We present a case of a 47-year-old female with a swelling on her scalp that was at first thought to be trichilemmal cysts. After two years, she returned to her general practitioner with a larger scalp mass. Following a biopsy, histological analysis revealed dermatofibrosarcoma protuberans (DFSP). She then had the tumor completely removed, resulting in clean margins. Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous soft tissue sarcoma that is locally aggressive. It has an incidence rate of 0.8-4.5 cases per million people per year, and it accounts for approximately 6% of soft tissue sarcomas . The majWe present the case of a 47-year-old female who had a painless soft mass on her scalp misdiagnosed as trichilemmal cysts instead of DFSP.In January 2021, a 47-year-old female presented to the family medicine clinic with a headache and swelling on the right side of her scalp. A nonenhanced computed tomography (CT) scan of the brain revealed the interval development of a small subcutaneous soft tissue density measuring 1.5 x 0.5 cm in the right parietal region  15/15) with no neurological deficit. The swelling was firm in consistency, painless, mobile, overlaying the skin, and without slippery edges. It measured 3.5 x 4.3 cm with no sign of inflammation or a history of recent trauma. A CT scan of the head showed a significant increase in the size of the swelling in the right parietal region, measuring 6 x 3.5 x 4.5 cm in anteroposterior view with no evidence of a solid component; the underlying parietal bone appeared grossly unremarkable with no evidence of bony destruction (Figures An excisional biopsy was then performed, and a tissue sample was sent for histopathological analysis. DFSP was diagnosed after the interdepartmental consultation in surgical pathology, and complete excision with margins was advised. An urgent referral to oncology for a metastatic workup was made. CT of the chest, abdomen, and pelvis with IV contrast and a bone scan all revealed no definite signs of solid organ, pulmonary, or bone metastasis. A month later, the patient was admitted and underwent wide excision of the lesion, and the defect on the scalp and neck was simply covered with a graft from a donor area. Her postoperative period was uneventful, and she was discharged from our hospital.DFSP is a rare soft tissue neoplasm first identified by Sherwell and Taylor in 1890. Darier and Ferrand described it as a progressive recurrent dermatofibroma in 1924. One year later, Hoffmann named it DFSP; DFSP had been reported under a variety of names, including keloid-like sarcomatous tumors, hypertrophic morphea, progressive and recurring dermatofibroma, fibrosarcomatous minors with attenuated dermal surfaces, and skin fibrosarcoma ,7. It isDFSP has no known cause yet; however, skin injury, tattoos, and pre-existing scars have been suggested as potential risk factors . It can Even though metastasis is uncommon, a metastatic workup, including a CT scan of the chest, abdomen, and pelvis, a lymph node USG, and a chest x-ray, should be performed. In some cases, a preoperative MRI may be useful . A treatDFSP is a rare, slowly growing tumor that arises from the dermis. It usually occurs in the trunk or proximal extremities. Tumors on the scalp are relatively uncommon in clinical practice. Due to its rarity, misdiagnosis might occur, and a complete excision with a safe margin is usually delayed, and only local excision is performed. Surgeons should be aware of that to improve the health status and outcomes of those patients. In addition, due to the relatively high rate of local recurrence, follow-up should be highly encouraged.


Our case describes the imaging characteristics of a tongue hematoma and lingual artery pseudoaneurysm following oral surgery, treated with a liquid embolic agent prior to repeat instrumentation. Identifying particular imaging cues that suggest underlying vascular pathology is essential to prevent unnecessary, potentially fatal instrumentation. A liquid embolizing agent can be used to endovascularly treat an unstable pseudoaneurysm in the oral cavity. Pseudoaneurysms, or “false aneurysms,” are rare lesions in the vasculature . They ocPseudoaneurysms can occur anywhere in the vasculature. Prior approaches for aneurysm and pseudoaneurysm treatment include vascular plugs, platinum coiling, mechanical embolization, and surgical repair ,3-5. HowWe describe imaging findings of a lingual artery pseudoaneurysm and tongue hematoma on computed tomography (CT) and magnetic resonance imaging (MRI) following oral surgery treated minimally invasively using the Onyx 18 liquid embolization agent . This case was previously presented as a meeting poster at the 2023 American Society of Neuroradiology Annual Meeting on April 29, 2023-May 3, 2023.A 61-year-old female patient with a history of atrial fibrillation on oral anticoagulation, hypertension, hyperlipidemia, recent drug-induced liver injury, and gastroesophageal reflux disease underwent a tooth extraction at an external oral surgery office. One week afterward, she reported left-sided tongue pain and swelling that progressively worsened, prompting a presentation to the emergency department per advice from her oral surgeon. She had computed tomography (CT) and magnetic resonance imaging (MRI) of the neck. A CT was done on presentation, and an MRI was done 15 hours later, while the patient was being observed. CT with contrast of her neck demonstrated a 2.5 cm lesion on the ventral surface of the left side of the tongue, consistent with a vascular appearance  and magnetic resonance angiography (MRA). The patient was taken to the neuroangiography suite. Using a 0.038” Glidewire guide wire , a 6 French Envoy guiding catheter  was positioned into the left external carotid artery. A Synchro-2 microwire  and Excelsior SL-10 microcatheter  were advanced into the lingual branch of the left external carotid artery. Contrast injection in the artery visualized with digital subtraction angiography (DSA) demonstrated a pseudoaneurysm originating from the distal lingual artery Figure . At this point, the decision was made to pursue treatment of the aneurysm to prevent further hematoma expansion. After injecting dimethyl sulfoxide (DMSO), Onyx 18 liquid embolizing agent  was injected at the target site utilizing standard technique Figure . Repeat There were no intraoperative complications, and the postoperative course was uneventful. The bulging mass in the patient’s tongue subsided over a few days. Although residual contrast was present on immediate postoperative imaging, follow-up CT after two weeks showed no retained contrast. CTA performed one-month following endovascular embolization was potentially concerning for a small residual pseudoaneurysm with surrounding hematoma Figures , 9. One Approaches to pseudoaneurysms can vary depending on their severity, size, and location. While some relatively stable pseudoaneurysms do not require emergent treatment, other pseudoaneurysms in critical locations require immediate intervention. Pseudoaneurysms in the oral cavity are a particular danger due to the risk of massive bleeding . In thisDelayed identification of pseudoaneurysms can present with severe complications, particularly if presenting as a ruptured lesion in the head and neck region. Thus, the risk of fatality elucidates the need to promptly and astutely identify pseudoaneurysms on imaging. The imaging findings from the CT and MRI supported a vascular lesion rather than an infection or a mass. It was important to differentiate between a vascular lesion, an infection, or a mass-like tumor early in the diagnostic process. If it were a mass or infection, then the next diagnostic steps would have involved a biopsy, sampling, or drainage of the lesion, which could have provoked bleeding from the fragile pseudoaneurysm and subsequently caused fatal airway obstruction. The risk for fatal obstructing hemorrhage illustrates the significance of identifying efficient modalities for pseudoaneurysm management. The literature addressing pseudoaneurysm management is limited. Treatments of pseudoaneurysms in the groin, gastrointestinal system, or aorta can include ultrasound-guided thrombin injections . HoweverUnlike prior described cases, our case utilized Onyx 18, a liquid embolizing agent. Onyx 18 has been used as a preoperative embolizing agent before the use of a plug or pushable coil during surgery [Pseudoaneurysms in the lingual artery occur following oral cavity procedures, emphasizing the importance of rapid evaluation and diagnosis of pseudoaneurysms and associated hematomas as they are potentially fatal postoperative complications. Imaging findings had features more consistent with a vascular lesion, rather than an infectious fluid collection or solid tumor. The workup for the other differential diagnoses would have involved invasive procedures, such as a biopsy, that could have provoked bleeding and fatally obstruct the airway. Consequently, identifying the vascular nature of the lesion on imaging is significant. For urgent tamponading of an unstable vascular lesion, Onyx 18 liquid embolization is a useful endovascular, neurointerventional approach for pseudoaneurysm treatment. The use of Onyx 18 provides optimism for the success of minimally invasive approaches to pseudoaneurysm treatment in the head and neck area without the need for coiling.


Pyogenic granuloma (PG) is a common reactive oral lesion predominantly involving the gingiva and rarely occurring on the dorsum of the tongue. It can develop at any age but more commonly in the second decade with a female predilection. Numerous factors are associated with its development, and surgical removal is the standard treatment.Various surgical modalities have been used to excise it. Herein, we report a case of a female patient in her late 60s who presented with an exophytic lesion involving the dorsum of the tongue, which was excised using a 940 nm diode laser. In addition, it discusses the advantages of diode laser as a surgical modality and describes this lesion's clinical features and pathogenesis. Pyogenic granuloma (PG) is a common reactive exophytic pedunculated or sessile soft tissue growth that can occur in the oral cavity ,2.The etiology of PG still needs to be clarified. However, numerous factors have been reported to be associated with its development, such as local irritation, trauma, dental plaque, hormonal factors, and some medications -4.Although PG may develop at any age, the highest prevalence was in the second decade. Pyogenic granuloma occurs more commonly in females, which may be attributed to the vascular effects of female hormones ,5,6.The prevalence of oral pyogenic granuloma is estimated to be around 1.85% among all oral hyperplastic lesions. It primarily affects the keratinized gingiva, with a higher incidence in the maxillary gingiva than the mandibular gingiva and a greater occurrence in the anterior rather than the posterior region. Involvement of extra-gingival areas, such as the buccal and labial mucosa, palate, and tongue, is rare ,8.The standard treatment for oral PG includes eliminating the etiological factors and conservative surgical removal of the lesion. Various surgical modalities have been used to excise oral PG. Cryosurgery, cauterization with silver nitrate, sclerotherapy, injection of absolute ethanol, sodium tetradecyl sulfate and corticosteroids, and neodymium-doped yttrium aluminum garnet (Nd:YAG) and CO2 laser, as well as laser photocoagulation, have all been proposed as treatment options ,5,6,9.Oral PG has no potential for infiltrative growth or malignant transformation. The recurrence rate after conservative excision is approximately 16%, with a higher chance of recurrence when it involves the gingiva or appears in pregnant women. Incomplete surgical removal, failure to eliminate the cause, and new trauma to the area can lead to recurrence ,10.Herein, we present a case of PG involving the dorsum of the tongue in a medically compromised female patient. The lesion was excised using a 940 nm diode laser, which resulted in a short healing period with no postoperative pain, ulceration, or scarring.A 69-year-old Saudi female patient presented to the oral medicine clinic in Prince Sultan Military Medical City in Saudi Arabia with a chief complaint of a lesion on her tongue. The patient had noticed this lesion about one year ago. It was painless and did not increase in size.The patient was previously diagnosed with hypertension, hyperlipidemia, osteoarthritis, and osteoporosis. She was under medical care for these conditions and was on the following medications: atenolol, atorvastatin, and IV denosumab. The extraoral examination was unremarkable.The intraoral examination revealed a painless, well-circumscribed, exophytic, sessile, red, nodular lesion with a pink base (approximately 2 mm in depth) located on the right side of the dorsum of the tongue. It was rubbery in consistency and measured about 0.5 × 0.6 cm. Our clinical differential diagnosis included pyogenic granuloma, hemangioma, vascular malformation, and foreign body granulomatosis. Differentiation between these lesions depending only on the clinical appearance is impossible. Thus, biopsy and histopathological assessment of the obtained biopsy are required to reach the final diagnosis.Patient laboratory tests were within normal limits, including complete blood count with differential, blood coagulopathy, and general profile. The lesion was excised under local anesthesia  using a 940 nm diode laser  with an initiated E4-4mm surgical tip. The tip was applied in contact mode with a focused beam using the circumferential incision technique to excise the tissue . Bleeding was then stopped using the hemostasis setting , and two interrupted 4/0 coated VICRYL sutures were placed to avoid food and debris entrapment and contamination of the surgical site Figure -1D. No pThe specimen was placed in 10% neutral buffered formalin and was sent for histopathological examination. Microscopic examination showed a parakeratinized stratified squamous surface epithelium. The underlying connective tissue stroma was fibrous with numerous and various shaped and sized engorged blood vessels with a central lobulated area of a highly vascular proliferation of granulation tissue and endothelial cells. The endothelial cells were positive for CD31  and negative for human herpesvirus 8 (HHV8) and cytokeratin (CK) AE1/AE3. Accordingly, the diagnosis of pyogenic granuloma (lobulated capillary hemangioma) was reached Figure -2C.The patient reported no postoperative discomfort, pain, or complication. The lesion showed adequate healing after only two days post-surgery. The two-week follow-up visit observed complete healing without ulceration or scarring. The patient was seen again at a three-month post-surgery evaluation visit and was found to be doing well with no complaints or recurrence of the lesion Figure , 3B.Pyogenic granuloma is a reactive hyperplastic neoplasm involving the oral cavity. Some authors claimed that the condition was initially reported by Hullihen in 1844, and the term pyogenic granuloma was established by Hertzel in 1904. Others claimed that Poncet and Dor originally reported the condition in 1897 as botryomycosis hominis, as they had suspected a fungal cause, while Crocker later introduced the term pyogenic granuloma in 1903 ,3,5,11. Various terms have been used in the literature for PG, such as granuloma pyogenicum, eruptive hemangioma, and granuloma gravidarum. The term pyogenic granuloma has also been considered inaccurate and misleading since this lesion is not accompanied by pus nor histologically resembles granuloma ,13.Clinically, PG usually manifests as a solitary, soft, exophytic, painless, pinkish-to-red mass with a pedunculated or sessile base that can be easily injured, causing bleeding ,14. HoweThe highest prevalence of PG occurs in the second decade of life, with the gingiva being the most commonly involved intraoral site ,5,6. In The etiology of PG remains unclear, and numerous factors are associated with its development -4. In thThe clinical manifestation of PG can mimic other angiomatous intraoral lesions, presenting a significant obstacle to clinical diagnosis . The difThe standard treatment of oral PG is conservative surgical removal and elimination of etiological factors. Various surgical modalities have been used to excise oral PG ,3,5,6,9.In this reported case, where a 940 nm diode laser was used for the surgical excision, the procedure was found to be simple to perform with minimum bleeding and excellent precision. It was well accepted by the patient, who showed no signs of fear or discomfort during the procedure. She also reported no postoperative pain or complications. Optimum healing was achieved with no residual ulceration or scarring within two weeks. Moreover, the excised specimen was adequate for histopathological examination.We presented a case of pyogenic granuloma, which was surgically removed using a 940 nm diode laser. The procedure was accomplished with minimum bleeding and discomfort. Postoperative healing occurred rapidly and without postoperative pain or scarring.Diode-assisted surgical excision provides a stress-free environment with a more comfortable experience for both the clinician and patient; thus, it should be considered as a practical alternative to the traditional surgical technique.


Lung cancer stands as the second most prevalent tumour and the foremost cause of cancer-related mortality. It typically manifests through respiratory symptoms. Subcutaneous metastases originating from pulmonary cancers are rare occurrences, with a remarkably low incidence.A 53-year-old patient, with a history of smoking and unchecked chronic obstructive pulmonary disease, sought care at our outpatient clinic due to the rapid development of a subcutaneous mass. The patient underwent surgical excision of the mass under local anaesthesia. The anatomopathological examination confirmed the diagnosis of cutaneous metastasis from an infiltrative adenocarcinoma. A whole-body CT scan revealed an invasive mucinous adenocarcinoma of the lung. Consequently, palliative chemotherapy was initiated. Unfortunately, the patient succumbed to the disease three months later.Subcutaneous metastasis originating from pulmonary sources is a rare phenomenon, with scant literature available on the subject. The presence of pulmonary cutaneous metastasis serves as an ominous sign of rapidly progressing and aggressive lung cancer. The prognosis in such cases is reserved, with an overall survival rate measured in months. The approach to management in these instances predominantly revolves around palliative chemotherapy, although surgical excision of metastases may be considered in select cases.Lung cancer unmasked by subcutaneous metastasis represents a rare clinical scenario. While chemotherapy remains the cornerstone of treatment, surgical intervention to remove metastases may be contemplated in a restricted subset of cases. Further research is imperative to ascertain the impact of surgery on both quality of life and overall survival. •Skin metastases of lung cancer are very uncommon and represent evidence of the aggressive nature of the primary tumour.•Invasive mucinous adenocarcinoma of the lung is a rare subtype of lung adenocarcinoma.•Removal of skin metastases of lung cancer may hold promise in slightly improving patient outcomes.•A rapidly evolving subcutaneous mass could potentially signal a malignant nature, necessitating thorough investigation. Herein,2A 53-year-old patient, with a long history of smoking and unmonitored chronic obstructive pulmonary disease, was referred to our outpatient clinic for a rapidly evolving subcutaneous mass for a three-month duration. Upon examination, a distinctive, painless, and palpably solid subcutaneous nodule, measuring 2 by 2 cm, was discovered on the dorsum. Remarkably, there were no overt signs of local inflammation. The patient exhibited pursed-lip breathing, with a breathing rate of 22 cycles per minute. The oxygen saturation level was at 90 % and the auscultation revealed decreased breath sounds and dullness to percussion on both sides of the chest, indicative of bilateral pleural effusion. The patient underwent surgical full skin excision of the nodule down to subcutaneous fat under local anaesthesia and was referred to the pneumology department. Upon gross examination, the specimen revealed an irregular, fibrous nodule measuring 22 by 14 mm surrounded by adipose tissue . The his3Metastasis occurring in subcutaneous tissue is a rare occurrence, with an overall incidence rate of a mere 5.3 % . The abiThe diagnostic challenge with skin metastasis arises from the diverse array of clinical presentations it can assume. These manifestations may take the form of fibrotic processes, nodules, cellulitis, zosteriform lesions, or ulcerations. Strikingly, these skin alterations can often be painless, displaying a spectrum of colours and sizes ranging from 2 mm to 6 cm ,10. FaceMalignancies in the upper lobes of the lungs exhibit a higher propensity for skin metastasis . The majIn the traditional approach to stage IV lung cancer treatment, decisions are reached through multidisciplinary meetings. The cornerstone of treatment is palliative chemotherapy, contingent on the patient's overall health and performance status. Drug selection is tailored to the specific histological type. Since 2012, a new approach has emerged for stage IV patients with skin oligo-metastases. Those who underwent a combination of chemotherapy and surgical excision of skin metastases exhibited superior outcomes compared to patients receiving chemotherapy alone ,21,22. E4Skin metastases unveiling pulmonary cancer represent a seldom-discussed topic in medical literature, and their presence is typically indicative of a particularly reserved prognosis. While systemic treatment remains the cornerstone of management in this advanced stage, recent emerging research suggests that surgical removal of these metastases may hold promise in slightly improving patient outcomes. Clinicians should keep a high index of suspicion when encountering a rapidly evolving subcutaneous mass and not take the issue lightly because the prognosis may hinge upon a prompt diagnosis.A written consent was obtained from the patient to publish this case report.Anis Hasnaoui.N/A.Ethical approval was deemed unnecessary by our institutional ethical committee, as the paper is reporting a single case that emerged during normal practice.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Anis Hasnaoui: Conceptualization, Writing-Reviewing and Editing. Racem Trigui: writing-Original draft preparation. Amal Benasr: Data curation. Mariem Nouira: Writing-Reviewing. Fakhreddine Ben Abdallah: Data curation. All authors read and approved the final manuscript.The authors declare that they have no competing interests.


A 10-year-old, male-neutered, domestic short-hair cat was examined at the Veterinary Health Center Emergency Service at Kansas State University for a one-day history of dyspnea. Prior to thoracocentesis, sedation was provided. The cat stopped breathing after sedation and went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was unsuccessful. At necropsy, there was severe pleural effusion and bilateral pulmonary atelectasis. The myocardium of the atria and ventricles, and tunica adventitia of coronary vessels, pulmonary artery, and aorta, had pale, firm, multinodular masses ranging from 0.3 to 0.5 cm in diameter. Multiple nodules were also present in the liver. Multifocally expanding the epicardial fat and compressing the underlying epicardium, infiltrating, and expanding the myocardium, and expanding the walls of major vessels, there was a multinodular, unencapsulated, densely cellular neoplasm composed of polygonal epithelial cells arranged in nests and packets and supported by a fine fibrovascular stroma. The nodules in the liver had similar histologic features. In this case, neoplastic cells at the primary and metastatic sites were intensely immunoreactive to synaptophysin, variably reactive to chromogranin A, and negative for neuron specific enolase, cytokeratin, vimentin, thyroglobulin, and smooth muscle actin. The gross, histologic, and immunohistochemical findings support the diagnosis of chemodectoma, with metastases to the liver. Synaptophysin and chromogranin A were the most useful immunohistochemical markers to diagnose malignant chemodectoma in this cat. Primary cardiac neoplasms are rare in domestic cats and very few reports exist in the literature. Most commonly reported cardiac neoplasms in these animals include lymphoma, hemangiosarcoma, rhabdomyosarcoma, ganglioneuroma, metastatic tumors, and less frequently, aortic and carotid body tumors (paraganglioma/chemodectoma) –14. UnliChemodectoma is a generally benign neoplasm composed of neoplastic chemoreceptor cells and are often benign. Chemoreceptor cells are present in several tissues of the body, including aortic and carotid bodies located in the submandibular and cranial cervical regions and adventitia of major vessels at the base of the heart, pancreas, eyes, ear, and some cranial nerves . ChemoreChemodectomas are known to be functionally inactive, and most of the observed clinical signs are associated with the space-occupying effects of the tumor or other complications such as tachypnea/dyspnea secondary to pleural effusion or dysphagia as a result of esophageal compression . There hIn dogs, there is minimal risk of metastasis but this is common , 25, 26.To date, very few cases of chemodectoma in cats are reported in literature, and much less documentation of local or distance metastasis of the neoplasm is available , 24, 27.A 10-year-old, male-neutered, domestic short-hair cat was referred to the Kansas State University Veterinary Health Center Emergency Service for evaluation of a one-day history of dyspnea with previous reported episodes of wheezing during the fall season. The cat was otherwise healthy and respiratory clinical signs were previously attributed to exposure to wildfire smoke. On arrival, the cat had an open mouth breathing and was placed in an oxygen cage for supportive care. After stabilization, a more thorough examination revealed reduced bilateral lung sounds, but no murmur was evident on auscultation. Thoracic focused assessment with sonography for trauma, triage, and tracking testing (TFAST) revealed moderate bilateral pleural effusion more markedly affecting the right hemithorax. The cat was given butorphanol (0.23 mg/kg) intramuscularly and furosemide (3 mg/kg) intravenously. The respiratory rate decreased after the administration of medications, but the patient was still orthopneic. Subsequently, Midazolam (0.2 mg/kg) and Alfaxalone (0.75 mg/kg) were administrated intravenously to facilitate therapeutic thoracocentesis. Although sedated, the respiratory rate of the patient continued to decrease, and he developed cardiac and pulmonary arrest shortly after. Cardiopulmonary resuscitation (CPR) was performed, and spontaneous breathing returned. The cat developed cardiac arrest again after about 10 min and additional CPR was performed but was not successful.At necropsy, the animal was in good nutritional condition with adequate subcutaneous and intra-abdominal fat, as well as adequate skeletal muscling. The pleural cavity contained approximately 700 mL of thick, clear, fluid. Bilaterally, the lungs were diffusely atelectatic. The pericardium was firmly adherent to the right and left atria and the pericardial cavity contained approximately 5 mL of free, dark red, slightly viscous fluid. The epicardium, epicardial adipose tissues, interatrial septum, the tunica adventitia of coronary vessels, pulmonary artery, and aorta, had multiple, adherent, firm, pale, multinodular masses ranging from 0.3 to 0.5 cm in diameter, which were red-to-white and marbled on cut surfaces . After f2 (10 consecutive 400X fields). The neoplasm had multifocal areas of hemorrhage and necrosis characterized by cytoplasmic hypereosinophilia and nuclear pyknosis and karyorrhexis; and was rarely infiltrated by moderate numbers of lymphocytes and macrophages. Epicardial fat, tunica adventitia, media and intima of large arteries were also infiltrated and effaced by nests and packets of neoplastic cells. In the liver, nodules were consistent with metastatic dissemination from the heart neoplasm based on similar histologic and morphological features. Immunohistochemical analysis of sections of the heart and liver neoplasm was performed at Kansas State Veterinary Diagnostic Laboratory following internal validated protocols. All immunostains are listed in Histologic evaluation was performed on routinely processed formalin-fixed, paraffin-embedded tissue sections (5 μm) stained with hematoxylin and eosin (H&E). All H&E reagents were purchased from StatLab, McKinney, Texas, US. Microscopic evaluation of the masses in the heart revealed an infiltrative, non-encapsulated, poorly circumscribed, densely cellular multilobulated neoplasm composed by polygonal cells arranged in nests and packets and supported by a fine fibrovascular stroma . NeoplasThis report describes primary cardiac and vascular chemodectoma with hepatic metastatic dissemination in a domestic cat. As mentioned previously, primary heart neoplasms are rarely reported in domestic cats. However, chemodectoma, hemangiosarcoma, ectopic thyroid, and parathyroid carcinoma have been documented , 8. TherChemodectomas are non-chromaffin neuroendocrine tumors arising from neoplastic transformation of chemoreceptor cells located within the tunica adventitia of major blood vessels, frequently at the bifurcation of the common carotid arteries (carotid body) and along the aortic arch (aortic body) , 29. CheIn general, chemodectomas are non-functional, space-occupying, and locally invasive masses, with a low reported metastatic potential (up to 22% in canine tumors) . SimilarThe cat in this report was 10 years old which falls within the common age range at which chemodectomas have been reported 10–15 years). In general, older animals are more susceptible to neoplastic diseases because of the inherent chronic exposure to environmental insults, inevitable accumulation of DNA damage, or impaired DNA repair mechanisms. In canines, metastasis to the liver, lung, kidney spleen, bone marrow, lymph nodes  years. I has beenExpression of neuron specific enolase (NSE) was present in all neoplastic cells in canine aortic body neoplasm irrespective of metastasis . HoweverIn this case, the exact tissue origin of the neoplasm is unknown (carotid vs. aortic body vs. atrium). The respiratory distress in the cat is attributed to pleural effusion and bilateral pulmonary atelectasis, secondary to the neoplasm. The neuroendocrine origin of the neoplasm was confirmed by positive immunoreactivity to synaptophysin and chromogranin A. Interestingly, neoplastic cells in the liver were also strongly positive for synaptophysin and chromogranin A, and negative for the other previously stated immunohistochemical markers. Thyroid, epithelial, and mesenchymal tumors were ruled out with the specific immunohistochemical markers as previously described . Taken tIn conclusion, this case report describes the clinical, gross morphologic and histopathologic features, as well as immunoreactivity of neoplastic cells in a metastatic feline chemodectoma. This neoplasia should be considered as a differential diagnosis in cases of sudden onset of respiratory distress, pleural effusion, pulmonary atelectasis, and a space occupying mass in the thoracic cavity in domestic cats. Immunohistochemical analyses indicate that synaptophysin and chromogranin A are more useful ancillary tests in the diagnosis of feline chemodectomas. Based on this current report and the review of relevant literature, a recommended immunohistochemical panel to support the diagnosis of chemodectoma in domestic cats include synaptophysin and chromogranin A . The neoThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study of animals in accordance with the local legislation and institutional requirements. Written informed consent from the owners for the participation of their animals was not required in accordance with the national legislation and the institutional requirements.SA, KC, and FMF wrote, reviewed, and edited the manuscript. JT reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.


Despite its rare incidence of 1/40,000, fetal cardiac rhabdomyoma (CR) represents the prevailing type of benign cardiac fetal tumors, which commonly affects the ventricles. Fetal CRs rarely occur in the right atrium. Thus, the presentation of atrial fibrillation and premature atrial contractions (PAC) due to a solitary cardiac rhabdomyoma is an extremely rare scenario. Our literature review found that only 2% (1 out of 61) of rhabdomyoma cases were found in the right atrium. The majority of fetal cardiac rhabdomyomas are associated with tuberous sclerosis complex (TSC).A 7-day-old male neonate presented with arrhythmias and an atrial mass for further evaluation. Echocardiography revealed a hyperechoic, round, uniform right atrial mass (25 mm). An abdominal and testicular ultrasound showed multiple thin-walled cortical cysts in both kidneys and a scrotal hydrocele, respectively. His laboratory workup was insignificant except for hypomagnesemia. Electrocardiography revealed junctional rhythm and PACs with wave distortions. A brain magnetic resonance imaging scan revealed multiple subependymal lesions on the frontal and occipital horns of the lateral ventricles. These findings Fig. , along wDespite CR’s predominance in the ventricles, a diagnosis of rhabdomyoma should be kept in mind in the presence of a solitary atrial mass and PACs. Physicians should evaluate systemic findings related to TSC and provide appropriate follow-up and family screening. Surgical resection is not always required, and symptom management can be achieved through medical treatment alone.The online version contains supplementary material available at 10.1186/s12872-023-03639-4. Tuberous sclerosis complex (TSC) is an autosomal dominant condition that is distinguished by the presence of hamartomas in multiple organs throughout the body, including the heart . ApproxiTwo previous literature reviews of all published cases with CRs and TSC-associated CRs were conducted up until 1990 and from 1990 to 2011, respectively , 7. We cIn this report, we present a rare presentation of PACs in a neonate due to a right atrial rhabdomyoma associated with TSC.A 7-day-old male neonate, born to non-consanguineous parents, gravida 3 para 2, at 39 weeks of gestation, cried immediately after birth and showed no signs of respiratory distress syndrome. He was referred to our department after an external clinic detected a solitary mass in the RA along with atrial fibrillation. He was initially asymptomatic and was admitted to the nursery for further care and monitoring of his cardiac condition. His family history included an older sibling who had been diagnosed with TSC at 2 years of age.Upon admission, the chest and abdominal physical examinations were normal. Peripheral pulses were symmetrical, and heart rate was normal (120 bpm). An irregular rhythm was detected during auscultation.Echocardiography showed a mildly dilated RA with a hyperechoic, homogenous mass measuring 25 × 20 mm in the superolateral wall of the RA with an outpouching that pointed towards the tricuspid valve  revealed a junctional rhythm with PACs occurring at a rate of 1 contraction every 4 beats on the aVL electrode, in addition to wave distortions on both the aVR and aVF electrodes Fig. . CompletFurther investigation with a brain magnetic resonance imaging (MRI) scan showed multiple subependymal nodules in the frontal horn of the right lateral ventricle and occipital horns of both lateral ventricles, which were characterized by high signal on both T1 and T2-weighted images Fig. . The resAnticonvulsants were prescribed. The patient remained asymptomatic until discharge. Daily cardiac investigations were conducted during his hospital stay. Since there were no major symptoms or hemodynamic instability, the patient was monitored through regular follow-ups. The patient has remained asymptomatic to date. He had a normal ECG at 9 months with no arrhythmias or PACs. Imaging prior to 9 months demonstrated signs of regression, but further imaging is required. The patient is scheduled for imaging in 2 months.Tuberous sclerosis complex is an autosomal dominant genetic disorder characterized by the formation of hamartomas in various organs such as the skin, brain, heart, lungs, kidneys, and liver . It occuWith a rare incidence of 0.2% , CRs areThe clinical features of TSC consist of seizures, hydrocephalus, mental retardation, rhabdomyomas, renal angiomyolipomas, developmental delay, spine malformations, and skin angiofibromas . CRs areThe diagnosis of rhabdomyoma can be determined through prenatal ultrasound or MRI during the third trimester of pregnancy or in the early neonatal period , 13. UltThe diagnosis of TSC relies on clinical criteria that are categorized as major and minor Table  15].Ta.Ta15].To confirm the diagnosis, at least two major criteria or one major and two minor criteria must be present. A probable diagnosis can be made with one major criterion or two or more minor criteria . Our casRegarding the treatment and management of TSC, significant progress has been made with mechanistic target of rapamycin complex 1 (mTORC1) inhibitors leading the way . If the Additional file 1:.Additional file 2:.


Recently proposed diagnostic criteria for iatrogenic cerebral amyloid angiopathy (iCAA) have sparked increased recognition of cases across the globe. Whilst these patients tend to have a tumultuous course, much like sporadic CAA, there is a high degree of variability. What is unique in this case is the breadth of clinicoradiological data available, including handwritten surgical notes from 1985. In retrospect, early imaging changes of what would ultimately lead to profound morbidity, were apparent 30 years after inoculation with cadaveric dural tissue.In this case study we examine the clinicoradiological features of a case of probable iCAA and draw awareness to the presence of this disease in Australia.This case was admitted under the care of the author at the Royal Brisbane and Women's Hospital (RBWH). Clinical details and data were gathered during the patient's care and consent for publication provided by the enduring power of attorney.This 56-year-old female presented in 2018 with left hemiparesis, neglect, and dysarthria secondary to a large right frontal lobe intracerebral hemorrhage (ICH) without an underlying macrovascular cause. MRI brain demonstrated diffuse superficial siderosis assumed related to previous surgical interventions during the mid-1980s for a Chiari malformation and cervical syrinx. There was evidence of extensive white matter disease, discordant with her lack of cerebrovascular disease risk factors. Brain biopsy confirmed CAA. Archived surgical notes confirmed exposure to Lyodura in 1985 and 1986. Two decades of MRI data were available for review and illustrate the evolution of CAA, from normal post-operative findings to marked and unrecognized abnormalities 4 years prior to her first ICH.This is the first Australian case of probable iatrogenic CAA (iCAA) to have such extensive documentation of clinicoradiological evolution. It demonstrates the aggressive course iCAA can take and provides insights into early disease manifestations, relevant to the more common sporadic cases. A brief review of the history of commercial cadaveric tissue use in Australia highlights enormous changes in medical practice over the last 50 years. Awareness within Australia should be raised for this clinical phenomenon, and cases collated to contribute to the growing international pool of evidence. In the last 5 years there has been a surge in the number of cases of presumed iatrogenic cerebral amyloid angiopathy (iCAA) reported. Following pivotal presentations at the 2020 International Cerebral Amyloid Angiopathy Association (ICAA) Conference, case finding increased exponentially with more than 50 cases worldwide now published  and CAA on autopsy of 8 individuals who died from iatrogenic CJD (iCJD)  in 2018 after presenting with acute dense left hemiparesis, dysarthria, and neglect. Her blood pressure on presentation was 119/76. Initial CT imaging, including angiography revealed a large right frontal lobe intracerebral hemorrhage (ICH) and no underlying macrovascular lesion.Her clinical history was gathered via her next of kin, medical records from the Queensland public health system and her Primary Care Physician. She was a Sicilian Australian non-smoker, non-diabetic, of healthy weight, with no hypertension, a healthy cholesterol profile (without treatment) and no family history of dementia, stroke, or ischaemic heart disease. She had no past medical history of any previous traumatic brain injury, stroke, transient focal neurological event (TFNE) or cognitive impairment. There was an ill-defined period of right upper limb paraesthesia in 2014 which was attributed to cervical radiculopathy considering concomitant pain.Between 2016 and 2018 she was commenced on Aspirin, Enalapril and Rosuvastatin by a Primary Care Physician in response to incidental MRI findings of chronic small vessel ischaemia but she had not met criteria for primary or secondary stroke prevention at that time and those medications were ceased following this first admission with ICH in 2018, during which her average systolic blood pressure was 100 mmHg.Formal digital subtraction cerebral angiography on Day 2 of her first admission was unremarkable.MRI brain demonstrated multifocal and bilateral cortical superficial siderosis (cSS) and periventricular white matter hyperintensities (WMH) with some confluence but sparing of the basal ganglia and brainstem. Marked cerebellar siderosis was noted and initially thought related to a previous posterior fossa decompression for a Chiari malformation and cervical syrinx, a procedure she had undergone in 1985, and revised in 1986 at the RBWH. Extensive investigation for cerebral vasculitis was negative. She was managed in the acute stroke unit and stabilized for inpatient rehabilitation. Her initial improvement over several weeks was interrupted by a recurrent ICH. Over the subsequent 3 months she suffered 3 further ICHs in new locations, at near monthly intervals. Subsequent to the second ICH she underwent a brain biopsy which revealed CAA .A genetic panel for CAA variants  was negative. Her ApoE genotype was ε3/ε3, conveying no predisposition to CAA or AD.Between 2018 and 2023, the patient received 24 h supported care at her own residence after months of inpatient and outpatient formal rehabilitation. Her short-term memory was severely impaired, but some quality of life was garnered with her speech being largely intact, the capacity to stand transfer with assistance, and using an electric wheelchair outside the home. She was briefly re-admitted in 2019 for focal seizures with secondary generalization which ceased with regular Levetiracetam. Her course was further complicated by osteoporosis from prolonged immobility, currently managed with Bisphosphonates, and chronic pain owing to spasticity and radiculopathy.Whilst there had been little improvement since 2018, she had not suffered a further ICH until February 2023, at which point she developed a new right sided hemiparesis and abulia. Repeat CT imaging demonstrated a new and large volume ICH in the left medial frontal and parietal lobe. She remains an inpatient and has made minimal improvements, with rare single word outputs, quadriparesis but intact alertness and swallow maintaining an unmodified diet with full assistance.In 2021, the patient's archived medical records had been retrieved and documentation of the use of Lyodura was confirmed. Lyodural grafts were applied to the cranio-cervical junction in two separate neurosurgical procedures in 1985 and 1986.Intensive investigation allowed collation of nearly two decades of MRI data for review . These sIn further detail, MRI results were available from 2002 to 2018 and CT imaging from 2012 to 2023. All MRIs were performed on a 1.5 Tesla machine up until 2018, at which point images were acquired with 3 Tesla field strength. MRI from 2002 and 2006 shows a normal cerebellum on T1 and T2 sequences without the enlarged cerebellar folia present from 2014 onwards. In 2014 and 2016, MR sequences included susceptibility weighted imaging (SWI) in addition to T1, T2, FLAIR, DWI, ADC map, 3D T1 FIESTA, and T2 fat saturation. In accordance with the STRIVE criteria  demonstrates increased confluence of WMH (Fazekas grade 2), with ongoing sparing of the basal ganglia and brain stem. EPVS have increased to 20 within the basal ganglia, but to more than 40 within the left CSO, the right being obscured by the acute ICH. The cSS remains similar to 2016 and there are still no CMB.This case of iCAA meets the proposed diagnostic criteria  for the publication of this case report.CM is the sole author of this case report and completed all of the work necessary to compile the information required after acquiring written informed consent to publish and present de-identified material relating to the patient.


A glioependymal cyst (GEC) is a rare type of cyst that occurs within the brain and spinal cord. A 42-year-old male patient with a cystic lesion in the right frontal lobe was admitted to the hospital to have his headache, vertigo, and body spasms evaluated. MRI scans showed a mass in the right side of the frontal lobe which caused a mass effect over the lateral ventricle and corpus callosum. The patient became symptom-free after the craniotomy, followed by fenestration of cortices and cyst wall removal. Glioependymal cysts (GECs) are a rare but significant type of cyst that can develop in the central nervous system. These cysts are characterized by both glial and ependymal cells, which are important types of cells that provide support and protection to nerve cells in the brain and spinal cord. While GECs are typically benign, they can cause a range of symptoms if they grow large enough to pressure surrounding tissues. These symptoms can include headache, seizure, and neurological deficits, significantly impacting a person’s life. Despite the importance of the cysts, relatively little is known about their underlying causes or the approach for diagnosis and treatment . We presThis is a case of a 42-year-old female with a previous medical history of diabetes mellitus well controlled with antidiabetic medication. The patient presented to the emergency department with complaints of a sudden onset of intermittent headaches and dizziness for the past few months. He initially ignored the symptoms, attributing them to stress at work. However, the symptoms began to worsen and were accompanied by occasional episodes of nausea and vomiting. There was no history of unconsciousness, fever, or other medical conditions. The past history and family history of the patient remain insignificant. Physical and systemic examinations and all laboratory investigations were within normal limits. The patient’s EEG revealed a sharp wave pattern. On admission, an MRI was advised, which showed a 42 x 51 x 22 mm ( SI X TR X AP ) cyst. The margins were well-defined, and the lesion was oval on the right side of the frontal lobe with an intensity higher than that of CSF. This lesion was causing a mass effect over the surrounding neuroparenchyma and corpus callosum. No limited diffusion, calcification foci, or hemorrhage were detected inside the intra-axial well-defined lesion of the cysts, which appeared hypo-intense on T1 Figure .  These imaging characteristics led to the conclusion that the lesion was a GEC. The cyst wall was lined with flattened cuboidal epithelium, according to the microscopic analysis of the H and E stained slide Figure .Neuroglial and adipose tissues may be seen in the subepithelium. The histological characteristics indicated that the disease was a GEC. With the progression of symptoms, the surgeon performed a transcortical craniotomy, and the cyst wall was fenestrated. A large portion of the wall was resected. Intraoperatively, a clean fluid oozed out when the cyst wall was opened. The patient tolerated the surgery well, and during the six-week postoperative appointment, there was a complete resolution of the pre-operative signs and symptoms. A microscopic examination of the cyst wall showed a ciliated cuboidal ependymal lined tissue resting over a thin layer of glial tissue.GECs are uncommon, non-neoplastic, and epithelial-lined conditions in the central nervous system . The mosGECs are rare but significant conditions that can cause various symptoms, including headaches, dizziness, and nausea. Early diagnosis and prompt treatment are essential for a positive outcome. In this case, surgical removal of the cyst was successful, and the patient experienced significant improvement in his symptoms. Regular follow-up appointments are critical to ensure that the patient continues to recover and that there are no signs of recurrence.


Splenic rupture of all causes is a potentially life-threatening event for patients. The infrequency of atraumatic splenic rupture (ASR) poses a significant diagnostic challenge due to atypical findings. ASR is commonly due to a spleen with an underlying disease process such as malignancy, infection, coagulopathies, or neoplasms. However, ASR without an identifiable cause is rare and poses further complexity. In this case, a 57-year-old woman with a history of hypertension presented to the emergency department complaining of chest pain and was found to have a splenic hematoma. She underwent splenic artery embolization due to her continued hemodynamic instability. The patient was ultimately treated with a splenectomy, as embolization was unsuccessful. Gross pathology revealed no underlying disease processes, nodules, or masses. Splenic hemorrhage due to atraumatic rupture of the spleen is rare and without known pathology. The case illustrates the need for providers to have high clinical suspicion of such a diagnosis to stabilize and surgically manage these patients. Few instances of ASR without an identifiable cause are found in medical literature, and further knowledge of the subject is needed. Splenic rupture is a potentially life-threatening condition commonly due to blunt abdominal trauma that is extensively covered in the medical literature -3. HowevCases of ASR without the above etiologies are related because they lack the typical clinical presentation expected among these patients and present a challenge in determining appropriate management. Splenic rupture is a clinical diagnosis confirmed by a CT scan or laparotomy in hemodynamically unstable patients. There are well-established CT or ultrasound grading systems that can help guide the appropriate management of patients with ASR.A 57-year-old female presented to the emergency room complaining of chest pain. Her medical history was notable for hypertension treated with 5 mg of amlodipine once daily and 50 mg of metoprolol tartrate twice daily. Her family history was unremarkable. Her social history was remarkable for her smoking and alcohol use. Equal in timing, she reported chest pain localized to the left lateral side, radiating to the abdomen and left flank. The patient appeared to be in acute distress and diaphoretic. The patient denied any recent trauma. On physical exam, she was tachycardic and had diffuse abdominal tenderness to light and deep palpation. Her abdomen was non-distended, dull to percussion, and had no rebound tenderness. Pertinent laboratory findings included the following: normal hemoglobin 12.2 g/dL), normal blood urea nitrogen/creatinine ratio (15/1.4), and a mildly elevated troponin . A computer tomography angiography (CTA) of the chest, abdomen, and pelvis demonstrated a large peri-splenic hematoma measuring 12.5 cm × 15.4 cm × 13.1 cm with no definite active extravasation , and pneumococcal 23, and discharged on postoperative day 7.At that time, the patient underwent an emergency splenectomy, during which approximately 3.5 L of blood was evacuated. The spleen was actively bleeding through multiple fractures. Two units of PRBC and two units of FFP were administered intraoperatively. Gross spleen pathology revealed benign splenic rupture with evidence of hemorrhage, without nodules or discrete masses. There were no splenic artery abnormalities. Postoperatively, the patient was transferred to the ICU, where she remained hemodynamically stable with a positive hemoglobin trend. The remainder of this patient’s hospital course was unremarkable. She was given prophylactic vaccinations, including meningococcal A, meningococcal B, The majority of splenic rupture cases, overall, are due to blunt abdominal trauma . ASR is Investigation of cases defined as "true" ASR often involves other underlying pre-existing diseases such as diabetes, heart disease, splenic abscess, or malignancy . In thisHowever, the patient's history of hypertension and alcohol use disorder may have contributed to the atraumatic splenic rupture, but there has been no evidence in the literature. To the best of our knowledge, idiopathic atraumatic splenic rupture is a rare occurrence with an incidence of 0.1-0.5% .Treatment considerations for ASR should not take a different approach than those for typical causes of traumatic rupture. Hemodynamic stability is the primary consideration; however, total splenectomy should be considered as a first-line approach in cases with underlying malignancy or where the splenic function is compromised. A more conservative approach involves splenic artery embolization with IR, which was a successful treatment method for a spontaneous splenic rupture in a patient with COVID-19 . AdditioAlthough ASR is not a common cause of splenic hemorrhage, it should be considered a potential cause, and a total splenectomy should be anticipated.Splenic rupture without traumatic or pathological causes is a rare occurrence that can lead to hemorrhagic shock and death. Indeed, spontaneous ruptures are a rare occurrence. Patients with pre-existing conditions such as diabetes or heart failure over 40 presenting signs of diffuse abdominal pain, hypotension, and tachycardia should be considered for splenic rupture. After hemodynamic stability, additional workup for coagulopathies and underlying malignancies or conditions such as amyloidosis should be investigated. Splenic rupture should be considered in the setting of acute abdominal pain, despite no known traumatic or pathologic causes.


The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies. We present a case of chyloperitoneum in a 33-year-old woman secondary to penetrating abdominal trauma secondary to a gunshot wound. The patient was successfully managed with total parenteral nutrition and octreotide administration. To our knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature. Conservative management with the initiation of total parenteral nutrition and octreotide led to the resolution of this condition. The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction .The lymphatic system is a network of tissues that allows the return of excess interstitial fluid to the vasculature. In the intestine, the major function of gut lymphatics is to regulate the interstitial fluid balance and transportation of lipids . Lymph fDisruption of the flow of the lymph regardless of the etiology can result in extravasation of the lymph that can manifest itself as chylous ascites. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies . ChylousThis article presents a case of chyloperitoneum secondary to penetrating abdominal trauma due to a gunshot wound. To the authors’ knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature.A 33-year-old female with no past medical and surgical history of sleeve gastrectomy was brought to the emergency department after sustaining a gunshot wound to the left flank. The patient was hemodynamically stable upon arrival. Bilateral lower extremity weakness with motor strength 3/5 was noticed. Focused Assessment with Sonography for Trauma (FAST) was negative. Computed tomography (CT) chest/abdomen/pelvis with intravenous contrast and CT of the thoracic and lumbar spine were performed, which revealed evidence of right colonic injury with extraluminal air and fluid in the right paracolic gutter along with an acute comminuted fracture of the L3 and L4 vertebral bodies with retropulsion and compression of the spinal canal Figures , 2.The patient was taken to the operating room for exploratory laparotomy. Intraoperative findings included a trans-retroperitoneal bullet trajectory from the left flank, left psoas, and L3/4 vertebral bodies through the right psoas below the inferior renal pole and ascending colon with gross contamination. Right hemicolectomy with primary anastomosis and abdominal washout were performed.The patient had a prolonged hospitalization that was complicated by the presence of intra-abdominal collections that were initially identified on postoperative day 7 Figures , 4.Paracentesis of the abdominal collections with the placement of a pigtail catheter was performed twice by interventional radiology.The patient was noted to have an ongoing increased output of milky, odorless fluid from the drains (approximately 200-400 mL daily) with eventual dehiscence of the midline abdominal incision.Differential diagnosis included a missed renal/ureteral injury, the presence of a pancreatic fistula, and the very rare case of chylous ascites secondary to disruption of the cisterna chyli that lies adjacent to the first and second lumbar vertebral bodies. Although the collection was initially presumed to be infectious in etiology, this diagnosis was excluded given the absence of systemic findings, benign abdominal examination, diet tolerance, and failure to respond to antibiotics. A CT abdomen/pelvis with enteric contrast did not reveal any communication between the collections and the gastrointestinal tract. CT cystogram and ureterogram were performed, which did not show any evidence of a urinary leak. Indigo carmine dye was also administered through the urinary catheter in an attempt to highlight the drain output in case there was communication with the urinary system, but the test was negative. A fistulogram was also performed with the administration of water-soluble contrast through one of the pigtail catheters; however, no communication was identified between the collections and the gastrointestinal/ urinary systems Figure .The diagnosis of pancreatic fistula was rather unlikely due to the presence of low drain amylase (10 U/L). Given the high suspicion of chyloperitoneum, lymphoscintigram was performed, but unfortunately the study was limited and non-diagnostic. Triglycerides from the drains were sent and were initially within normal limits . The patient was given a fatty meal, and the exam was repeated. Drain triglycerides were 90 mg/dL. Given the high suspicion of chyloperitoneum, total parenteral nutrition (TPN) and octreotide 100 mcg three times daily were initiated and administered for one month. She was then initiated on a low-fat diet with medium-chain fatty acids and tolerated it well. The patient demonstrated significant improvement of the midline abdominal wound dehiscence, while the drain output gradually decreased. Drains were removed on postoperative day 66. The patient was discharged after 72 days of hospitalization. Complete closure of the abdominal wound dehiscence was evident three months after discharge. The term chyloperitoneum refers to the accumulation of triglyceride-rich, milky-appearing fluid in the abdominal cavity. It is an uncommon clinical entity that was first described by Morton in 1694 as a result of disruption of the cisterna chyli in the setting of tuberculosis . Since nThe majority of cases are due to malignancies (predominantly lymphoma), cirrhosis, and iatrogenic mechanisms/injuries due to disruption of the lymphatic flow during complex general surgery cases. In the pediatric population, the etiology is most likely congenital . TraumatThe clinical picture of a patient developing chylous ascites is usually insidious with gradual accumulation of peritoneal fluid and increased abdominal girth. As the disease progresses, vague abdominal pain, nausea, and paralytic ileus may appear . In our Several diagnostic tools are available. CT of the abdomen is particularly useful in identifying intra-abdominal collections. In the setting of chyloperitoneum, the accumulated fluid has a similar density to water and is readily distinguishable from hemorrhagic fluid, especially in the context of trauma . The patLymphoscintigraphy can also be used in order to demonstrate obstruction or leakage of lymphatic channels. It is performed with subcutaneously injected technetium-99m-labeled colloid, which, due to its high specificity for the lymphatic system, can provide useful information about the transport of the lymph. In the presence of a leak fluid, collections can be identified due to the high uptake of the radionuclide tracer. The limitation of the study arises from low spatial resolution and lack of spatial information . The useLymphangiography is considered to be the gold standard in defining chylous ascites secondary to obstruction . BesidesAbdominal paracentesis is the most important confirmatory test . Chyle tThe management of chylous ascites is usually conservative and aims to limit the chyle flow through the intestinal lymphatics. Dietary restrictions consist of the administration of a high-protein, low-fat diet with medium-chain triglycerides (MCT) , 6. In cMedical therapy consists of several different medications that aim to decrease the accumulation of chylous fluid in the peritoneal cavity. Somatostatin and its synthetic analog octreotide have been used in the management of chylous ascites. Although their mechanism is not completely understood, they have been shown to decrease portal venous pressure by inhibiting splanchnic vasodilation. They can also decrease intestinal peristalsis, fat absorption, thoracic duct flow, and triglyceride content in lymphatics . SomatosIf the chylous ascites does not respond to conservative measures, surgical management should be pursued. Abdominal paracentesis and drainage of the abdominal fluid play both diagnostic and therapeutic roles. Paracentesis should be used in combination with other conservative measures due to its decreased efficacy when used alone . LymphagPeritoneovenous shunting (LeVeen or Denver shunts) has been used in the past in the management of refractory cases, but their use is currently limited due to the high rate of shunt occlusion, sepsis, electrolyte imbalance, small bowel obstruction, and disseminated intravascular coagulation . SurgicaChyloperitoneum is a rare cause of ascites after traumatic injury. Although cases of chylous ascites have been described in the setting of blunt trauma, it can also be caused secondary to penetrating abdominal injury. For this reason, chylous ascites should be included in the differential diagnosis of intra-abdominal collections after abdominal trauma. The diagnostic and therapeutic management of traumatic chyloperitoneum remains a dilemma. Conservative management should be the first choice; however, surgical repair may be pursued in refractory cases.


Adult intussusception presents a diagnostic challenge given its non-specific symptoms. It is not as common as in infants and young children. Traditionally, diagnostic steps are invariably fit for normal adults, but not in pregnancy which faces certain limitations. A 40-year-old pregnant mother, gravida 9 para 8 at 34-week gestation, complained of intermittent epigastric pain for 2 days, requiring hospitalization. She soon developed minimal per rectal bleeding that was ruled out as hemorrhoid. Imaging was limited due to her pregnancy status. She later developed spontaneous delivery to a premature baby. Computed tomography (CT) revealed an ileocolic intussusception, which was confirmed via exploratory laparotomy. Histology was consistent with inflammatory fibroid polyp. Acute abdomen in pregnancy can be due to various causes, thus a high index of suspicion and early CT abdomen might help in early diagnosis and treatment. The benefit of doing CT on the mother and the risk of CT on the fetus is to be weighed as the timely diagnosis can prevent bowel ischemia and reduce maternal morbidity and mortality. Surgery remains the definite management in adult intussusception and an exact diagnosis can be made during the operation. Intussusception is one of the most prevalent pediatric surgical emergencies in infants and young children Adult intussusception presents a diagnostic challenge given its nonspecific symptoms. However, the subsequent steps include clinical examination, biochemical investigation and imaging modalities. Traditionally, those steps are invariably fit for normal adults, but not pregnancy which requires certain limitations. We report this case of ileocolic intussusception secondary to an inflammatory fibroid polyp in a pregnant woman and describe our experiences in managing her.A 40-year-old pregnant mother, gravida 9 para 8 at 34-week gestation with underlying Beta-thalassemia carrier and hypertension presented to the Emergency Department with intermittent epigastric pain for 2 days. Pain onset was followed by recurrent loose stools and vomiting. She had had recurrent epigastric pain since 2013 however was never properly investigated. She was then admitted with an impression of acute dyspepsia in pregnancy. Upon presentation, she appeared lethargic, dehydrated, and tachycardic with a heart rate of 109 beats per minute. Her blood pressure was still within the normal range. Abdominal examination revealed a gravid uterus with tenderness over the epigastric region with no peritonism. Her biochemical investigations showed hypoalbuminemia with an albumin level of 18 , however, the other laboratory studies were within normal limits. An initial ultrasonography scan was performed which did not show any significant findings apart from nonspecific dilatation of the small bowel with mild ascites.A day later, she passed out with minimal per rectal bleed associated with epigastric pain which spontaneously resolved. She denied any history of trauma or potentially contaminated food or water ingestion. She did not have any recent travel history or sick contact. She claimed the fetal kick chart was good and no per vaginal bleeding. Two days after the admission, she spontaneously delivered a healthy premature baby girl. Postdelivery, she was still complaining of recurrent epigastric pain which had migrated to the right flank. The patient eventually underwent abdominal computed tomography (CT) scan after the baby was delivered, which showed a long segment of small bowel intussusception  up to thWe performed an emergency laparotomy on her after the CT scan, which revealed a segment of the ileum intussuscepted into the caecum and ascending colon. The trial of reduction was a failure and a segment of the small bowel in that area was seen as ischemic, hence we decided on right hemicolon resection with primary anastomosis. The postresection specimen showed a 5×5 cm small bowel tumor arising from the ileal mucosa, situated 30 cm proximally from the ileocecal valve . HistopaIntussusception in adults is rare, representing up to 0.03% of all hospital admissions, but, intussusception in pregnancy is even rarer It is very challenging to diagnose intussusception during pregnancy. The presenting symptoms of nausea, vomiting, abdominal pain and constipation are common in pregnancy. In addition, the displacement of the bowel by the gravid uterus hampers the examination. Acute abdomen in pregnancy can be due to various causes including obstetric and non-obstetric causes. Thus, the diagnosis might be delayed. The majority of cases can present with obstructive symptoms and some are subtle symptoms, requiring meticulous clinical judgment with the use of radiological adjuncts to improve the diagnostic ability.Various imaging modalities have been utilized to establish the diagnosis of acute abdomen. Among the most convenient modalities used include plain abdominal and chest radiography. The abdominal radiographs in the supine position can reveal distended bowel loops with haustration or/and valvulae conniventes which are typical for bowel obstruction. Meanwhile, the presence of classical air under the diaphragm in the erect chest radiography indicates a visceral perforation. However, both are generally unable to discern the etiology of the blockage secondary to intussusception. Ultrasonography, being a reliable and convenient diagnostic tool with radiation-free benefits, proves to offer superior advantages over radiography CT scan is generally proven to be the most accurate investigation for intussusception with more than 80% accuracy ,11. It iAnother modality that can be chosen is magnetic resonance imaging (MRI). By using MRI on a fluid-sensitive sequence, an intussusception would demonstrate hyperintense intraluminal fluid with the low-to-intermediate signal intensity of the bowel wall with surrounding perienteric edema The decision was made for emergency laparotomy for this lady and failed trial of reduction with evidence of bowel ischemia, bowel resection was then performed in this case. Adult intussusception necessitates surgical intervention because of the possibility of malignancy Acute abdomen in pregnancy can be due to various causes, thus a high index of suspicion and early CT abdomen might help in early diagnosis and treatment. The benefit of doing CT on the mother and the risk of CT on the fetus is to be weighed as the timely diagnosis can prevent bowel ischemia and reduce maternal morbidity and mortality. Surgery remains the definite management in adult intussusception and an exact diagnosis can be made during the operation. Reduction is not recommended as there is a high risk of malignancy in adult intussusception and bowel resection is recommended.The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.A written and informed consent for publication of this case was obtained from the patient.


Abnormalities of the urachus include the patent urachus, cysts, sinus, and fistula. Each of these entities represents a failure of complete obliteration of the urachus. Contrary to other urachus anomalies, urachal cysts are usually small and silent unless they are infected. The diagnosis is often made during childhood. A benign noninfected urachal cyst discovered in adulthood is a rare condition.Herein we report two cases of benign noninfected urachal cysts in adults. The first case is a 26-year-old Tunisian white man who presented with complaints of clear fluid draining from the base of the umbilicus evolving for a week, with no other associated symptoms. The other case was 27-year-old Tunisian white woman who was referred to the surgery department with a history of intermittent draining of clear fluid from the umbilicus. The two cases had laparoscopic resection of urachus cysts.Laparoscopy represents a good alternative for the management of persistent or infected urachus, especially when this is suspected, despite a lack of radiological evidence. Laparoscopy in the management of urachal cysts is safe, effective, and offers good cosmesis, with all the advantages of a minimally invasive approach.Managing persistent and symptomatic urachal anomalies requires a wide surgical excision. Such intervention is recommended to prevent symptom recurrence and complications, most notably malignant degeneration. A laparoscopic approach offers excellent outcomes, and is recommended to treat these abnormalities. During the first stages of intrauterine life, the urachus connects the bladder to the allantois sac through the umbilicus. Toward the end of gestation, the urachus obliterates and becomes a fibrous band, forming the umbilical ligament between the peritoneum and fascia. Abnormalities of the urachus include the patent urachus, cysts, sinus, and fistula. Each of these entities represents a failure of complete obliteration of the urachus. Contrary to other urachus anomalies, urachal cysts are usually small and silent unless they are infected. The diagnosis is often made during childhood. Infection is the usual mode of presentation among adult cases, otherwise the condition usually remains asymptomatic. Benign noninfected urachal cysts discovered in adulthood is a rare condition considered.We present the cases of two patients with benign noninfected urachal cysts manifested in adulthood. The first case is a 26-year-old Tunisian white man who presented with complaints of clear fluid draining from the base of the umbilicus evolving for a week, with no other associated symptoms. He had no prior history of a lower abdominal mass and no voiding complaints. The physical examination revealed an outcome of clear fluid from the umbilicus with no signs of inflammation or a palpable mass, associated with a noncomplicated umbilical hernia. The results of all blood tests were normal. A subsequent urine culture was negative. We completed abdominal sonography that showed a small peri vesical hypoechogenic cystic formation reminiscent of a urachal cyst Fig. . The patThe second case had similar clinical presentations. The patient was a 27-year-old Tunisian white woman who was referred to the surgery department with a history of intermittent draining of clear fluid from the umbilicus evolving for a year, with no other associated symptoms. The patient was treated with antibiotics, but recurrence of the symptomatology was noted. Blood and urine tests were normal. Abdominal sonography combined with a computed tomography (CT) scan identified a urachal cyst of 3 cm. the patient underwent surgery and had a laparoscopic excision of the urachal cyst with no intraoperative incidents. The postoperative course was simple. Pathologic examination revealed the urachal cysts without any unusual features.For both patients, no recurrence of the symptoms was noted in the subsequent clinical follow-up.The urachus is an embryologic structure that communicates between the apex of the bladder and the umbilicus. It normally closes by birth. If any portion of this embryologic structure remains patent, a urachal abnormality results. Various types of remnants have been described, including cysts, sinus, diverticulum, and a patent urachus. It is a rare congenital anomaly, with an incidence of 1:300,000 in infants and 1:5000 in adults [Infection is the most common complication .Urachal remnants, most commonly cysts, require intervention when they become infected or symptomatic.As in the two reported cases, periumbilical drainage is the most common presentation of urachal cyst in adults and it is not necessarily associated with infection. Diagnosis is facilitated by imaging, especially ultrasound, which shows the cyst in the majority of cases. Otherwise, this examination can be replaced by a CT scan, especially in case of complications.In Tables Asymptomatic, noninfected urachal cysts can be approached with watchful waiting, while infected urachal cysts almost require treatment that includes antibiotics, percutaneous drainage, or surgical removal. The therapeutic option depends on the presenting signs and symptoms, in addition to the individual operability and eventual surgical complications. There are two possible treatment modalities of this entity: either percutaneous drainage followed by surgical removal or one-stage open, laparoscopic, or robotic removal; the decision depends on the surgeon’s expertise and technologies involved in each surgical approach and the unique characteristics of the urachal cystic lesion being evaluated .The nonoperative management of symptomatic urachal cyst is an acceptable approach and can be applied to infected urachal cysts after initial drainage. Infected cysts drained adequately may obliterate progressively and spontaneously. Ultrasonography is very useful for follow-up.et al, [With regards to complications, Cutting et al,  reportedet al, . Wide ciFurthermore, incomplete resection can lead to recurrence; therefore, appropriate debridement of the infected tissue is required , 24.Although it normally disappears to birth, part of the urachus may persist in few people. Urachal cysts can develop at any age. Urachal cysts are often not associated with any signs or symptoms; however, there are complications such as infection. In these cases, symptoms may include abdominal pain, fever, pain with urination, and/or hematuria. A laparoscopic approach is best to treat these abnormalities, with less comorbidity and undesirable events.


We present a case of a diffuse, vascular eruption localized to the left thigh and left abdomen in an otherwise apparently healthy 63-year-old male. The patient reported that the eruption was not bothersome and had been present for as long as he could remember. Due to its benign appearance in nature, the patient declined a biopsy or further follow-up. While reports of diffuse vascular eruptions have been associated with many genetic diseases, this case offers an example of a diffuse vascular eruption in a healthy patient. Further research is needed to understand the potential genetic or environmental factors contributing to the development of such lesions in healthy patients. Benign vascular lesions refer to non-cancerous growths or abnormalities of blood vessels . Many tyA 63-year-old healthy male patient presented to dermatology for evaluation of a non-pruritic, non-erythematous, vascular eruption. The patient stated that the eruption was unchanged and that he had had it for as long as he could remember. Notably, the patient reported no significant past medical or dermatologic history, with the exception of the eruption in question. Physical examination of the lesion revealed extensive clusters of vascular lesions in a segmental distribution, affecting the left upper extremity and left abdomen Fig. . Due to Vascular lesions, abnormal growths, or abnormalities of blood vessels can occur on various parts of the body demonstrating both cutaneous and internal involvement. Benign vascular lesions are generally classified into two broad categories: vascular tumors and vascular malformations .Common benign vascular tumors include cherry angiomas, spider angiomas, and venous lakes. Cherry angiomas appear as small, bright red or purple bumps on the skin and tend to increase in number and size with age . In contVascular malformations refer to aberrant connections between arteries, veins, and lymphatic vessels . HemangiThe diagnosis of benign vascular lesions is most commonly clinical, but histologic evaluation can help distinguish among the various types of vascular lesions. Generally, dermoscopic evaluation of benign vascular lesions characteristically reveals vessels that are expanded or dilated, including red, purple, blue, or black dots, globules, lacunae, and structureless areas, as well as linear, linear irregular, hairpin, comma, and arborizing vessels . Biopsy The treatment of vascular lesions depends on type, size, location, symptoms, and individual patient preference. Vascular lesions that are asymptomatic and not cosmetically bothersome may not require treatment but should instead be monitored for potential changes. For benign vascular lesions that are cosmetically bothersome, a variety of topical and oral medications can be trialed, including topical and systemic beta-blockers, topical imiquimod, and corticosteroids . Other tExtensive, benign vascular lesions, as seen in our patient, have been observed in the context of specific genetic pathologies. For example, Sturge-Weber syndrome, a neurocutaneous disorder, is typified by vascular malformations resulting in facial port-wine birthmarks on the forehead or eyelid (V1 distribution), and in some cases V2 and V3 distributions . Von HipBased on physical exam findings, we believe our patient’s presentation is most consistent with unilateral, segmental cherry angiomas, or hemangiomas. Although our patient’s particular pattern of presentation is unique due to the extensive, unilateral, and segmental distribution, cherry angiomas are very common, benign findings in adults. In contrast, hemangiomas are often seen in infancy. These lesions are primarily composed of endothelial cells and pericytes and are characterized by a rapid proliferation phase followed by an involution phase . BecauseThis case report provides a unique contribution to the literature by documenting a rare occurrence of diffuse, unilateral, benign vascular lesions in an apparently otherwise healthy individual. Although a definitive diagnosis was not formally established, the most likely diagnoses are unilateral, segmental cherry angiomas, or hemangiomas. Our findings underscore the importance of comprehensive evaluation and differential diagnosis in the management of vascular lesions, even in the absence of other health concerns. Continued study is necessary to understand the potential genetic or environmental factors that may contribute to the development of such lesions in healthy individuals.


Teaching Point: Although inguinal hernias are very common, stomach entrapment within an inguinal hernia is rare. A 70-year-old man with history of multiple myeloma, hypothyroidism and type 2 diabetes mellitus was admitted in the emergency department for nausea and vomiting. Vital signs were stable. Clinical examination revealed no abdominal distension but a large irreducible right inguinal hernia, with mild pain. Laboratory findings showed neutrophilia with normal C-reactive protein level. An abdominal and pelvic computed tomography scan showed a large inguinal hernia (white arrow) containing a considerable part of the stomach (white star) (Inguinal hernia with stomach content is uncommon, with few cases reported in the literature . Compute


Black esophagus or acute esophageal necrosis (AEN) is a rare cause of upper gastrointestinal (UGI) bleeding usually involving distal esophagus. Proximal esophageal involvement is quite rare. We present an 86-year-old female with active coronavirus disease 2019 (COVID-19) infection who came in with newly diagnosed atrial fibrillation and was started on anticoagulation. She subsequently developed a UGI bleed, which was complicated by inpatient cardiac arrest. Following resuscitation and stabilization, UGI endoscopy showed circumferential black discoloration of proximal esophagus, with distal esophageal sparing. Conservative management was instituted and fortunately, repeat UGI endoscopy two weeks later showed improvement. This describes the first case of isolated proximal AEN in a COVID-19 patient. Acute esophageal necrosis (AEN) or black esophagus is a rare syndrome characterized by circumferential diffuse black appearance of esophageal mucosa with almost universal involvement of the distal esophagus, with rare cases involving proximal extension. Involvement of proximal esophagus, however, has only been limited to few case reports ,2. The eTM). She had a known history of hypertension, prediabetes, hyperlipidemia and osteoarthritis, and her home medications were atenolol, hydrochlorothiazide, lisinopril, pravastatin, and as-needed ibuprofen. On initial evaluation, she was tachycardic (170 beats/min). Electrocardiogram showed atrial fibrillation (AFib) with rapid ventricular response (RVR). She was started on intravenous diltiazem and unfractionated heparin, which was subsequently switched to amiodarone. Two days later, she developed hematemesis, melena, and epigastric pain, accompanied by a drop in Hb from 12.8 to 10.5 g/dL. Intravenous proton pump inhibitor (PPI) therapy was initiated and she was boarded for an upper gastrointestinal (UGI) endoscopy. Her AFib continued to be uncontrolled with intermittent periods of RVR. Unfortunately, this was complicated by a cardiac arrest followed by successful resuscitation with two cycles of chest compressions and defibrillation.An 86-year-old female with a recently diagnosed COVID-19 infection, was brought in via the emergency medical services for an episode of dizziness and shortness of breath. She also reported an episode of nausea and non-bloody emesis a few days ago which was deemed to be intolerance to her nirmatrelvir/ritonavir , ischemic etiology was reported to be the predominant cause of AEN . A “two-In our patient, the prolonged hypotension during the cardiac arrest in the setting of baseline known risk factors for microvascular insufficiency likely led to the development of AEN. AEN has been reported to be more common in the distal esophagus , but isMost patients with acute esophageal necrosis are symptomatic and present with signs and symptoms of UGI bleeding, including hematemesis and melena ,7. OtherGiven the rarity of the condition, limited data is available to guide management. Initial management is mainly supportive with intravenous fluids and treatment of underlying illness. Intravenous proton pump inhibitors (PPI) should be used with strict avoidance of oral intake. Submucosal epinephrine injections to treat active bleeding may have a detrimental role given the epinephrine-induced vasoconstriction can further worsen the ischemic injury . ReporteAEN is a rare cause of esophageal ischemia presenting as UGI bleeding, especially in individuals with baseline ischemic risk factors. Even though distal AEN has been commonly reported in the literature, it may also be limited to the proximal esophagus. Management is largely supportive with strict avoidance of oral diet and PPIs. We describe the first reported case of isolated proximal AEN in a patient with COVID-19.