ankylosis. Zhangcai  reportedStaphylococcus aureus. The infection of the joint initiates an inflammatory response in the joint and subsequent joint destruction. The sequelae are the development of increased intraarticular pressure which subsequently leads to decreased flow, ischemia, and necrosis of cartilage leading to TMJ ankylosis [The pathological involvement of the TMJ can be due to bacterial, viral, and fungal microorganisms . The micnkylosis . In bothImaging plays an integral role in the diagnosis. In a computer tomography scan, this presents as an osteolytic lesion involving the TMJ area as seen in our case. Treatment consisted of reversal of the underlying condition, aggressive surgical management, and antifungal protocol ,12. We mIn conclusion, this is the first report of mucormycosis causing temporomandibular joint ankylosis. The case highlights the inclusion of mucormycosis as a cause of TMJ ankylosis and the direct spread of infection from the contiguous site. It can be successfully managed with both medical management, and aggressive debridement and interpositional arthroplasty. During management, special attention should be given to the adjacent area of the temporomandibular joint, and the necrotic region should be completely removed.


The incidence of abnormalities regarding the celiac-mesenteric trunk (CMT) has been reported to be between 1% and 2.7%, whereas for visceral aneurysms the incidence is between 0.1% and 0.2% of the general population. Anatomical variations in the CMT may be the result of abnormal embryogenesis of the primitive segmental splanchnic arteries that supply the bowel and several abdominal organs. The clinical presentation may range from vague abdominal symptoms to aneurysm rupture with a significant mortality risk. In this case, we describe the clinical history of a 37-year-old man with postprandial abdominal pain likely related to the celiac-mesenteric trunk enlargement, associated with high resistance flow in the proximal site. Postprandial symptoms improved by avoiding large meals and surveillance for the CMT anomalies was recommended by cross-imaging including the echo-color-Doppler to assess blood flow modification. Albrecht Von Haller, a Swiss anatomist and physiologist, was the first to describe the anatomy of the celiac-mesenteric trunk (CMT) . The celThe arrangement of the anatomical structures, and the relationship between organs, the blood, and the lymphatic vessel network are the result of the growth process, rotation, and migration during embryogenesis and fetal development .Progenitor cell movement and aggregation during organogenesis are responsible for the final organs’ morphology and can be the cause of variations in arterial and venous vessels. More specifically, during embryogenesis, the main visceral arteries develop from four vascular roots derived from the primitive dorsal abdominal aorta. These four roots are joined by ventral longitudinal anastomosis. In the course of normal maturation, the gastric, hepatic, and splenic roots join to form the main celiac axis, while the fourth root develops separately into the superior mesenteric artery. An interruption of the ventral anastomosis process may lead to a wide variety of vascular anomalies . SeveralCMT anatomic variations are rare; they have been reported to range between 1% and 2.7% of cases , whereasIn the absence of aneurysm rupture, symptoms may be insidious and progressive with malaise, postprandial epigastric/abdominal pain or discomfort, sometimes associated with back pain, early satiety, nausea, and/or vomiting often attributed to another etiology or functional disorder, leading to delay in diagnosis ,5,26,27.A physical examination is usually not helpful for diagnosis. In cases where the aneurysm has expanded to a large size, it may present as a palpable mass in thin individuals , albeit Ultrasonography and cross-sectional abdominal vascular imaging, including computed tomography (CT) and magnetic resonance (MR), provide an accurate diagnosis of CMT anomalies. Echo-color-Doppler is particularly helpful for measuring blood flow inside the abnormal trunk. Moreover, imaging can simultaneously exclude additional conditions.The suggested approach to a visceral aneurysm is early intervention. However, observation with surveillance could be an option for some small aneurysms and accordingly for trunk enlargement .2). He was a former cigarette smoker and did not practice physical exercise. At the visit time, he was unemployed and consumed a balanced diet. The patient complained of gastroesophageal reflux disease (GERD) symptoms, motility-like dyspepsia, and abdominal pain localized in the epigastric region and right hypochondrium occurring nearly 30 min after meals, lasting approximately 30–60 min and exacerbated by sitting, usually improving within two hours. Additionally, the patient complained of constipation and a weight loss of 5 kg in the last two years. He had no significant comorbidities, except for appendectomy and two inguinal hernia repairs on both sides in his youth. The family history was negative for major disorders.A 37-year-old white Caucasian man came to our attention during a gastroenterological visit. Anthropometric features were: height 185 cm, weight 100 kg  for hepatic, pancreatic, intestinal, infectious, celiac, autoimmune, and hematological diseases showed normal results. The upper endoscopy and colonoscopy were negative for significant findings. Interestingly, in the ultrasound scan of the abdomen cavity, we noticed agenesis of the left hepatic lobe, splenomegaly, and enlargement (1.89 cm at the ostium and 1.53 cm downstream) of the CMT  .Abnormalities were also present in the CT scan with and without contrast medium .The echo-color-Doppler revealed a high resistance flow in the proximal site of the CMT .By comparing previous and current imaging tests, an increase of 5 mm in CMT diameter in 5 years was observed.The consulted team of vascular surgeons recommended surveillance over intervention for the CMT anomalies by cross-imaging, according to the guidelines of the European Society of Vascular Surgery .High doses of second-generation proton pump inhibitors twice daily, in addition to prokinetics, were prescribed, and lifestyle with dietary modification was proposed. In the follow-up visit (three weeks later), the patient reported an improvement in GERD and motility-like dyspepsia symptoms, despite the persistence of the post-prandial pain exacerbated by large meals. Because of this, the patient was asked to avoid large meals with high fat content. More specifically, the patient was advised to reduce the main meal portion sizes (lunch and dinner) and, in case of hunger, to add snacks between meals. At the third follow-up visit (2 months later), the patient reported an improvement in abdominal symptoms and quality of life through the adoption of a different eating pattern. Moreover, he maintained a steady weight.Causes of chronic abdominal pain and weight loss in adults are several and frequently prompt an extensive workup. More specifically, our patient complained of upper abdominal pain located in the right upper quadrant and epigastric region, characteristic locations for biliary and/or liver etiologies. However, laboratory studies were normal over time, excluding hepatobiliary disorders. Due to their rarity, visceral artery anomalies and associated modifications in blood flow are often unsuspected in patients reporting abdominal complaints. The majority of visceral abnormalities and/or aneurysms are asymptomatic and detected during autopsy. In our case, the CMT anomaly was labeled by the radiologist as an enlargement. Although there are no specific symptoms reported in the literature for CMT anomalies, in the case of a hepatic aneurysm, symptoms are represented by nausea and pain in the right hypochondrium or mesoepigastrium radiating to the back. Patients with splenic artery aneurysms complain of nausea and vague abdominal discomfort in the mesoepigastric quadrant or left hypochondrium, associated sometimes with left shoulder discomfort due to diaphragm irritation. Almost half of patients with splenic artery aneurysms present with moderate splenomegaly . Most ceThis case of unexplained abdominal pain includes a difficult-to-diagnose condition that is not frequently encountered by most clinicians but is nonetheless important to accurately recognize. The clinical presentation of CTM anomalies may range from vague abdominal symptoms to aneurysm rupture with a significant mortality risk especially when complicated by a high blood flow resistance. Postprandial symptoms improved by avoiding large meals and surveillance was recommended by cross-imaging, including echo-color-Doppler, to assess the magnitude of blood flow modification.


Gallstone ileus is a rare entity that causes bowel obstruction by gaining access through a cysto-enteric fistula. This is a case report of a 70-year-old man presenting with small bowel obstruction secondary to distal jejunal gallstone ileus impaction. He is not known to have any predisposing factors. He was managed effectively with an enterolithotomy. Early diagnosis is key to a good prognosis. Although other management options are available, enterolithotomy with or without cholecystectomy remains the gold standard of management. Gallstone ileus is a rare entity, often occurring in the elderly population, and accounts for <1% of mechanical bowel obstructions. It occurs as a result of a cholecysto-enteric fistula. This episode is often preceded by acute cholecystitis. The diagnosis is challenging and should be suspected in the elderly who present with abdominal distension in a virgin abdomen.This is the case of a 70-year-old man who presented to the ER with a 2-day history of abdominal pain, distension, and vomiting. The episode began with a 1-day history of right upper quadrant pain. He has no other medical or surgical history and has never been diagnosed with gallstones.On examination, his vitals were stable. His abdomen was distended, soft, and non-tender. Bowel sounds were absent. The lab investigations were all within the normal range.The plain film of the abdomen showed multiple air-fluid levels on the erect film  and smalThe patient was taken to the operating theater, and an upper midline incision laparotomy was carried out. The site of the foreign body (stone) was identified in the distal jejunum , and an Although gallstone ileus is an uncommon cause of small bowel obstruction, it accounts for 1%–4% of all intestinal obstructions .in-situ growth [Gallstone ileus occurs in 0.3%–0.5% of patients with cholelithiasis . The stou growth . Once itu growth . The secu growth . Less coCT is the investigation of choice. Plain films can reveal dilated small bowels, confirming small bowel obstruction . The preAnother surgical option that also carries lower morbidity is laparoscopic retrieval of the stone; this, however can be challenging due to the difficulty faced when manipulating the distended bowel and requires special expertise. Non-invasive management, such as endoscopic retrieval of the obstructing stone, could also be an option in selected patients .Gallstone ileus should be suspected in elderly patients who present with small bowel obstruction and have had no previous abdominal surgery. The procedure of choice remains a simple enterolithotomy. Laparoscopic retrieval of the stone could be an option.


Soft tissue chondroma is a relatively rare, slowly growing, benign cartilaginous tumor. This solitary mass can imitate chondrosarcomas in radiologic and histological characteristics. The diagnosis is hard to establish on clinical presentation and relies on careful radiological examination. The lesion is equally prevalent in both genders and primarily affects people in their forties and sixties. They may occur in any part of the body; however, they are most commonly observed in hand and foot. We report the case of a 61-year-old female who presented with heavily ossified soft tissue chondroma within the plantar fascia of her left foot. A conclusive diagnosis was established via histopathological examination. The chondroma was marginally excised, and the postoperative period was uneventful. Chondroma is a benign cartilaginous tumor that develops from bone . It has A 61-year-old female presented in outpatient department with a long-standing symptomatic mass on the plantar aspect of her left foot in the area of 3rd and 4th metatarsal. The patient noticed this lesion two years prior to the examination due to persistent pain and was treated conservatively with changing shoe gear, padding and orthosis. There was associated tenderness in the involved region, and pain (diffuse) was more severe when bearing weight. Vitals of patient were stable and initial blood workup was normal. Multiple well corticated ossicles in relation to the mid aspect of the 3rd and 4th metatarsal on the plantar side were observed on radiological examination Figure . Corticosteroid injections were discussed as a treatment option, but the patient refused. Surgical excision of the mass was carried out. Tibial nerve block was done using naropin, and further regional block was done in a V fashion proximal to incision using dexamethasone and naropin combination. Lazy S incision was made overlying the palpable mass. The incision was deepened through the subcutaneous tissue. Dissection carried down to the level of plantar fascia where upon palpation, it was noted that the lesion was in between the plantar fascia and the flexor digitorum brevis muscle belly. The bony lesion measuring 23x13x9 mm was dissected and passed on from the operative field for histopathology. On histopathological examination, the excision showed a benign multinodular osteocartilagenous lesion. The nodules were formed by a peripheral rim of lobulated hyaline cartilage merging with trabeculae of woven and lamellar bone through enchondral ossification. Within the cartilaginous matrix, a mildly cellular population of bland chondrocytes occurring in nests and situated within lacunar spaces was observed . Despite the suspicion of calcified plantar fibromatosis on ultrasound, there was no spindle cell proliferation in this case to suggest fibromatosis. The lesion appeared to be marginally excised. Hence, it was confirmed that the lesion was a heavily ossified soft tissue chondroma.Soft tissue chondroma  is a soft-tissue tumour that is extremely rare ,10,11. BClinically, the tumour appears as a single, slowly growing solid or rubbery well-defined mass . It deveRadiological and histological findings are of paramount importance in establishing diagnosis of STC. A well-demarcated extraosseous soft tissue mass can be seen on radiographs . CalcifiDespite STC being a benign tumour, thorough excision should be performed to relieve any symptoms such as pain or struggle with footwear . It is rSoft tissue chondroma is a rare benign tumor that mostly affects the extremities, such as the hands and feet. Clinically, soft tissue chondroma of the foot presents as a mildly painful cutaneous lump. Therefore, In individuals with slow-growing and mildly painful cutaneous nodules, STC should be included in differential diagnosis. Preoperative diagnosis is difficult to establish; however, calcifications are clearly visible on radiological examination, which may indicate STC. Surgical excision of the mass is the treatment of choice to relieve symptoms. Histological examination of the lesion aids in forming a conclusive diagnosis. Postoperative period is normal and recurrence is rare.


A 14-year-old male presented with worsening chronic intermittent abdominal pain, mild anemia, positive fecal occult blood test, and elevated calprotectin. Computerized tomography and magnetic resonance imaging showed ileal dilation with mucosal enhancement and inflammatory changes suspicious for inflammatory bowel disease (IBD). Prominent mucosal folds were suggestive of gastric heterotopia, but Meckel’s scan was negative. Upper endoscopy, colonoscopy, and double balloon enteroscopy were grossly and microscopically normal. Laparotomy revealed 17 cm of a dense, inflamed, stenotic segment of ileum. The strictured ileum had perforated and had been concealed by an adjacent loop of small bowel, ultimately producing an obstructive IBD-like picture, but was found to be histologically consistent with gastric oxyntic mucosa. This case illustrates the challenges of diagnosing and treating heterotopic gastric mucosa, and the importance of considering diagnoses other than IBD when evaluating stricturing disease of the small bowel. Heterotopic gastric mucosa (HGM) is an abnormal histological finding in which oxyntic gastric tissue, identifiable by an abundance of parietal and chief cells, is found elsewhere in the gastrointestinal tract –3. This A previously healthy 14-year-old male presented with 1 year of worsening intermittent abdominal pain and acute constipation. He used no medications and endorsed no significant family or travel history. Initial physical examination revealed only mild generalized abdominal pain. Admission labs showed hemoglobin of 10.4 g/dL, with normal albumin of 4.0 g/dL, C-reactive protein, and erythrocyte sedimentation rate. Stool was fecal occult blood test (FOBT) positive with elevated calprotectin 240 μg/g. Computerized tomography of the abdomen/pelvis with intravenous contrast and subsequent magnetic resonance enterography revealed dilatation of a mid to distal ileal segment up to 10 cm wide, with mucosal hyperenhancement, surrounding inflammatory ascites, reactive mesenteric adenopathy, and a tiny outpouching indicative of diverticula or inflammatory process. Prominent mucosal folds seen in the dilated segment were considered by the radiologist to be suggestive of gastric heterotopia. To evaluate this, Meckel’s scan (Fig. Given his chronic nonspecific symptoms, anemia, positive FOBT, and imaging findings concerning for inflammatory process, IBD was suspected. Purified protein derivative placed for potential steroid use was negative. Esophagogastroduodenoscopy and colonoscopy were normal grossly and microscopically. IBD serologic, genetic and inflammation panel was negative. One month later, elective double balloon enteroscopy was performed and was notable only for a narrowed but nonobstructed area of bowel 10 cm from the ileocecal valve, dilated most significantly at the mid ileum. Biopsies taken from the proximal terminal ileum, distal terminal ileum, and mid ileum showed normal histology. Mid ileal biopsies showed focal acute inflammatory changes, but were normal elsewhere. The patient remained clinically stable throughout this procedure.The patient underwent exploratory laparoscopy that revealed a cocoon of dense intestinal adhesions proximal to the ileocecal valve, with multiple enlarged surrounding lymph nodes. After conversion to laparotomy and extensive lysis of adhesions, an inflammatory stenotic strictured area of ileum was found adhered to and concealing a perforation Fig. . SeventeThis otherwise healthy male presented with chronic nonspecific symptoms of abdominal pain, mild anemia, and constipation. His labs were unremarkable with the notable exception of positive FOBT and moderately elevated fecal calprotectin and abnormal findings in the mid-ileum on computerized tomography and magnetic resonance enterography. These findings suggested the initial consideration of IBD. HGM was considered a potential etiology for the prominent folds found on imaging, but a negative Meckel’s scan contributed to our suspicion of IBD. When discussing the false-negative Meckel’s scan, we considered that the affected bowel segment may have been indistinguishable from the bladder due to close proximity , 7. This4 Alternatively, capsule endoscopy has been found to result in a positive diagnosis rate ranging from 45% to 76%.1 In our patient, capsule endoscopy was not an option given our concern for ileal stricture inhibiting the passage of the capsule through the intestinal tract. Confocal laser endomicroscopy has been employed to identify HGM.5 Providing 1000 times magnification through the endoscope allows the user to differentiate normal from pathologic tissue. Future use of confocal laser endomicroscopy, under the right circumstances, could preclude the need for confirmatory biopsy. Narrow band imaging is an additional tool that allows visualization of the microvascular architecture of concerning tissue and can help differentiate ectopic pyloric-like mucosa and intestinal epithelium (Endoscopy, colonoscopy, and double balloon enteroscopy were unable to distinguish the pathology in this case. HGM is generally reported to be grossly normal by endoscopic perception.Surgical intervention is the most definitive approach for diagnosis and treatment of HGM . EndoscoHGM remains challenging to diagnose and treat due to the variable production of gastric acid in the tissue and spectrum of resultant symptoms ranging from abdominal pain and constipation to weight loss, anemia, and perforation . Labs caA.R. reviewed case, drafted manuscript, and approved final draft. T.R. reviewed case and approved final draft. M.K. reviewed case and approved final draft. A.N. reviewed case, assisted with figure creation, approved final draft. C.Y. reviewed case, revised manuscript, approved final draft. This paper has not been published or been considered for publication in any other journal at this time.


Polyarteritis nodsa (PAN) is a rare disease characterized by acute focal inflammatory damage to small and medium arteries. PAN complicated by ruptured aneurysm is an infrequent presentation with the most affected arteries being the renal and mesenteric arteries.A 76-year-old female presented with a low-grade fever, generalized body aches, and abdominal pain. Investigation revealed intraperitoneal bleeding secondary to a ruptured and actively bleeding right omental artery aneurysm. Clinical manifestation, angiography and histology were consistent with PAN. Laparotomy was performed for stabilization and resection of the bleeding aneurysm followed by post operative steroids and cyclophosphamide. Patient was discharged in a stable condition. We reviewed seven cases found in the literature of omental artery aneurysm and rupture. Four cases were proceeded with laparotomy and aneurysm resection while three cases were proceeded with a less invasive approach of arterial embolization.Omental artery aneurysm is a rare occurrence with even fewer reported cases associated with PAN. Of the seven reported cases, all patients were treated with a surgical intervention. In addition, PAN patients should be treated post-operatively with a course of steroids and cyclophosphamide. Polyarteritis nodosa (PAN) is a rare form of vasculitis affecting approximately 30.7 per 1,000,000 people with a predominance for middle-aged men . The infA 76-year-old female was admitted with 2 weeks history of low-grade fever and generalized body aches. Further inquiry revealed 3-day history of gradual diffuse abdominal pain. The pain was markedly worse in the right lower quadrant. The patient had no other past surgical or medical problems. She denied any alcohol, tobacco or drug abuse. In the emergency department the vital signs revealed temperature of 38.5 °C, blood pressure of 149/87 mmHg, pulse of 117 bpm, and respiratory rate of 22 breaths/min. Systemic physical exam revealed pale conjunctivae and systolic ejection murmur of 2/6 over the apex of the heart. Examination of the abdomen revealed mild distention with tenderness all over the abdomen that was worse in the right and lower abdomen. The rest of the examination was within normal limits.3, hemoglobin of 9.5 gm/dL, platelet count of 175 per mm3, calcium level of 7.3 mg/dL, albumin level of 2.6 gm/dL, creatinine level of 0.93 mg/dl, and C-reactive protein level of 13.3 mg/dl. All other laboratory values were within normal limits.Laboratory results revealed white blood cell count of 18,500 per mmCT scan abdomen revealed intraperitoneal fluids. CT angiogram was unavailable, therefore, we proceeded with an abdominal aortic angiogram, which revealed a right omental artery aneurysm Fig. . LaparotBased on her histopathologic diagnosis of PAN the patient was started on intravenous steroids and cyclophosphamide postoperatively for systemic inflammation. During her hospitalization she had persistent low-grade fever; all her cultures were negative. After 10 days, the patient was discharged home in stable condition. Follow-up revealed a stable condition and no recurrence of her symptoms. Patient was lost for follow-up after 1 month.PAN is a rare cause of vasculitis first described by Rokitansky in 1852 and published by Kussmaul and Maier in 1866 . PrimaryDue to the rarity of the disease, clinical suspicion should be confirmed with a biopsy of the medium-sized arteries for histological analysis or angiography if biopsy cannot be performed . HistoloVisceral artery aneurysm is an extremely rare condition with a reported incidence of approximately 0.01–2% . PreviouOmental artery aneurysms are rare and are associated with a high risk of rupture necessitating prompt treatment. Due to its rarity definitive guidelines regarding indications for intervention or surgery have not yet been established. However, an open surgical approach has been most frequently reported. Kramman et al. reported an endovascular embolization approach that was successful 85% (11/13) of the time . HoweverThe treatment of PAN vasculitis with a rare presentation of visceral artery aneurysm is achieved by either operative or non-operative management. Conservative treatment includes the use of corticosteroids and cyclophosphamide and is reserved for patients with non-urgent clinical presentations. Surgical interventions include aneurysm resection or embolization and is reserved for acute abdomens.


A radicular cyst, also known as a periapical cyst or root end cyst, is a type of odontogenic cyst that is typically associated with permanent teeth. The radicular cyst usually is associated with maxillary central incisors followed by mandibular first molars. It occurs as a result of bacterial infection and pulpal necrosis which leads to inflammatory stimulation of the epithelial cell rests of Malassez along the periodontal ligament area of the tooth. Most cases of the radicular cyst are asymptomatic and they are diagnosed accidentally during routine radiographic examination. This article presents a case report of a 42-year-old male with an apical periodontal cyst associated with the maxillary anterior region. Early diagnosis and treatment planning is necessary. This article signifies the role of the surgeon in the early diagnosis and treatment plan of the cyst. In the intricate landscape of oral and maxillofacial pathology, radicular cysts stand as intriguing enigmas. These benign yet potentially destructive lesions have long perplexed dental and medical professionals alike, demanding a deeper understanding to ensure timely diagnosis and effective management . As we eA 42-year-old patient visited our outpatient department with a one-month history of pain in the upper left anterior jaw, accompanied by swelling for the past 10 days. The patient had previously applied ayurvedic medication and experienced bleeding and pus discharge for about a month. The pain was sharp and intermittent, worsened during chewing, and improved with medications. The patient also reported a history of fever, paresthesia in the area, and discomfort while bending for the past eight days. Over time, this pain worsened and led to the development of swelling in the upper left molar region, which has been progressively increasing in size. The swelling in the upper left molar region gradually increased and reached the present size. On extraoral examination, no facial asymmetry was seen  revealed a well-defined radiolucency in the periapical region of 22-24 measuring approximately 2.5 x 2 cm; it was roughly oval in shape and had well-corticated borders Figure .Based on the patient's history, clinical examination, and radiographic examination, a provisional diagnosis of radicular cyst and acute exacerbation of chronic periapical abscess at 22-24 was made. According to pulpal diagnosis, the tooth was nonvital, and according to periapical diagnosis, displayed acute exacerbation of a chronic periapical abscess. Based on the surgeons' point of view and assessment of all the necessary findings, a clinical diagnosis of radicular cyst with 22-24 was confirmed. It was decided to surgically incise the lesion under local anesthesia along with enucleation and curettage.Radicular cysts are more common in males than in females . They teIn conclusion, radicular cysts are common yet often unnoticed oral conditions, potentially affecting both primary and permanent dentition. Close post-surgery follow-up is advisable, for bone regeneration purposes. However, to date, this patient is not ready for further follow-up.


This is the first reported case of lesser sac empyema secondary to a foreign body perforation in the posterior stomach. Although PubMed and Google Scholar search reports cases of lesser sac empyema alone and foreign body penetrations, there are currently no reported cases of a lesser sac abscess secondary to a foreign body. Patients with a lesser sac empyema present atypically with an insidious onset. The lesser sac should be examined in patients with peritonitis without a clear source.A 48-year-old female presented to the emergency department with acute onset epigastric pain. The patient was tender in the epigastrium and left upper quadrant with associated guarding. The patient had elevated white cell count and C-reactive protein, with a computed tomography scan identifying a foreign body posterior gastric wall perforation. The patient was managed with endoscopic drainage of the lesser sac empyema and surgical washout of the abdomen.Foreign bodies are investigated using different imaging modalities, with computed tomography being able to further evaluate the size, shape, and complications. Intra-abdominal collections can be managed through three different methods: percutaneous drainage, endoscopic drainage, and surgery. Patients with peritonitis would require a laparoscopic or open surgical washout of the abdomen and inspection of the lesser sac would be necessary if no obvious source is identified.Foreign body ingestion requires careful history taking and assessment. Patients with lesser sac empyema present atypically, and this can lead to delayed surgical referral and management. Contained intra-abdominal collections can be drained percutaneously or endoscopically. Foreign body (FB) ingestion is rare in adults compared to children . Of FB iPatients with intestinal perforation by an ingested FB often present with an acute abdomen, fever, peritonitis, nausea, and vomiting. These often occur in the elderly, alcoholics, psychiatric patients, and patients who wear dentures .Plain radiographs may not identify some objects such as wood, thin bones, plastic, and glass, so computed tomography of the abdomen and pelvis (CTAP) is recommended in cases of suspected perforation secondary to FB ingestion. CTAP can also evaluate the FB in terms of size, shape, location, and depth of penetration to guide management.Although FB ingestion and associated perforation are common, there are currently no reported cases of lesser sac empyema formation following FB perforation. Lesser sac empyema can occur from the perforation of the posterior gastric fundus or gastric body. Patients with lesser sac empyema usually have an atypical presentation, due to the contained perforation, though this may develop into generalised peritonitis.An FB within the stomach and duodenum should be retrieved within 24 hours if it is sharp, magnetic, or greater than 5 cm in length, and within 72 hours if the diameter is greater than 2 cm or batteries that are not passed within 24 hours [If the empyema is contained, it can be drained endoscopically. However, patients who present with peritonitis should proceed directly to surgery for a washout of the abdomen.A 48-year-old female presented to the emergency department with acute epigastric pain, on a background of peptic ulcer disease on pantoprazole, smoking, and occasional alcohol use. On examination, the patient was tender in the epigastrium and left upper quadrant with guarding. On full blood examination, she had leucocytosis (15.6 x 10^9/L) and had a C-reactive protein level of 434 mg/L. Erect chest X-ray and electrocardiogram were unremarkable.A CTAP was performed and demonstrated a likely ulcer or partial FB perforation on the posterior wall of the gastric antrum, with regional lymphadenopathy Figure . The patTwo days after the gastroscopy, the patient developed severe abdominal pain and proceeded to a repeat gastroscopy, which demonstrated a large amount of pus within the stomach. A pin-hole-sized perforation was identified in the posterior pre-pyloric region Figure . The sitFollowing the second gastroscopy, the patient became febrile and tachycardic and proceeded to the theatre for laparoscopy. There was free fluid in all four quadrants and a large collection of pus in the lesser sac. The lesser sac was carefully entered using a lateral approach (through the gastrosplenic ligament), and a washout of both the lesser sac and all four quadrants was completed laparoscopically. Jackson-Pratt drains were placed within the lesser sac cavity and anterior to the stomach. The patient was subsequently transferred to the ICU.The patient’s post-operative course was complicated by a portal vein thrombus, which was incidentally diagnosed on follow-up CTAP the day after surgery. The patient was gradually uptitrated to therapeutic anticoagulation, and the pigtail drain was removed endoscopically 10 days post-operatively.Foreign body ingestionFB ingestion is rare in adults compared to children . FBs arePatients with perforation by an ingested FB are rare and most often present with an acute abdomen, fever, peritonitis, nausea, and vomiting. This is most common in the elderly, alcoholics, psychiatric patients, and patients who wear dentures .Imaging can aid in the initial evaluation of the FB perforation. However, imaging should not delay definitive management, especially in patients with obstructive symptoms, such as drooling and difficulty swallowing. Typically, erect chest X-rays and abdominal X-rays can identify radio-opaque objects; however, they may not detect other foreign bodies such as wood, thin bones, plastic, or glass. Computed tomography (CT) scan is the preferred imaging modality in cases of suspected FB perforation. Studies have shown that CT scans have a sensitivity and specificity of 85.7-100% and 66.7-100%, respectively. It can evaluate the FB in terms of size, shape, location, depth of penetration, number, and complications from the FB [FB retrieval is typically performed endoscopically and very rarely surgically. Complete oesophageal obstruction, battery ingestion, or sharp FB in the oesophagus should be retrieved endoscopically within two hours ideally, up to six hours. Patients with incomplete oesophageal obstructions can be retrieved within up to 24 hours -11. FB wLesser sac empyemaLesser sac empyema secondary to FB perforation of the gastrointestinal tract has not been previously reported. Since posterior gastric perforation can lead to contained empyema within the lesser sac, these patients may initially present atypically. Early recognition of this differential diagnosis is important to avoid delays to surgical referral and management, as in our presented case .Although intra-abdominal collections are commonly managed with percutaneous drainage , the lesPatients proceeding to surgery may require laparoscopic or open washout of the abdomen. Posterior gastric perforation can be difficult to identify intraoperatively, and so examination of the lesser sac may be necessary by Kocherization of the duodenum.FB ingestion is rare in adults and a careful history is required to help diagnose the cause of presentation. Patients with lesser sac empyema may present atypically, and recognition of this important differential diagnosis is necessary to facilitate prompt surgical referral and management. Contained intra-abdominal collections can be drained percutaneously or endoscopically. However, patients with peritonitis will require surgical washout of the abdomen, and the lesser sac should be assessed if no obvious culprit is found.