Congenital limb defects are sporadically encountered in dogs during normal clinical practice. Literature concerning their diagnosis and management in canine species is poor. Sometimes, the diagnosis and description of congenital limb abnormalities are complicated by the concurrent presence of different malformations in the same limb and the lack of widely accepted classification schemes. In order to improve the knowledge about congenital limb anomalies in dogs, this report describes the clinical and radiographic findings in four dogs affected by unusual congenital forelimb defects, underlying also the importance of reviewing current terminology.Four dogs were presented with thoracic limb deformity. After clinical and radiographic examinations, a diagnosis of congenital malformations was performed for each of them. In one case, a deformity involving both the radial and ulnar side of the distal limb was observed. Based on clinical and radiological evaluations, a diagnosis of postaxial terminal longitudinal ulnar hemimelia was performed. The term ectrodactyly was used to refer different malformations characterized by skin and soft tissue separation of the distal forelimb observed in two dogs. Simple complete uncomplicated syndactyly of the right forelimb, and complex incomplete uncomplicated syndactyly of the left forelimb were diagnosed in the fourth case. To the authors’ knowledge, ectrodactyly and simple complete uncomplicated syndactyly are very uncommon anomalies in companion animals and have been rarely documented. Moreover, postaxial terminal longitudinal ulnar hemimelia has still not been reported in dogs. Appendicular skeletal dysostoses are a group of dysmorphologies arising from alterations of the limb’s developmental process, resulting in a wide range of abnormalities involving individual bones or portions of bones of the growing embryo body extremities .Hereditary (genetic aberrations) and environmental factors  can cause an abnormal developmental process or an interference with a normal developmental process, respectively ,3.Limb formation is an intricate process, which takes place during the first weeks from D23 to D35) of gestation in dogs  to D35 o,5 PresumCongenital defects and varying associations of stilopodium, zeugopodium and autopodium dysmorphologies have been previously described in cats and dogs. ,10,11,12Recent reports of forelimb and hindlimb malformations of carnivores include ectrodactyly , preaxiaDespite the growing number of reports, in dogs the current knowledge about congenital limb deformity is very poor. Moreover, compared to human literature, in veterinary medicine a complete and unequivocal description of many congenital defects is still lacking.In order to improve the knowledge about congenital limb anomalies in dogs, the aim of this report is to describe the clinical and radiographic findings in four dogs affected by dysostoses of the distal extremities.The importance of this report lies in it helping the clinician to recognize more easily the features of rarely reported congenital limb deformities in canine species in order to perform a diagnosis.No ethical approval was required in compliance with European Directive 2010/63/UE and Italian Regulation D.Lgs n. 26/2014 because all the data derived from routine veterinary clinical practices.Four client-owned, crossbreed young dogs were presented each with an obvious deformity in the forelimbs. All dogs had an unknown history and the anomalies of forelimbs were supposed to be congenital. The sites of deformation were assessed by physical and radiographic examination. Forelimb radiographs were obtained using an Analogic Radiographic/Fluoroscopic Table System , Italy) with a digital radiography system , Italy) in different projections: mediolateral, oblique and dorsopalmar views. The following X-ray exposure setting was used: 40–60 kV, 8–12.5 mAs, 100 cm film-focus distance, no grid.Below, the physical and radiographic findings of enrolled dogs are described.A two-year-old male dog was referred for a nonfunctional right forelimb due to decreased range of motion of the right elbow joint and moderate disuse muscle atrophy with no pain during palpation.On physical examination, coexistent clinical abnormalities were a reduced number of digits (hypodactlyly) with a complete rotation of the lateral nail, and an ectopic digit-like structure in the elbow region. Three complete footpads  were observed. A footpad was also present in the digit like structure .The radiographic examination consisted of two views, including a mediolateral view of the forelimb section and a dorsoplantar view of the manus .In the mediolateral view of the forelimb section, a severe deformity was observed due to a collapse of the elbow joint, which was in acute flexion. The radial head and the humeral condyle were deformed, showing a rounded and irregular articular surface. The ulna showed only the olecranon, whereas the medial and distal ulnar portions were missing.The olecranon and trochlear notch were hypoplastic. This may suggest that the trochlear notch dislocated long before presentation, explaining the stiffness of the elbow joint.In the soft tissue near the caudal surface of the radial head a rudimentary digit containing a hypoplastic metacarpal bone and proximal, middle and distal phalanx, without evidence of joints, was observed, suggestive of an ectopic digit-like structure. It was characterized by the outline of the hypoplasic fifth metacarpal bone and the proximal, medial and distal phalanges of the fifth digit. The dorsopalmar view of the manus showed no ulnar carpal bone, accessory bone and distal line of carpal bones. The radial carpal bone, two complete digits and a hypoplasic metacarpal bone without its phalanges, were noted. A 180° rotation on the axial plane of the lateral distal phalange was observed. The remaining digits and soft tissue were within the normal limits. Clinical and radiographic findings showed a postaxial terminal longitudinal ulnar hemimelia with absence mid and distal ulna, ulnar and accessory carpal bone, distal carpal bone IV and an ectopic fifth digital ray.No treatment was performed for managing the congenital deformity because the dog had no evidence of discomfort.An 11-month-old female dog was referred for a nonfunctional right forelimb without pain at palpation. The clinical examination showed a lobster’s claw involving the paw, carpus and antebrachium. The skin and soft tissues of the distal limb were split between radius and ulna up to the proximal third of the antebrachium. The ulnar carpal bone, metacarpal bone and phalanges showed a 180° rotation on the axial plane. The ulnar carpal joint was in acute cranial flexion, with a mediocaudal rotation of the manus moving medial to the radio. The radial carpal joint was also in acute flexion .The radiographic examination consisted of mediolateral and dorsocaudal views of the right forelimb section , where aA severe hypoplasia of the proximal epiphysis of the radius was observed, the radial head showed a severe deformation with the flattening of both medial and lateral epicondyles and an increased dimension of the radial fossa was noted. The olecranon was lengthened and flattened.A soft tissue separation between radius and ulna along the interosseous ligament and a severe increase of the intraosseus distance were observed. The ulna was shorter than radius. The radius-carpal joint was normal with a short bone compatible with the radial carpal bone, which in turn was articulated with a carpal bone of the second line. The carpal joint was in acute flexion. One metacarpal bone, dorsal and ventral sesamoids and two phalanges of the first digits  were noted.The distal epiphysis of the ulna was articulated with the ulnar carpal bone and accessory bone. This joint was in acute cranial flexion showing a 180° rotation on the axial plane, with a mediocaudal rotation of the manus moving medial to the radio. One metacarpal bone and one dorsal sesamoid were noticed; we assumed a fusion of the two proximal phalanges resulting in one “stubby bone”. Two medial and distal phalanges were articulated with the stubby bone. Clinical and radiographic findings were consistent with ectrodactyly.No treatment was considered at time for managing the congenital deformity.A 10 months-old male dog was referred for an abnormal aspect of both front paws, not associated with lameness. Physical examination of the involved limb revealed a deformity of the paw characterized by a cutaneous absence of normal separation between II–III digits and IV–V digits. The right paw showed one metacarpal pad and three digital pads, whereas the left paw showed one metacarpal pad and two digital pads . The radIn the left manus, a complete bony fusion between proximal phalanges of the fourth and fifth digit was noted.Clinical and radiographic findings were a simple complete uncomplicated syndactyly of the right limb and a complex incomplete uncomplicated syndactyly of the left limb.The dog had no evidence of discomfort, so that no treatment was performed.A one-year-old male dog was referred for right forelimb lameness. Physical examination revealed a deformity of the paw characterized by the presence of only two digits and a “cleft hand aspect”. Two digital pads in each paw and one carpal pad in the palmar view were observed . The radOn X-ray, normal radius and ulna bones, deformed radial and ulnar carpal bones, small and deformed carpal bones and the presence of only two complete digits articulated with carpal bones of the distal line, were noticed. A digit showed one supernumerary footpad, instead the other finger a hypoplasic footpad. Clinical and radiographic findings were consistent with ectrodactyly. No treatment was performed for managing the bone deformity.In veterinary medicine, Nomina Embryologica Veterinaria (NEV) 2017) is the only classification system recognized that allows classifying many congenital limb malformations. However, it needs to be expanded in order to improve and facilitate communication about the specific characteristics of congenital anomalies in animals ,19,20,2117 is theIn this study we reported the clinical and radiological patterns of four appendicular skeletal dysostosis in canine species. Clinical observation is only the first step in the diagnosis of bone malformations, so that radiographic evaluations are essential to evaluate the extent of deficits.In case 1, a malformation involving the antebrachium and carpal bones and paw of the right thoracic limb was reported. An additional feature was the presence of a floating digit-like structure without any bony attachment to the elbow joint. This congenital defect was identify as postaxial terminal longitudinal ulnar hemimelia.To the authors’ best knowledge, no similar deformities have been reported in dogs, other animal species or humans, although a variable degree of ulna and digit deficiency has been observed in the latter ,23. ThisIn case n.2 and 4, a diagnosis of ectrodactyly was performed, according to clinical cases of limb malformations previously described ,25. In bIn case 3, a diagnosis of syndactyly of the pectoral limbs was performed. To our knowledge, no report of simple complete uncomplicated syndactyly of the right forelimb and complex incomplete uncomplicated syndactyly of the left forelimb exists, as described in this report.Over time, the term “hemimelia” has been adopted for better specifying congenital deficits of limbs, where one or more bones were totally or partially missing ,17.In veterinary medicine, different patterns of this malformation were classified as hemimelia terminal, when all or parts of the middle and distal bones were absent and hemimelia intercalary when segments of the middle portion of the limb were lacking, while the located proximally and distally structures developed normally . Each ofCanine defects of the medial and central rays of the limb bud have been previously described and named as radial hemimelia and ectrodactyly ,17,26. MIn canine medicine, the term hemimelia has previously proved useful to identify which segments of the limb were misshapen or missing . HoweverIn humans, some studies permitted detection and classification of complex forms of ulnar longitudinal deficiencies, such as those characterized by the presence of radial-side abnormalities of the manus . MoreoveThe term “ectrodactyly” means one or more digits are missing or not fully developed, even though in veterinary medicine this term was also used to indicate a median distal cleft of the limb ,12,14,35Some authors reported that soft tissue separation involves the metacarpus, whilst distal cleft of the limb extended up the carpus joint occurs sporadically in dogs . Few casFor this kind of malformation, the use of the generic term ectrodactyly does not aid in planning of treatment because it is used to identify different anomalies, such as oligodactyly and cleft of the foot, paw or limb . SchistoIn case 3, the diagnosis of syndactyly of the pectoral limbs was based on the human nomenclature, already widely accepted in veterinary medicine. A simple syndactyly occurs when adjacent digits are merged only by skin and soft tissue. A complex syndactyly is characterized by the lack of separation of hard tissues, in addition to skin and soft tissue abnormalities. Syndactyly may further be qualified as complete, when digits are interconnected throughout their entire length, and uncomplete when total connection of adjacent digits does not occur. If other anomalies are associated with syndactyly, the term complicated syndactyly may be adopted, whereas the definition of uncomplicated syndactyly should be used otherwise ,40,41. PAlthough little is known about the basic mechanisms of congenital limb deformities, several aetiological factors have been identified . Causes In our cases, there was no information concerning traumatic events, inbreeding and/or environmental or genetic factors, so that the aetiology of these abnormalities remains unknown.This report improves the literature about congenital limb deformities, describing the patterns of rarely reported lesions and discussing how difficult it is to know the correct identification and classification.A well-defined classification scheme of congenital dysmorphologies of the forelimb is advisable. Novel nomenclature should take into consideration both the genetic basis and the wide spectrum of morphological features of limb dysostosis.Extrapolation from the human literature has been considered of limited value  but in oLikely, the real prevalence of these conditions in companion animals is little known; therefore, further reports are required.


Diaphragmatic hernias may occur as either congenital or acquired. The most important cause of acquired diaphragmatic hernias is trauma, and the trauma can be due to blunt or penetrating injury. Diaphragmatic hernia may rarely be seen after thoracoabdominal trauma.A 54-year-old Turkish male patient admitted to the emergency department with abdominal pain and dyspnea ongoing for 2 days. He had general abdominal tenderness in all quadrants. He had a history of a stabbing incident in his left subcostal region 3 months ago without any pathological findings in thoracoabdominal computed tomography scan. New thoracoabdominal computed tomography showed a diaphragmatic hernia and fluid in the hernia sac. Due to respiratory distress and general abdominal tenderness, the decision to perform an emergency laparotomy was made. There was a 6 cm defect in the diaphragm. There were also necrotic fluids and stool in the hernia sac in the thorax colon resection, and an anastomosis was performed. The defect in the diaphragm was sutured. The oral regimen was started, and when it was tolerated, the regimen was gradually increased. The patient was discharged on the postoperative 11th day.Acquired diaphragmatic hernia may be asymptomatic or may present with complications leading to sepsis. In this report, acquired diaphragmatic hernia and associated colonic perforation of a patient with a history of stab wounds was presented. Diaphragmatic hernias may occur because of a congenital embryonic defect in the diaphragm or can stem from all types of trauma. High-energy blunt or penetrating traumas may cause a rupture in the diaphragm. Penetrating traumas are also divided into gunshots injuries or stab wounds. Diaphragmatic hernias should be considered in patients with a history of blunt or penetrating trauma to the upper abdominal quadrants. The organs such as stomach, small intestine or colon can be incarcerated in the diaphragmatic defect, and ischemia and subsequent necrosis may occur, which may lead to fatal complications. In this case, we present a colon perforation due to a diaphragmatic hernia. The patient had a history of stab wounds three months prior.A 54-year-old Turkish male patient admitted to the emergency department with abdominal pain and dyspnea ongoing for 2 days. He had general abdominal tenderness in all quadrants, and lung auscultation revealed decreased respiration sounds on the left. He had a history of a stabbing wound in his left subcostal region 3 months prior without any pathological findings in the thoracoabdominal computed tomography (CT) scan Fig. . The patDiaphragmatic hernia was considered due to the history of a stab wound, accompanied by the physical examination findings. Thoracoabdominal CT revealed a diaphragmatic hernia and fluid in the hernia sac Fig. . Due to Diaphragmatic injury is a rare injury occurring in 0.8 to 8% of all traumas . FaecopnIf the laceration of the diaphragm is large, herniation is more easily detected. Sometimes a small laceration in the diaphragm may be asymptomatic in the earlier period after the trauma and therefore cannot be detected. Asymptomatic occult injuries of the diaphragm can turn to a diaphragmatic hernia between 2 months and 50 years after the trauma , 5.A small laceration during trauma can grow over time, causing herniation of organs. Thereafter, herniated stomach, small intestine, omentum or colon can be incarcerated. Patients may present with gastrointestinal symptoms due to herniation or with respiratory problems such as chest pain, dyspnea, tachypnea and cough or hiccups.Ischemia, necrosis and related perforation can be seen in the organs with hypoxia. It can be a clinical life threatening condition that extends to septic shock.Sometimes imaging procedures may fail to detect the defect in the diaphragm. Similarly, thoracoabdominal CT of the presented case which was performed for a left upper quadrant stab wound 3 months prior to the admission with abdominal pain and dyspnea did not show any diaphragmatic defect. It is possible that a small laceration increases in size with time and reaches the extent to which the organs can become herniated. Laceration in the diaphragm can be seen in different degrees in blunt traumas, depending on the pressure difference between the abdominal and thoracic cavities. The laceration size also depends on the strength of the diaphragmatic tissue. Diaphragmatic laceration due to blunt trauma usually causes radial tears in the diaphragm, while penetrating injuries are indicated by small holes that follow the size of the projectile . The rolA wide variety of symptoms related to diaphragmatic herniation have been described in case reports. In one case, hematemesis was observed due to the bleeding of a herniated gastric fundus. In another case, splenic vein thrombus was observed . StudiesIf the organs move towards the thorax and decrease the vital capacity of the lung due to herniation in the supine position, the posture of the patient should be adjusted accordingly. Diaphragmatic hernia should be operated. Surgical options are conventional  or minimally invasive surgery . Mortality rates due to the elective repair of diaphragmatic hernias are low. This rate increases up to 80% in emergency surgery, especially in cases accompanied by necrosis and perforation , 11. MesClinicians should be aware of small lacerations in the diaphragm after penetrating abdominal traumas, and could follow the patients for the potential development of diaphragmatic hernias. There may be fatal consequences such as hernia-associated faecopneumothorax. This can be avoided by being suspicious and then maintaining the appropriate approaches.


This patient had a non-traumatic ICH, without focal neurological deficits on presentation. The patient had no complications while hospitalized despite the imaging findings. Clinicians should keep a broad differential similar to causes of spontaneous non-traumatic unilateral ICH, including uncontrolled hypertension, tumor mass, coagulopathies, and vasculopathies. Although brain CT is the most appropriate study in the acute setting, MRI is the gold standard for definitive diagnosis and should be performed urgently to further characterize the lesions. Clinicians should be aware of non-traumatic ICH complications, which include aspiration pneumonia, quadriparesis, hemiparesis, and recurrent stroke. Management is supportive mainly by reducing risk factors for complications, including blood pressure control, aspiration precautions, reversing coagulopathies, frequent neurological checks, and consultation with multiple disciplines such as neurosurgery or neurointerventional radiology.A 62-year-old man with a past medical history of uncontrolled hypertension, tobacco abuse, and type 2 diabetes mellitus (DM) presented to the emergency department due to worsening confusion over the last 24 hours as reported by a friend. A CT brain without contrast was obtained, which demonstrated a bilateral intracerebral hemorrhage (ICH). Spontaneous bilateral intracerebral hemorrhage is an exceedingly rare condition with only 30-40 reported cases A spontaneous unilateral intracerebral hemorrhage (ICH) is a well documented medical condition; however, a spontaneous bilateral ICH is exceedingly rare, with only 30-40 reported cases . The rarA 62-year-old man with a reported past medical history of uncontrolled hypertension was seen at our hospital emergency department due to worsening confusion over the last 24 hours with an acute exacerbation of confusion, witnessed by friend 30 minutes prior to the initial evaluation. Upon arrival, he had no specific complaints. He was on a daily 81 mg aspirin and multiple blood pressure medications. He denied any other past medical or surgical history. He had no family history of diabetes; he had no history of coagulopathy but was unsure about any family history of any neurological disease or cancer. Social history was significant for smoking two cigarettes a day for 15 years but quit 10 years ago. On exam two hours after initial emergency department evaluation, he was alert and oriented to person, place, time, and event, but did elicit some confusion and had a Glasgow Coma Scale (GCS) of 14 . Cranial nerves II-XII were grossly intact, yet horizontal gaze was noted to be mildly abnormal. The remainder of his neurological exam was unremarkable with pupils equal, round, and reactive to light; sensation to light touch intact to upper and lower extremities; 5/5 grip strength as well as in the upper and lower extremities; deep tendon reflexes (DTRs) 2+/4 in upper and lower extremities bilaterally; no dysdiadochokinesia appreciated; and no truncal ataxia. The heart was found to be at a regular rate but bradycardic. No heart murmur was noted, and blood pressure was not elevated.STAT computed tomography (CT) brain without contrast showed parenchymal hemorrhage of the right basal ganglia and intraparenchymal hemorrhage of the left lentiform nucleus Figure . ComprehThe patient was admitted to the ICU overnight and recovered an additional 48 hours on the telemetry floor. His hospital course was unremarkable except for one dose of hydralazine PRN, and his systolic blood pressure remained less than 160. Neurosurgery was consulted, and no neurosurgical intervention was indicated. A magnetic resonance imaging (MRI) brain scan was obtained on the first day of admission demonstrated that hematoma was subacute in the bilateral basal ganglia, as seen on the initial scan Figure  with no IncidenceSpontaneous unilateral intracerebral hemorrhage (ICH) is reported to be 24.6 per 100,000 person-year; however, a spontaneous bilateral ICH is exceedingly rare, with only 30-40 reported cases, and clinicians should be aware of the management, complications, and risk stratification recommendations. Of the previously reported cases of multiple spontaneous simultaneous ICH, 10.5% died, 10.5% was considered severely disabled, 2.6% was left in a vegetative state, 10.5 % walked with a cane, and 5.2% had a good recovery [Differential diagnosis which places patients at risk for multiple spontaneous intracerebral hemorrhages [This patient presented with subtle changes in behavior and mental state but had no focal deficits on the exam, highlighting the importance for clinicians to consider spontaneous ICH in patients with mental status changes. The main causes of spontaneous ICH include hypertension, tumor mass, coagulopathies, and vasculopathies . Risk faorrhages . Even moorrhages .ManagementComplications of a nontraumatic spontaneous bilateral basal ganglia ICH include aspiration pneumonia, quadriparesis, hemiparesis, and recurrent stroke . ManagemSpontaneous bilateral ICH is a rare event and can present severely with quadriplegia or, as in this case, with mild neurological deficits. Advanced age, history of hypertension, and prior stroke are the most common risk factors for spontaneous bilateral ICH, but subsequent follow up is necessary to rule out more rare disease processes. Although the brain CT is the most appropriate initial study in the acute setting, MRI is the gold standard for definitive diagnosis and should be performed urgently to further characterize the lesions. CT angiography is a critical test to assess for vascular malformation, which could require intervention.


Glial tumors manifesting this phenomenon are referred to as gliosarcoma. These tumors are usually mistaken for cerebral metastases or meningioma at operation. Their histological studies have revealed an admixture of gliomatous and sarcomatous tissues, which leads to a biphasic pattern. The mesenchymal component can present in different forms such as fibrosarcoma, undifferentiated pleomorphic sarcoma, chondro-osteogenic, and myogenic differentiation, as well as angiosarcomatous and liposarcomatous types. Squamous differentiation, Herein, we report a rare case who was admitted to the emergency room with decreased consciousness resembling methadone poisoning. Clinical work-up showed a temporoparietal mass on radiological investigation. Histopathological evaluation of the brain mass revealed a gliosarcoma with adenoid formations and a mesenchymal component, which manifested as chondrosarcomatous differentiation. Immunohistochemical studies confirmed the histologic diagnosis through positivity for EMA, GFAP, S100, and vimentin expression in different components. Central nervous system tumors characterized by mixed neuroepithelial and mesenchymal features are highly heterogeneous. Most glial tumors manifesting mesenchymal features as sarcomatous elements are glioblastomas, so the designation of gliosarcoma is generally taken to connote a glioblastoma variant. According to the WHO 2016 classification of glial tumors, this tumor type is considered as grade IV. It has been suggested that approximately 2% of otherwise conventional glioblastomas generate malignant mesenchymal components. Clinically, they are divided into “primary” and “secondary” forms, based on whether they present as gliosarcoma de novo or the sarcomatous component only arises after the recurrence of a classic glioblastoma.They usually affect the adult population in the fourth to the sixth decade of life. Men are more frequently affected than females (M: F ratio 1.8:1) . Most of these tumors arise in the absence of recognized predisposing factors, but they have also been associated with prior irradiation, including the intracranial instillation of Thorotrast .During operation, many are initially mistaken for cerebral metastases or (when attached to the dura) meningiomas, errors resulting from their characteristic circumscription and firm textures. These attributes in turn reflect the high content of connective tissue fibers typical of the gliosarcoma but foreign to most other neuroepithelial neoplasms .Obviously, Gliosarcoma may be a poorly delineated peripheral grayish mass with central yellowish necrosis stippled with red and brown color change from recent and remote hemorrhage, while the sarcomatous component producing a firm discrete mass .The strikingly biphasic architecture of these tumors observed in histological examination is due to a combination of gliomatous and sarcomatous tissues. The mesenchymal components would be quickly diagnosed as fibrosarcoma or undifferentiated pleomorphic sarcoma in a soft tissue setting, but chondro-osteogenic and myogenic differentiation may also be encountered in this setting. Variants that harbor angiosarcomatous, liposarcomatous, and mixed mesodermal-type elements have been reported as well. Squamous differentiation, adenoid formations, and glandular structures may also be displayed within the glial regions of selected cases .The distinction of gliosarcoma’s dimorphic constituents can be further achieved using a combination of traditional histochemical and immunocytochemical techniques. Sarcomatous components are richly invested with connective tissue fibers, which can be observed through reticulin impregnation methods, but do not express GFAP, the reverse being true of the glial population .We reported here a rare case of gliosarcoma that histologically presented chondrosarcomatous and adenoid formed components.A 53-year-old man with a history of opium addiction was admitted at the emergency ward with decreased level of consciousness (GCS=3) resembling methadone poisoning. Then, the patient was admitted to the Intensive Care Unit (ICU) and associated work-up such as brain CT scan was performed.Spiral brain CT scan with IV contrast reported a 57×47 mm heterodense mass with cystic and hemorrhagic components and severe peripheral edema with pressure effect on the right lateral ventricle in the right temporoparietal lobe, which enhanced obviously with contrast. Midline shift to left side was also evident. As a result of imaging findings, the patient was transferred to the neurosurgery ward for surgical treatment .Intraoperatively, an ill-defined lesion was seen with foci of hemorrhage suspicious for ICH or hemorrhagic brain tumor. Some parts of the mass had firm to hard consistency. Incisional biopsy was performed due to the large size of tumor and infiltrative borders.The specimen received in the pathology ward consisting of multiple creamy brown fragments of brain tissue in total measuring 2.5×2×1.5 cm. The paraffin block and slides were prepared and stained with hematoxylin and eosin. On histological evaluation, brain tissue was seen with an infiltrative neoplastic growth, which showed a biphasic pattern, composed of malignant glial and mesenchymal components. The glial component showed increased cellularity with cells arranged in diffuse infiltrating sheets, having pleomorphic hyperchromatic nuclei arranged in fibrillary matrix.  Many cells with bizarre nuclear atypia interspersed with areas of pseudopalisading necrosis. Microvascular proliferation was not seen. The mesenchymal component contained spindle cells arranged in fascicles and sheets, along with nuclear atypia and mitoses. Areas of well-differentiated cartilaginous elements containing atypical chondrocytes with bizarre oval to spindle nuclei lying in lacunae and some of them containing more than one nuclei in one lacunae, surrounded by chondroid stroma, were seen. Some small areas also showed epithelial differentiation as adenoid formations -4Reticulin stain showed increased deposition of collagen within the mesenchymal areas . On immuOn the second day of surgery, cardiac arrest happened and the patient died.Gliosarcoma was first described by Stroebe in 1895 as a brain neoplasm consisting of both glial and mesenchymal components . It is dHistologically, the glial component meets the cytologic criteria of glioblastoma, while the mesenchymal component may show a wide range of morphologies with origins ranging from fibroblastic, cartilaginous, osseous, smooth, and striated muscle, to adipose cell lineage . DespiteAnother theory has recently drawn attention to a monoclonal origin for both components of gliosarcoma, with the sarcomatous component originating via aberrant mesenchymal differentiation of the malignant glioma. Recent studies have confirmed the argument that both elements of this biphasic neoplasm may arise from a single progenitor clone rather than separate clones. Both glial and mesenchymal elements may be derived from a common neoplastic neuroectodermal progenitor cell , 10, 11. et al. reported an extremely unusual variant of liposarcomatous differentiation in gliosarcoma displaying clusters of isolated lipoblasts in the sarcomatous portion of the tumor ( et al. reported a rare case of gliosarcoma with chondrosarcomatous differentiation, which can occur as one of the types of mesenchymal differentiation in this tumor ( et al. showed that a very uncommon morphological variation in high grade astrocytomas and also gliosarcomas was pseudoepithelial morphology. This mostly consists of an adenoid pattern mimicking adenocarcinoma, and less frequently, simply a large cell or epithelioid pattern. True epithelial differentiation in the form of squamous nests and true glands rarely occurs in gliosarcoma (Vlodavskyhe tumor . Rajeshwis tumor . The stuosarcoma , 15.In comparison to differential diagnosis such as immature teratoma and malignant intracerebral nerve sheath tumors findings of primitive neuroectodermal component and negative GFAP staining are helpful respectively , 16.Given the available evidence, it is obvious that the occurrence of multiple types of sarcomatous differentiation in gliosarcoma is rare. We reported one case of tumor that presented with two different components as chondrosarcomatous and epithelial structures as adenoid formations, which is very rare and has not yet been reported. According to the IHC findings, which revealed negative expression of IDH1, similar to most forms of gliosarcoma, this case is also an IDH-wildtype form that supports its de novo nature., it may also have mesodermal-type elements such as adenoid formations.Even though gliosarcoma is a malignant growth with biphasic architecture of gliomatous and sarcomatous tissues


Colonoscopy is a procedure that enables a physician  to directly image and examine the entire colon. It has both diagnostic and therapeutic benefits with a relatively low morbidity rate. Complications have been well described in the literature. Nevertheless, it is necessary for operators to be aware of the rare complications of colonoscopy. Acute appendicitis is an unusually rare occurrence following a colonoscopy, and it can be easily confused with other complications of the procedure. Prompt recognition of this complication can lead to early, effective treatment, and delayed diagnosis can lead to serious results. We present a case of a 33-year-old man who underwent a routine colonoscopy with no intraoperative complication who presented with appendicitis two weeks later as a rare delayed side effect; such a delayed presentation has not been described in the literature previously. This case highlights that appendicitis should be considered in the differential diagnosis of right-sided lower abdominal pain following a colonoscopy. Colonoscopy is a commonly performed procedure with diagnostic and therapeutic intents. It is the gold standard test for the diagnosis of colonic diseases, and up to one-third of patients report at least one minor transient gastrointestinal (GI) symptom after colonoscopy such as abdominal pain, nausea, vomiting, and bowel spasm . Noninfectious complications include colonic perforation, bleeding, splenic injury, postpolypectomy syndrome, and cardiopulmonary adverse events. Infectious complications include bacteremia, cholecystitis, and diverticulitis ,3. One e3; inflammatory markers including C-reactive protein and erythrocyte sedimentation rate were both unremarkable (Table A 33-year-old man with a past medical history of ulcerative colitis underwent a routine colonoscopy where a benign polyp was found and removed with no complications. Approximately 15 days after the colonoscopy, the patient presented with lower mid-abdominal pain that radiated to the right lower quadrant. He described the pain as feeling like he needed to pass gas. Four days later, he arrived in the emergency room due to worsening pain. His vitals on admission showed a temperature of 98.8°F, a blood pressure of 129/66 mmHg, a heart rate of 80 beats/minute, and a respiratory rate of 18 cycles/minute. The white blood cell count was 11,100 cells/mmPhysical exam showed tenderness of the right lower quadrant without guarding. Axial computed tomography of the abdomen and pelvis with contrast showed dilated appendix measuring 21 mm with periappendiceal stranding consistent with acute appendicitis. The base of the appendix showed appendicolith, which is a calcified deposit within the appendix, 11 mm in diameter. There were no coexisting findings of colitis suggesting a flare-up (Figure There was no evidence of an abscess. The patient underwent a laparoscopic appendectomy, which was converted to an open appendectomy due to significant adherence of the appendix to the retroperitoneum. Surgery was successful after the open appendectomy, and the patient is currently recovering well. Colonoscopy is useful as a diagnostic and therapeutic tool for colorectal disease. It is a relatively safe procedure, but it has some risks, and major complications include bleeding and perforation. Minor complications may occur more commonly and include abdominal pain, vomiting, nausea, intestinal spasm, and mucosal tears in the lining of the colon . Rare coPCA is thought to be mainly caused by luminal obstruction, like the so-called barium appendicitis after a barium enema, and this can occur by obstruction of the appendiceal orifice via the retention of barium -5. The sAcute appendicitis after lower GI endoscopy has an estimated incidence of 3.8 to 4.9 per 10,000 colonoscopies ,9. The iThe duration of symptoms can last zero to nine days . Our patAlthough PCA is a rare entity, it poses a diagnostic challenge given the similarity of presentation with other more well‐known complications. Physicians should always be aware of this rare complication, as an early recognition can lead to early, effective treatment, and delayed diagnosis can lead to serious outcomes.


Pheochromocytoma (PCC) and Paraganglioma (PGL) are rare neuroendocrine neoplasms. These tumors harbour disastrous consequences during surgery due to catecholamine hypersecretion if they are undiagnosed or prepared inadequately preoperatively.A 41- year- old lady presented with mild left flank discomfort. She had experienced recurrent anxiety attacks accompanied by palpitations and headache which were managed previously as panic attacks. Radiologic investigations showed a retroperitoneal mass that located anteromedial to the left kidney, separated from the left adrenal gland and adherent to the 4th duodenal segment. During admission, her vital signs showed slight elevation of blood pressure (140\90–160\110) mmHg, thus 24-h urine metanephrine and normetanephrine were requested and the results revealed normal values. Upper gastrointestinal endoscopy failed to pass beyond the 3th duodenal segment and showed no pathologic evidence. According to her findings, a diagnosis of duodenal gastrointestinal stromal tumor (GIST) was suspected. During laparotomy, crises of hypertension and tachycardia followed by severe hypotension made the resection of the misdiagnosed mass very tricky. Immunohistochemical staining studies confirmed the diagnosis of paraganglioma.Paraganglioma is a life threatening disease and should always be considered as a differential diagnosis of asymptomatic retroperitoneal mass. The aim of our study is to present a challenging case of an undiagnosed retroperitoneal paraganglioma and to alarm our colleagues from such troubles. Pheochromocytoma (PCC) and paraganglioma (PGL) are rare neuroendocrine tumors of chromaffin cells which secrete catecholamines from adrenal medulla (80–90%) and extra-adrenal paraganglia 10–20%) respectively . T. T4]. Th. T. T4].During surgery, undiagnosed PGL or inadequate preoperative preparation can be life threatening due to hypertensive crisis followed by hypotension and cardiac arrhythmia. We hereby present a case of retroperitoneal PGL which was misdiagnosed as duodenal GIST.A 41-year- old lady presented with a history of mild left flank discomfort and mild hyperglycemia. She had experienced recurrent anxiety attacks accompanied by palpitations and headache. She denied any history of hypertension. She was diagnosed 3 years ago as a panic disorder patient and was treated with fluoxetine and chlorpromazine. She had a history of uncomplicated three deliveries and tonsillectomy.Physical examination showed slightly pale patient, pulse rate about (90–110) beat per minute (bpm) and blood pressure (BP) about (140\90–160\110) mmHg. Mild tenderness in the left hypochondriac area was noticed.Laboratory tests results are included in Table .Table 1Computed tomography (C.T) with intravenous and oral contrast demonstrated a well defined heterogeneous retroperitoneal mass 9 × 7.3 × 6.5 cm containing a necrotic centre with well peripheral enhancement. The mass was located anteromedial to the left kidney and separated from the left adrenal gland, anterolateral to the aorta and connected with the 4th duodenal segment. No evidence of lymph node enlargement or metastatic lesion was noticed Figs , 2, 3. TBecause of the presence of tachycardia attacks, mild hyperglycemia and newly discovered hypertension, we requested 24-h urine metanephrine and normetanephrine to rule out hormonally functioning mass. The results were within normal limits including thyroid function tests Table .Due to the lack of our facilities, upper gastrointestinal endoscopy failed to pass beyond the 3th segment of the duodenum and was normal.Because of the unspecific symptoms of our patient, the C.T findings, the laboratory investigations  and the absence of histological biopsy, we diagnosed the mass primarily as duodenal GIST.The patient was scheduled for laparotomy to resect the suspected duodenal GIST.Preoperative preparation included anti hyperglycaemic medication (Metformin 500 mg PO twice daily) and anti hypertensive medications . Fourteen days later, the patient was readmitted for laparotomy.Preoperative assessment revealed controlled vital signs. During the induction of general anaesthesia and intubation, all vital signs remained normal. When midline incision was preformed, BP and pulse started shooting up 220\130–250\145) mmHg and 120–135) bpm respectively. To control hypertension, deepening the anaesthesia was performed by administration of sedative and analgesic drugs, in addition to vasodilator drugs. The decision was taken to perform minimal manipulation mass excision. At first, the mass appeared to be retroperitoneal adherent to the 4th segment of the duodenum and Treitz ligament with hypervascularized surface and strict adherence posteriorly  that secrete norepinephrine mainly , 5.PGLs are divided according to their site and hormonal secretion into:PGLs are classified as functioning and non-functioning tumors according to their hormonal activity. Functioning PGLs are manifested by the classic triad of headache, palpitation and diaphoresis in only about (24%) of cases. Hypertension is found to be absent 13%), persistent (29%) and paroxysmal (48%) 3%, persi. In C.T Duodenal gangliocytic paraganglioma (DGP) is one of the differential diagnoses of duodenal GIST. DGP is a rare nonchromaffin neuroendocrine neoplasm which lacks the ability to secrete catecholamine –8. Both If PGL is suspected, fractionated plasma metanephrines analysis is the test of choice . The senIn our patient, there was no familial history to point to a hereditary reason.When PLG is still clinically suspected inspite of negative investigations, 123 I-metaiodobenzylguanidine (MIBG) scintigraphy is recommended to detect the tumor (unavailable in our institute) , 12. FinObtaining full consideration to the patient’s history and the clinical findings; and subsequently, requesting the proper diagnostic investigations  could help in the distinction between PGL and other retroperitoneal mass as GIST.Laparoscopic resection for small non-invasive tumor, otherwise laparotomy for large tumor, is the preferred curative therapy for localized PPGL after adequate preoperative medical preparation . A new rPreoperative hydration and liberal salt intake are necessary to reverse catecholamine-induced blood volume contraction and to avoid hypotension after tumor resection , 12.All PPGLs have a metastatic potential to liver, bones and lymph nodes. Depending on the genotype, metastasis occurs in approximately 10–20%) of PCC and about (50%) in PGL . Therefo0% of PCCIn case of slow growing metastasis appears on 123 I-MIBG scintigraphy, 131 I-MIBG is recommended as the first-line of treatment. In case of rapid progressing metastasis, chemotherapy  is considered as a palliative therapy [Some of the limitations of our study are that fractionated plasma metanephrines and gene mutations were not assessed.PLG is life threatening disease and should always be considered as a differential diagnosis of asymptomatic retroperitoneal mass. Due to the dangerous consequences of PGLs, we strongly recommend to evaluate and treat such cases at institutes with adequate expertise.


Bone granulomas (BGs) due to foreign bodies are a rare condition, especially in children, with only few cases reported in literature. As foreign bodies are not always visible on imaging, BGs can mimic bone tumors. We hereby present a case of a six-year-old boy with histopathologically confirmed BG of his right hand fifth finger due to intraosseous foreign bodies, along with imaging work-up.  Foreign body granulomas in soft tissues are well-known entities, both in adults and children -2. On thA six-year-old boy was referred to the ED because of pain and soft tissue swelling of fifth finger in his right hand which was been increasing for one month. The patient presented no impairment of functionality of the finger and no purulent reaction. In the clinical records, there was a superficial soft tissue trauma one month earlier, as the child fell while playing in the garden. At the ED admission, the patient had no fever and no sign of inflammatory syndrome from laboratory tests. Radiographs showed a round-shaped radiolucent lesion of the middle phalanx of the right hand fifth finger with a volar interruption of the cortex. No periosteal reaction was visible. The adjacent soft tissues were swollen. The joint space appeared normal Figure  .In correspondence of the bone lesion at radiographs, the MRI revealed a replacement lesion in hypo-signal in T1-weighted sequences and hyper-signal on T2-weighted images. Besides, MRI showed an extension to the nearby soft tissues around the phalanx to the distal interphalangeal joint  and macrophages. The foreign bodies appeared as synthetic fibers but their exact origin was unclear Figure .The final diagnosis consisted of a BG due to intraosseous foreign bodies. After surgical curettage, and oral antibiotic treatment (flucloxacilline), the patient showed a good clinical evolution at three weeks follow-up. Three months after the surgery, the patient lasted asymptomatic with a complete disappearance of the soft tissue swelling. No follow-up radiographs were performed.Bone granulomas caused by foreign bodies in children are rare, with only a few cases described in the literature -5. It waBone granulomas caused by an intraosseous foreign body is a rare condition in children. BG should be included in the differential diagnosis of lytic lesion of the hand phalanges in children, even in case of nonpenetrating trauma.


Pneumatosis cystoides intestinalis (PCI) is defined by the presence of gas within the bowel wall. It is often asymptomatic and usually benign but may be associated with significant morbidity and mortality. In this patient, PCI was found incidentally on screening colonoscopy, and biopsy of the affected mucosa resulted in deflation of a cyst. Pneumoperitoneum was then identified on subsequent CT. Because pneumoperitoneum is associated with bowel perforation in most cases, it is often treated as an indication for operation. This case of benign and asymptomatic pneumoperitoneum was managed conservatively without complications. Clinicians should be able to identify PCI as a potentially benign finding on colonoscopy as well as a potentially benign cause of pneumoperitoneum. This understanding presents an opportunity to avoid the unnecessary morbidity and costs associated with surgical exploration or additional endoscopic procedures. Pneumatosis cystoides intestinalis (PCI) is a rare finding of intramural gas within the walls of the small and/or large intestine. PCI is not itself a diagnosis but is a radiographic or physical finding that may be associated with an underlying disease process . An autoWe present a case of PCI identified incidentally on screening colonoscopy with concurrent pneumoperitoneum present on CT. Our objective is a contribution to, and review of, current literature regarding this topic.A 65-year-old woman presented for her first screening colonoscopy. Her medical history was significant for morbid obesity, anxiety, hypertension, and a 46 pack-year history of tobacco use. She had previously undergone a laparoscopic cholecystectomy, ventral hernia repair, and cylindroma excision but had no surgeries in the 12 months prior to her presentation. Her medications at the time included hydrochlorothiazide and losartan. She had no family history of colon cancer or any recent significant gastrointestinal symptoms.The patient’s colonoscopy revealed polypoid grape-like masses protruding through the mucosa, consistent with PCI at the splenic flexure as well as small, benign colonic polyps at other areas of the colon Figure .Biopsy of one of the grape-like masses at the splenic flexure was performed resulting in its visible rupture and collapse. Histologic examination of the biopsy demonstrated empty, submucosal cysts lined by multinucleated giant cells Figure . Post-procedure CT images showed multiple, thin-walled, air-filled submucosal cysts with evidence of intraperitoneal free air Figure . Given tThe pathogenesis of PCI remains incompletely understood, despite several hypotheses. These hypotheses suggest mucosal damage in combination with increased intraluminal pressure secondary to mechanical causes, bacterial production, or pulmonary gas traveling along the perivascular spaces of mesenteric vessels ,5,6. AppIdentification of PCI may be increasing along with the use of CT in diagnosing abdominal pathology . CT is tDifficulty identifying patients with PCI secondary to a potentially deadly pathologic cause remains a barrier to management. A 2013 review found PCI to represent a benign finding in 60% of cases and was associated with significant morbidity and mortality in approximately 40% of cases. Their analysis found a lactate elevation of 2.0 or greater to be the strongest independent predictor for pathologic disease. This lactate elevation in combination with hypotension or vasopressor need was found to have a predictive probability of 93.2% for pathologic disease . LactatePneumoperitoneum, or free air in the abdominal cavity, is a concerning imaging finding that prompts immediate attention. It is estimated that 85%-95% of cases of pneumoperitoneum are associated with perforation of intra-abdominal viscus, and thus the tendency towards surgical management. In contrast, pneumoperitoneum found in association with PCI is often a benign finding but does not rule out viscus perforation . This paAs the number of screening colonoscopies continues to rise, recognition of PCI by experienced endoscopists will become increasingly important. Identification can avoid misdiagnosis of polyposis or neoplasm and reduce unnecessary additional diagnostic studies while also ensuring proper management and follow-up to rule out pathologic causes. Although it is uncommon, clinicians and radiologists should also be on the lookout for PCI as a cause of benign pneumoperitoneum. Asymptomatic patients without concerning findings on exam may be managed conservatively with serial exams and avoid the complications and costs associated with surgical exploration or additional endoscopic procedures.


Congenital unilateral agenesis of the ovary and fallopian tube is a rare condition that has been previously described in the literature. While this condition is benign, studies have proposed it could be associated with infertility. The purpose of this report is first to highlight a rare incidental finding of unilateral ovarian and fallopian tube agenesis. Secondly, we aim to discuss the various imaging modalities used for the detection of uterine, ovarian, and fallopian tube defects and their shortcomings. Our case describes a 37-year-old G4P0030 woman with an obstetric history of spontaneous abortion and ectopic pregnancy, presenting at 38 weeks gestational age with polyhydramnios. The patient received routine obstetric care with no abnormalities being reported on routine ultrasonography. Elective cesarean section was performed at which time the incidental condition discovery of unilateral agenesis of the right ovary and fallopian tube was made. This case is unique since the incidental diagnosis of unilateral right ovarian and right fallopian tube agenesis occurred during cesarean delivery instead of through imaging. It is important for patient counseling to understand the typical workup and deficiencies in pelvic imaging concerning congenital anomalies Congenital unilateral agenesis of the ovary and fallopian tube is a rare condition that has been previously described in the literature . IncidenA 37-year-old G4P0030 woman at 38 weeks gestational age was admitted to the labor floor due to polyhydramnios. Vital signs were within normal limits. Her medical history was notable for fibroids and a renal angiomyolipoma. Family history was unremarkable. Obstetric history revealed a history of one elective abortion, one spontaneous abortion occurring at five-weeks gestation age, and a right tubal ectopic pregnancy occurring at six-weeks gestational age. The ectopic pregnancy was treated with methotrexate.Laboratory tests were all within normal limits. Fetal ultrasound evaluation showed normal fetal growth, with a normal biophysical profile except for her amniotic fluid index, which was 30cm. The non-stress test was reassuring. Considering the patient’s history of prior miscarriages, advanced maternal age, and polyhydramnios, the decision for cesarean delivery was made. Cesarean section was performed in the operating room (OR), and a 3256g healthy male infant with a five-minute Apgar score of eight was delivered.At a cesarean delivery, a small 1cm portion of the fallopian tube at the cornua was identified but the distal segment was absent Figures . In addiMüllerian duct defects represent an uncommon etiology for infertility in women . StudiesThe number of reported cases remains small but typically, most cases according to the available literature are diagnosed incidentally following laparoscopy for gynecological or obstetric concerns . A few sAdditionally, visualization of the ovaries and fallopian tubes can present an added challenge. While most ultrasound specialists can identify these structures, it is not unheard of for them to be missed. One study by Lefringhouse et al. examined the accuracy of detection in normal women with transvaginal ultrasound. They found that ovaries were observable in 82.7% of cases while the fallopian tubes were observable in 77.2%, increasing to 85.2% if the ovary was identifiable . VariousOur case was interesting in that the patient reports never having received any abnormal ultrasound findings during her obstetric care. To our best knowledge, this case is unique since the incidental diagnosis of unilateral right ovarian and right fallopian tube agenesis occurred during Cesarean delivery. It is important for patient counseling to understand the typical workup and deficiencies in pelvic imaging concerning congenital anomalies. While this condition is benign, this incidental discovery can have a stressful psychological impact on the patient. Thus, awareness of this rare condition can be helpful information for the clinician to consider.


Plexiform cervical neurofibromas are benign neoplasm, extremely rare, difficult to diagnose and to manage. Only some cases have been reported in the literature.We report the case of a 60-year-old man admitted for a lateral neck mass, for which the surgical indication was the increase in volume of this mass, as well as the aesthetical impairment, the surgical exploration found the tumor attached to the cervical plexus. The excision of the mass was performed without damaging nerve. The pathological study was in favor of a plexiform neurofibroma.Even though Plexiform cervical neurofibroma are extremely rare, and their diagnosis are not often primary evoked in front of any growing mass of this region, the surgeon must keep in mind the existence of these neoplasms as a differential diagnosis of a neck tumor.Surgery remains the gold standard in the treatment of these locally invasive tumors. It is essential that the surgeon keep in mind the possibility of these tumors as a differential diagnosis of a neck tumor. •Plexiform cervical neurofibromas are benign neoplasm, extremely rare.•Difficult to diagnose and to manage.•Their symptomatology is variable and depends on their topography.•The clinical aspect is not specific, and the diagnosis is confirmed after a biopsy with anatomopathological examination.•Surgery remains the gold standard in the treatment of these locally invasive tumors. PlexifoFormerly known as "plexiform neuroma" or the plexiform neurofibroma is a "royal tumor" and differs from theother types of neurofibroma by the importance of the component schwannian . the dia2A 60-year-old male patient was referred to our otolaryngology department. The patient had an irrelevant past medical history with no known allergies. He had a history of smoking (25 pack-years).he reported with a long standing swelling in the right supraclavicular region. The swelling Persisted for more than ten years.On clinical examination, it was found that the swelling was firm in nature, non-tender, and non-pulsatile. It was located at the level 5 region and measured 5 × 4 cm, . No otheCT scan revealed a large well-defined mass located in the right supraclavicular region. It measured 7 × 3.5 cm (transverse × anteroposterior measurements). . FurtherThe surgical exploration found the tumor attached to the cervical plexus. .The exciIn the pathological study, the tumor was poorly limited, unencapsuled, containing numerous neoformed with Cystic tumor proliferation, with elongated spindle-shaped cells with corrugated nuclei, without atypia, on a fibrous background. .In immunRegarding the increase in the volume of the mass and the esthetic problem, the patient was planned for a resection churgical. The patient was followed up carefully, without evidence for local recurrence 1 year after surgery.3Neck nerve tumors are rare primary tumors, but have beenknown since 1742 when Haller discovered the carotid corpuscle; then in 1803 Rodier introduced the term “neuroma” for tumors ofthe peripheral nerves .PNF, an uncommon benign tumour, usually presents at birth or in the first years of life . A neck Recent advances in immunohistochemistry and imaging allowincreasingly precise diagnosis ,9. The mPlexiform neurofibroma is strongly associated with neurofibromatoses, especially Von's disease Recklinghausen (NF1), where it occurs in 24–32% of the patients ,12. The _discrete cutaneous neurofibromas of the epidermis or dermis;_discrete subcutaneous neurofibromas that are deeper;_deep nodular neurofibromas;_diffuse plexiform neurofibromas.Plexiform neurofibroma belongs to the group of to the 4 types of neurofibromas encountered in the NF1 according to the classification of the consensus conference of 1988 from the National Institute of Health Development :_discretThese masses can be quite disfiguring, and hemifacial hypertrophy can occur. These tumors are known to cause symptoms ranging from minor discomfort to extreme pain. The consistency of the lesion has been compared to that of a “bag of worms” because of the presence of soft areas interspersed with firm nodular areas. This consistency was well appreciable in the lesion seen in our patient. These lesions sometimes demonstrate a vascular nature.On CT, the NFPs appear spontaneously isodense with respect to the muscles. They take up contrast only weakly, less than the muscle, which gives them a hypodense aspect (different aspect from schwannomas and neuro-fibrosarcomas) . On MRI,At histological analysis, a localized, solitary neurofibroma iscomposed of interlacing fascicles of wavy, elongated cells thatoften contain abundant amounts of collagen. Rarely, myxoid areasand degenerative regions could be found in neurofibromas. Diffuseneurofibroma contains very uniform, prominent fibrillary collagen.Both localized and diffuse neurofibromas are positive for S-100protein at immunohistochemical analysis but this is not a stablefinding ,18. It nIn anatomopathology, neurofibroma is poorly limited, not encapsulated, with the absence of thick-walled vessels; Immunohistochemistry is of limited value in this differential diagnosis .Treatment of localized and diffuse neurofibromas (not associ-ated with NF-1) is often surgical resection. Neurofibromas cannotbe easily separated from normal nerve, and complete excision ofthe neoplasm may require sacrifice of the nerve. While tIn our case report, total removal of the lesion was performed because it was not relatedto a major cervical nerve. Transformation to malignant peripheral nerve-sheath tumoursis the most feared complication of NF-1 but is less common insolitary neurofiroma and diffuse neurofibroma .The estimatedprevalence of malignant transformation varies from 2 to 29%. Sud-den increase in size of a previously diagnosed neurofibroma wellknown to be clinically and radiologically stable, should be viewedwith great suspicion of malignant transformation and must leadto immediate biopsy. Malignant transformation of these lesions, without association to NF-1, is rare and not well documented in the literature .4Solitary plexiform neurofibroma has to be considered in the differential diagnosis of cervical masses. They are rare tumors with low risk of malignant transformation. If local con-ditions and the general condition of the patient allow surgery, complete resection of the lesion can be proposed.Surgery remains the gold standard in the treatment of these locally invasive tumors; however, guidelines need to be established regarding the selection of surgical candidates. It is essential that the surgeon keep in mind the possibility of these tumors as a differential diagnosis of a neck tumor.Not commissioned, externally peer reviewed.The authors declare having no conflicts of interest for this article


Quadriceps tendon rupture is an uncommon injury and mostly occurs among middle aged individuals that are involved in sports such as running or jumping. Spontaneous bilateral quadriceps tendon rupture is a rarer injury, however, can be debilitating. Patients with such injuries usually present with history of minor trauma, swelling and inability to actively extend the knee. Its occurrence secondary to minor trauma is mostly associated with chronic diseases and long-term use of certain medications. Occurrence of simultaneous bilateral quadriceps tendon rupture in the absence of trauma in a healthy patient with no known medical condition is yet to be reported and therefore requires a high index of suspicion for early diagnosis and effective management to avoid complications. The aim of this case report is to create awareness of the spontaneous occurrence of this injury in the absence of the reported risk factors. We report the unusual case of a 60-year old healthy man who presented with a spontaneous simultaneous bilateral quadriceps' tendon rupture in the absence of trauma and no medical risk factors. We report the unusual case of a 60-year old healthy man who presented with a spontaneous simultaneous bilateral quadriceps tendon rupture in the absence of trauma and no medical risk factors. Consent was taken from him to be used as a case report being a rare case. The man had full recovery after surgery and physiotherapy and was discharged home. Spontaneous bilateral quadriceps tendon rupture is a rare occurrence. The index case report is important as there was no history of trauma and it was bilateral. Quadriceps tendon rupture is uncommon and occurs predominantly after major trauma among the middle-aged group involved in sport activities. It can A 60 year old male businessman was standing and fell down suddenly, with difficulty innstanding, pain in both knees. No prior history of trauma. No history of steroid use or renal problems, no history of use of injections. No previous surgery.Clinical findings: dimpling on the superior pole of both patellae . This confirmed the diagnosis of bilateral quadriceps tendon tear as well as radiological diagnosis of partial tear of the patellofemoral ligament.Therapeutic intervention: he was counselled for and subsequently underwent surgical tendon repair using Krakow method of tendon repair. Exposure of the ruptured tendon revealed full thickness rupture at the superior pole of the patella  and the inability to actively extend the knee is found only in 60% of the cases ,11. HoweTreatment: surgical repair remains the treatment of choice and involves open repair and reconstruction. Prompt repair is recommended to avoid complications such as retraction and quadriceps muscle atrophy [ atrophy . Employe atrophy . Post-su atrophy . After w atrophy . The pat atrophy . HoweverSpontaneous simultaneous bilateral quadriceps tendon rupture is a rare occurrence. Our patient had no prior trauma, no chronic disease, not obese and was not on any medication shown to increases the risk of tendon rupture. We report a unique case of bilateral tendon rupture that required high index of suspicion for prompt diagnosis and management.


Paragangliomas (PGLs) are extremely rare neuroendocrine tumours arising from extra-adrenal chromaffin cells. PGLs are clinically rare, difficult to diagnose and usually require surgical intervention. PGLs mostly present catecholamine-related symptoms. We report a case of Acute abdomen as the initial manifestation of haemorrhagic retroperitoneal PGL. There has been only one similar case reported in literature.rd day of admission, her abdominal pain was slightly relieved, but haemoglobin decreased from 10.9 to 9.4 g/dL in 12 h suggesting that there might be active bleeding in the abdominal cavity. Thus, we performed a midline laparotomy for the patient. Haemorrhage was successfully stopped during operation. The retroperitoneal tumour with haemorrhage was completely removed. The abdominal pain was significantly relieved after surgery. The patient initially presented with acute abdomen instead of catecholamine-related symptoms. The diagnosis of retroperitoneal PGL with haemorrhage was finally confirmed by postoperative pathological and immunohistochemical results. The postoperative course was uneventful. At the 1-year follow-up visit, no tumour recurrence was observed by Single Photon Emission Computed Tomography. A literature review was performed to further understand and analyse the aforementioned disease.We present a unique case of a 52-year-old female with acute abdomen induced by haemorrhagic retroperitoneal PGL. The patient had a 5-h history of sudden onset of serve right lower quadrant abdominal pain radiating to the right flank and right lumbar region. Patient had classic symptoms of acute abdomen. Abdominal ultrasound revealed a large abdominal mass with a clear boundary. A Computed Tomography Angiography (CTA) of superior mesenteric artery was also performed to in the emergency department. The CTA demonstrated a large retroperitoneal mass measured 9.0 × 7.3 cm with higher density inside. A provisional diagnosis of retroperitoneal tumour with haemorrhage was made. The patient received intravenous fluids, broad-spectrum antibiotics and somatostatin. On the 3Acute abdomen as the initial manifestation of haemorrhagic retroperitoneal paraganglioma is extremely rare. Abdominal Computed Tomography is essential to locate the lesion and differentiate between other causes of acute abdomen. PGLs are hypervascular tumours. We should be aware that ruptured retroperitoneal PGL with massive bleeding could be life threatening and require emergency laparotomy. Paragangliomas (PGLs) are rare neuroendocrine tumours originating from extra-adrenal chromaffin cells. PGLs are located along the autonomic nervous system, especially in the retroperitoneum around the organ of Zuckerkandl. Pheochromocytomas (PCCs) arise from the adrenal medulla . The incAcute abdomen is a clinical syndrome characterized by acute abdominal pain that is severe, rapid in onset and localized or generalized . Acute a9/L, neutrophilic granulocyte 87.10%. Abdominal ultrasound showed a large abdominal mass with a clear boarder. Blood flow could be found inside it. The patient suffered from an intolerable acute abdomen. The superior mesenteric artery embolus and abdominal aortic aneurysm were also suspected. Computed Tomography Angiography (CTA) was further done to identify nature of the retroperitoneal tumour and make differential diagnosis.A 52-year-old Chinese female was admitted to the emergency department for 5-h history of acute onset of right lower quadrant abdominal pain accompanied with nausea and vomiting. The pain was crampy, increasing in intensity, and radiated to the right flank and right lumbar region. No aggravating or relieving factors were noted. She had no headache, palpitation, sweats and hypertension. There was no significant relevant past medical history. The patient had received an open appendectomy at the age of 25 and a left ovarian cystectomy at the age of 27. She also had right salpingectomy due to an ectopic pregnancy at the age of 38. Physical examination of the abdomen showed mild tenderness in the right lower quadrant. The following laboratory data were observed: a hemoglobin concentration of 10.9 g/dL, leukocytes 14.49 × 10According to the CTA of superior mesenteric artery, a large retroperitoneal mass measured 9.0 × 7.3 cm was located posterior to the 3rd part of duodenum and below the head of the pancreas. The retroperitoneal mass had a slightly increased but non-uniform density shadow at venous phase. The density of retroperitoneal mass showed no enhancement appearances at arterial phase Fig. a, b. Therd day of admission, her abdominal pain was slightly relieved, but hemoglobin decreased from 10.9 to 9.4 g/dL in 12 h, suggesting the presence of active bleeding in the abdominal cavity. Hence, she was persuaded to have immediate surgical intervention and underwent an exploratory laparotomy.The patient was admitted to our department. From these physical and radiographic findings, we diagnosed a retroperitoneal tumour with haemorrhage. The pain was crampy and intolerable. Emergency surgery was initially recommended after admission. But the patient wished to avoid operation and chose conservative treatment. She received treatment of intravenous fluids, hemagglutinase, and somatostatin. Antibiotic was also used to prevent abdominal infection. It was quite risky that the patient initially refused to follow our advice. We continuously assessed the pain degree of patient and measured haemoglobin concentration. Measurement of tumour markers, including AFP, CA 19-9, and CEA, were also finished. The levels of tumour markers were within the normal range. On the 3Upon the surgical exploration: A scarlet red retroperitoneal tumour was found between the colonic hepatic flexure, the 2nd to 3rd parts of the duodenum, pancreatic uncinate process and the abdominal aorta. The tumour had a complete capsule and dense peritumoural adhesions to the surrounding blood vessels  staining Fig. a, b. TheImmunohistochemistry (IHC) revealed the following profile: chromogranin A (CgA) (+), synaptophysin (Syn) (+), DOG1 (−), S-100 (−), CD56 (+), AE1/AE3 (−), CD117 (+), and Ki -67  Fig. a–i.Fig. Patient received antibiotic treatment for 5 days. Considering that intraoperative blood loss and high bleeding risk after surgery, she received 4 units (200 ml each) of PRBC transfusions and 640 ml fresh frozen plasma on the first postoperative day. On postoperative day 10, she was discharged, tolerating a regular diet with no further complains. At the 1-year follow-up visit, serum metanephrines of the patient were in normal range and no tumour recurrence was observed by Single Photon Emission Computed Tomography.A literature review was conducted by PubMed, Web of Science, and OVID. The documentation retrieval was identified with the key words of “paraganglioma” and “acute abdomen” through June 2020. There were few reports and acute abdomen were mostly induced by ruptured PCC. Only one case of haemorrhagic retroperitoneal PGL initially manifesting as acute abdomen was reported . PGLs arPGL can be further divided into sympathetic and parasympathetic types according to their clinical and biological characteristics . SympathPGLs are usually characterised by catecholamine-related symptoms and also rarely asymptomatic until reaching enormous size or having complications. PGLs mostly present with catecholamine-related symptoms and signs referable to hypersecretion of catecholamines and their metabolites . PatientGenetic testing is advised for patients with PGLs to find out genetic mutations causing the disease. The revolutionary genetic advances have already improved understanding and made more discoveries of PGL , 24. CurBiochemical testing should ascertain whether oversecretion of catecholamines or metanephrines exist . In both18F-fluorodihydroxyphenylalanine, 18F-fluorodeoxyglucose, 18F-fluorodopamine, 11C-hydroxyephedrine or 68Ga-labelled somatostatin analogues have lower radiation exposure and superior image quality but a higher cost than MIBG However, these PET approaches can be used as alternatives to 123I-MIBG or as additional procedures if 123I-MIBG scanning is negative [Imaging examination for PGLs should be done simultaneously to make diagnosis and differential diagnosis. Imaging is usually performed after laboratory examination confirms the catecholamine excess. CT or magnetic resonance imaging (MRI) is necessary to promptly locate the PGLs. As for PGLs, the sensitivity of CT is lower than MRI , 34. Funnegative , 38. OurFull preoperative preparations for patients with PGL are important to avoid perioperative complications, especially when biochemical testing confirms oversecretion of catecholamines. Patients should receive preoperative medications including α-adrenergic blockers, β-adrenergic blockers and calcium channel blockers if necessary. Admitted patients should receive preoperative fluids the night before surgery to increase blood volume, which prevents a rapid increase (with catecholamine release) or decrease (with a decrease in the catecholamine burden) in blood pressure . Our patThe standard treatment for PGL is surgical resection. PGLs rely on many kinds of operations due to their different locations. The laparoscopic surgery for abdominal PGLs has been proved to be as reliable as laparotomy. Some surgeons insist a retro-peritoneal laparoscopic surgery for suprarenal PGLs and a transperitoneal laparoscopic surgery for infrarenal PGLs . HoweverTo improve the outcomes of patients who cannot receive surgical treatment, palliative treatment options contain localized therapies such as radiotherapy, radiofrequency or cryoablation and systemic therapies like chemotherapy or molecular targeted therapies. The therapeutic principle goals for metastatic PGLs aim to control symptoms caused by catecholamine over secretion, improve life quality, prolong the survival time, and reduce other complications .Morphologically, PGL typically consists of polygonal chromaffin tumour cells with sustentacular cells around. Moreover, tumour cells are separated by abundant capillary network and arranged nest like . Cytological characteristics includes granular cytoplasm, prominent nucleoli, vesicular nuclei, pseudoinclusions inside nuclei and so on. There might be secondary changes like haemorrhage, haemosiderin deposition, sclerosis and pigmentation of lipofuscin or melanin. Pathologists could easily diagnose it according to its characteristics –48.Immunohistochemistry could confirm the pathological diagnosis and make differential diagnosis with other microscopically similar tumours. CgA is the most specific feature and helps distinguish PGLs from other neuroendocrine tumours. PGLs are usually positive for synaptophysin (Syn), which is less specific than CgA because adrenal cortical carcinomas can also have diffused positive Syn staining –51. CD56Our patient did not have any preoperative symptoms secondary to catecholamine secretion, such as headache, palpitations, sweats or tremor. Hypertensive crisis was not found during the exploratory laparotomy. Pathological examination showed that the tumour cells were nest-like and arranged in a cribriform pattern. Immunohistochemistry revealed a CgA (+) and Syn (+) profile. Thus, we present a case of haemorrhagic retroperitoneal PGL. The process of diagnosis and treatment of this patient was extremely complex and difficult.Acute abdomen induced by haemorrhagic retroperitoneal PGL is highly rare, and only 1 case has been reported worldwide by 2019. Kwok-Kay Yau reported a male with right lower quadrant pain and the acute abdomen was originally misdiagnosed as acute appendicitis. Without preoperative CT or MRI of abdomen, the retroperitoneal tumour with haemorrhage was not found until laparoscopic appendectomy. The patient had to receive a second surgery after finishing abdominal CT and MRI . Our casAcute abdomen induced by retroperitoneal lesions is extremely rare and complex. Retroperitoneal tumor accompanied with infection, hemorrhage or compression might lead to an acute abdomen. To the best of our knowledge, retroperitoneal tumors manifesting as an acute abdomen were reported, such as retroperitoneal myelolipoma, PGL, lymphangioma, hemangiopericytoma, leiomyoma, Ewing's sarcoma, lymphangioleiomyomatosis, cystic teratoma, adrenal lipoma, spontaneous renal angiomyolipoma, PCC, renal oncocytoma, renal adenoma, carcinoid tumor and so on , 54–65.Myelolipoma is a rare benign tumor composed by adipose tissue and hematopoietic cells. Similar to the distributions of PCCs and PGLs, myelolipomas are usually located in adrenal gland and rarely extra-adrenal –68. TherPGLs do not present only catecholamine-related symptoms but they may also be asymptomatic, such as parasympathetic and part of sympathetic PGLs. Acute abdomen as the initial manifestation of haemorrhagic retroperitoneal paraganglioma is extremely rare. Abdominal Computed Tomography is essential to locate the lesion and differentiate between other caused of acute abdomen. It is currently recognized that PGLs have some metastatic potential and are hereditary. Biochemical testing, especially for metanephrine levels, and imaging techniques are helpful in diagnosing and locating tumours. The definitive treatment for PGL is surgical resection. Full preoperative preparation could prevent life-threatening perioperative complications. PGLs are hypervascular tumours. We should be aware that ruptured retroperitoneal PGL with massive bleeding could be life threatening and require emergency laparotomy.


Gangliocytic paraganglioma is a rare tumors mainly arises from the second part of the duodenum. The tumor is generally benign, but some cases are associated with lymph node or distant metastasis. It must be differentiated from other tumors. The main treatment is good local surgical resection. Most patients have good prognosis after an appropriate resection.A 47-year-old male patient presented with recurrent attacks of epigastric pain and melena. The general examination revealed pallor with no jaundice. The abdomen was soft with no tenderness. There were no stigmata of chronic liver diseases. The hemoglobin level was 8 gm/dl with normal liver and renal functions. The patients received compatible blood. Endoscopy showed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. During surgery, the anterior wall of duodenum was opened, and a 4 cm pedunculated polyp was excised which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. The frozen section examination revealed a benign lesion. The final histopathology result was consistent with the diagnosis of gangliocytic paraganglioma. The patient had smooth post-operative recovery and no postoperative complications.Gangliocytic paraganglioma is a rare tumor which mostly affects the second part of the duodenum. The tumor is considered benign but the possibility of the malignancy with lymphatic and distant metastases must be excluded before any surgery. The management plan must be addressed carefully and continuous follow up is recommended. Kepes and Zacharias also described its characteristics cellular features. The tumor has a characteristic 3 distinct types of cells: spindle cells, epithelial cells, and ganglion cells, identification of all these three components is essential for the diagnosis [The tumor was first described by Dahl et al. in 1957, after that some cases were reported until 1971 when Kepes and Zacharias named the tumor as The tumor usually affects middle aged people with slight male predominance. There is no specific symptom related to the tumor, patients may be asymptomatic and discovered incidentally during imaging for other purposes, it may cause mass effect causing abdominal pain, gastrointestinal bleeding which could be life threatening due to mucosal ulceration over the lesion, features of intestinal obstruction or bile duct obstruction. Most cases are hormonally inactive, however, some cases are reported with somatostatin or pancreatic polypeptide secretion. One case is reported in association with Von Recklinghausen disease suggesting a possible link ,5.This tumor have a variety of differential diagnoses such as carcinoid tumor, ganglio-neuroma, pigmented paraganglioma and gastrointestinal stromal tumor (GIST), hamartoma, lymphoma, hemangioma and duodenal cancer and sarcomas. This differentiation is usually done by imaging, biopsy or immunohistochemical analyses detecting the expression of various markers and proteins .The accurate preoperative diagnosis is very difficult in most cases. The main treatment is good local surgical resection either by the open approach or endoscopic approach, most patients have good prognosis after an appropriate resection .The work of this report case has been reported in line with the SCARE 2018 criteria .2A 47-year-old male patient presented to the surgical consultation with recurrent attacks of epigastric pain, melena, and epigastric fullness.Upper and lower GIT endoscopies were performed during the first admission which showed no abnormal findings.During the last presentation, the patient was admitted to the surgical unit.The patients had negative drug history. The family history was negative for any genetic diseases, and the psychosocial history was negative.2.1The general examination revealed pale conjunctivae, palms and oral mucosa. There were no cyanosis or jaundice.The blood pressure was 100/60 mmHg on admission, the pulse rate was 95 beats/minute, the temperature was normal and the body mass index was 38.The abdomen was soft with no areas of tenderness. There were no dilated veins over the abdomen with no stigmata of chronic liver diseases.2.2Investigations were performed for the patient. The hemoglobin level was 8 gm/dl with normal serum electrolytes, normal liver and renal function tests. The patients received 2 units of compatible blood and arrangement was done to perform another endoscopy.The endoscopy this time revealed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. CT-scan of the abdomen was normal with no abnormal findings.2.3Arrangement was done to perform surgical intervention, during surgery we adopt an upper midline incision, exploration of the abdominal cavity showed normal liver, spleen, and omentum, with no ascites and no dilated veins.Mobilization (kocherization) of the duodenum was performed, the anterior wall of duodenum was opened, and a pedunculated polyp (about 4 cm in size) was found which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. Excision of the polyp with its base was performed and was sent for frozen section examination during surgery which revealed a benign lesion with no signs of malignant activity.The posterior and the anterior duodenal walls were sutured transversely in two layers by a slowly absorbable 3/0 suture material (polydioxanone). The inner layer with continuous full thickness suturing and the outer layer with interrupted seromuscular suturing.The procedure was performed by two general surgeons who are specialized in the field of general surgery.The final histopathology examination revealed a well-defined mass in the submucosa of the duodenum that showed tri-phasic endocrine components; i.e. carcinoid like cells in compact nests and trabeculae, spindle cells (Schwan cells), and ganglion type cells of varying proportions. The immunohistochemical analysis of the polyp showed that all cells stained positive for synaptophysin, Schwan cells stained positive for S100 marker, with focal expression of pankerain in the endocrine cells. The mucosa and the margins were free from the tumor. These features were consistent with the diagnosis of duodenal Gangliocytic paraganglioma. 2.4The patient was admitted to the hospital for 5 days with smooth post-operative recovery and no postoperative complications.No specific postoperative considerations were undertaken.3The mean size of the reported cases was 25 mm size with maximum reported size of 10 cm. Tumors are usually is well demarcated with no definitive capsule .Immunohistochemical study is very important in the diagnosis, for epithelial cells and ganglion like cells CD56 and Syn show highest positive rates, while spindle-shaped cells express high levels of S-100 protein. It is reported that epithelioid and ganglion cells stain positive to the neuroendocrine peptides like somatostatin, pancreatic polypeptide, and serotonin [The incidence of lymph node metastases may be underestimated, this this is because most cases are treated with local excision without lymphatic dissection .There are less than 30 reported cases with lymphatic metastases and few cases with distant organ metastases, two cases of liver metastases and one with bone metastases have been reported. The malignant potential of the tumor depends on the size of the tumor being higher when the tumor is larger than 2 cm, younger age of the patient, and tumors invading the submucosa. Some authors suggest that tumors expressing bcl-2 and/or p53 also increase the metastatic potential to the regional lymphatics or distant organs ,10.The possible treatment options varies greatly depending on the clinical presentation, the size of the tumor and the local extension. Some cases are treated by endoscopic polypectomy especially in pedunculated lesions, the depth of the tumor invasion must be determined by endoscopic ultrasound before resection is performed. Simple excision is recommended as a curative management in some cases, other treatment option is pylorus preserving pancreaticoduodenectomy with dissection of the regional lymph nodes ,4.The management options must be discussed and planned carefully after an appropriate preoperative staging whenever possible but this may not be applicable especially in emergency presentations. Some patients may present with massive upper GIT bleeding and in such cases the priority is for resuscitation and emergency surgery may be required. Tumors that have an aggressive behavior and have local or distant invasion are treated with adjuvant radiation therapy. Continuous follow up is recommended due to the malignant potential in some cases ,10,11.4Gangliocytic paraganglioma is a unique type of tumor which mostly affects the second part of the duodenum. Although the tumor is considered benign in most literature, but the possibility of the malignant potential with lymphatic and distant organ metastases must be kept in mind and must be excluded before any form of surgery. The management is plan must be addressed carefully and continuous follow up is recommended.The authors report no declarations of interest.None.Ethical approval has been exempted by my institution for reporting this case.An informed written consent was taken from the patient for reporting the case and the accompanying images.Dr Ayad Ahmad Mohammed and Dr Sardar Hassan Arif contributed to the concept of reporting the case and the patient data recording.Drafting the work, design, and revision done by Dr Ayad Ahmad Mohammed.Dr Rafil T. Yaqo did the histopathological examination and immunohistochemical analyses.Final approval of the work to be published was done by Dr Ayad Ahmad Mohammed and Dr Sardar Hassan Arif.This work is case report and there is no need of registration.Dr Ayad Ahmad Mohammed is guarantor for the work.Not commissioned, externally peer-reviewed.


Jejunoileal atresia is a common cause of neonatal intestinal obstruction with high mortality and morbidity in a low resource setting where surgical care is lacking. Herein, a 4‐day‐old presented with features of acute abdomen and septicemia, managed with ileostomy diversion, and recovered uneventfully. Jejunoileal atresia is a common cause of neonatal intestinal obstruction with high mortality and morbidity in a low resource setting where surgical care is lacking. Herein, a 4‐day‐old presented with features of acute abdomen and septicemia, managed with ileostomy diversion, and recovered uneventfully. Herein, we presented a 4‐day‐old neonate who presented to the emergency department of St. Mary's Hospital Lacor as a referral from a distant peripheral hospital with features of acute abdomen and septicemia. He was resuscitated and an ileostomy diversion created. He recovered uneventfully from the hospital and discharged. However, he passed on upon readmission six weeks later from severe acute malnutrition. There should be a high index of suspicion on concomitant intestinal perforation in a neonate presenting with intestinal obstruction after delayed surgical care. Surgical approaches such as intestinal diversion should be sought carefully to mitigate serious consequences of anastomotic leak from primary bowel repair.Neonatal intestinal perforation is one condition with a high mortality rate.A plain radiograph of abdomen continues to be a useful tool for the diagnosis of neonatal intestinal obstruction demonstrating distended bowel loop or double bubble in proximal obstruction secondary to duodenal atresia.The management of neonatal intestinal perforation depends on the etiological factor and varies to include primary repair, resection and anastomoses, ileostomy, colostomy, gastrectomy, and gastroduodenostomy.2A four (4)‐day‐old neonate, born to a 21‐year‐old primiparous mother delivered at term with a birthweight of 2.30 kg, was admitted to the emergency department of St. Mary's Hospital Lacor as a referral from another health unit with failure to pass stool associated with abdominal distension, vomiting of nonbilious content, and irritability since birth. There was no yellowing of eyes or skin, and he was able to breastfeed well and passed urine normally.2.12) of 89% on room air and a pulse rate of 158 beats per min (bpm). The chest had normal air with normal breath sound and percussion note. The abdomen was grossly distended with visible collateral veins, diffusely tender with guarding. Upon digital rectal examination, there was a normal anus with a normal anal tone, no perineal fistula, and an empty rectum. Noted the absence of blast sign.He was ill‐looking, irritable, febrile at 38.3°C, with pink mucosal membranes, and was mildly dehydrated. He was in respiratory distress, respiring at 65 breaths per min with oxygen saturation  and operated. Intraoperative findings of a grossly distended ileum, 15 cm proximal to the ileocecal junction (ICJ) for a length of 16.0 cm, and a perforation 18.0 cm from the ICJ with edematous bowel and intraperitoneal contamination Figure a collaps3Neonatal intestinal obstruction is so devastating if access to care is not immediate. This may progress to possible proximal bowel perforation, aspiration, and increased intra‐abdominal pressure compromising breathing as seen in this child who was admitted with an oxygen saturation of 89% room air.The surgical management for ileal atresia reported by Hiller et al is in favor of primary resection and anastomosis than secondary anastomosis.4A high index of suspicion on concomitant intestinal perforation in a neonate presenting with intestinal obstruction after delayed access to surgical care while approaches such as intestinal diversion should be sought carefully to mitigate serious consequences of anastomotic leak from primary bowel repair.None declared.Okidi Ronald: wrote the background, discussion of the case, and preparation of the manuscript; Odwar Erick: participated in the case discussion; Komakech David: added background and summarized the case description, Aber Lucy Diana: provided photographs of the baby and obtained informed consent for publication of the case; and Nahurira violah: was involved in the writing of the abstract. All the authors participated in the management of this case.This case report was approved by the Lacor hospital institutional research and ethics committee (LHIREC).The mother gave written informed consent for the publication of her baby's clinical information including the photographs.