Cavernous hemangioma of the mesorectum involving the rectum: a rare case report

BACKGROUND

Gastrointestinal hemangiomas are very rare and are even rarer in the mesorectum. It is not clear whether mesorectal hemangiomas originate in the bowel wall or in the mesorectum. For clinicians, to correctly identify the imaging features of mesorectal hemangiomas is important.

CASE PRESENTATION

We herein describe a case of a 31-year-old male that presented with hematochezia and sensation of rectal tenesmus. Both the rectal MRI and contrast-enhanced CT scan of the whole abdomen indicated rectal wall thickening, marked dilatation, and tortuous vessels around the rectum. In addition, a contrast-enhanced portal venous phase CT scan showed the dilation of portal vein, splenic vein and inferior mesenteric vein. The dilated inferior mesenteric vein extending down to the mesorectum, and became marked dilatation and tortuous vessels around the rectum. The patient underwent laparoscopic surgical resection of the mesorectal lesion and the involved portions of the rectum. The surgical samples underwent pathological analysis, and a diagnosis of cavernous hemangioma was confirmed. Seven days after surgery, the patient was discharged without postoperative complications.

CONCLUSIONS

This case highlights the imaging features of mesorectal hemangiomas. In addition, in this current case, the mesorectal hemangioma more likely originated in the mesorectum.

Spontaneous uterine rupture of an unscarred uterus revealed by a subocclusive syndrome: A case report and review of the literature

Spontaneous uterine rupture of an unscarred uterus is a complication that has dramatic results for both mother and fetus. The clinical presentation commonly comprises abdominal pain and metrorrhagia however we report a case of spontaneous uterine rupture revealed by a subocclusive syndrome. We report a case of a young woman who came to the ER with 3 days of progressive abdominal pain and subocclusive syndrome. The current pregnancy was estimated at 32 weeks of amenorrhea and the patient was hemodynamically stable. An obstetric ultrasound was performed showing a progressive monofoetal pregnancy and moderate peritoneal effusion. In view of the presence of effusion on ultrasound and the subocclusive syndrome, an abdominal and pelvic CT scan with contrast was carried out, showing a fundal uterine rupture defect with contrast media extravasation and intraperitoneal hemoperitoneum. The patient was immediately transferred to the operating room for a caesarean section. Although CT scans use radiation, their contribution was essential to avoid maternal death.

Use of uniportal video-assisted thoracic surgery combined with a posterior approach to resect a dumbbell-shaped mediastinal granular cell tumor: A case report

Introduction

A dumbbell-shaped mediastinal granular cell tumor has never been reported, and there have been no reports of dumbbell-shaped tumors resected with a combination of uniportal video-assisted thoracic surgery and the posterior approach.

Presentation of case

An 18-year-old woman was diagnosed with a mediastinal dumbbell-shaped granular cell tumor by computed tomography. Complete resection was achieved via a posterior approach combined with the uniportal video-assisted thoracic surgery. First, a T3 left hemilaminectomy was performed in the prone position and the tumor located inside the intervertebral foramen was removed as far as possible. Next, the patient was repositioned to the right lateral decubitus position, a 2.5-cm skin incision was made on the 4th intercostal posterior axillary line, and resection of the residual tumor was performed. Pathological diagnosis of the resected tumor revealed a benign granular cell tumor. The patient recovered post-surgery and no tumor was reported in the 4-month follow-up magnetic resonance imaging.

Discussion

This is the first reported case of a mediastinal dumbbell-shaped granular cell tumor and its successful resection using a combined posterior and uniportal video-assisted thoracic surgery approach.

Conclusion

This is a potentially safe and effective procedure for mediastinal granular cell tumors, with outstanding cosmetic advantages.

•

Our case presented with a rare mediastinal dumbbell-shaped granular cell tumor.

•

The tumor was resected using a combined posterior and uniportal VATS approach.

•

This is a safe and effective procedure for mediastinal dumbbell-shaped tumors.

Monomorphic epitheliotropic intestinal T-cell lymphoma presenting as melena with long-term survival: A case report and review of literature

BACKGROUND

Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is a rare primary intestinal T-cell lymphoma, previously known as enteropathy-associated T-cell lymphoma type II. MEITL is an aggressive T-cell lymphoma with a poor prognosis and high mortality rate. The known major complications of MEITL are intestinal perforation and obstruction. Here, we present a case of MEITL that was diagnosed following upper gastrointestinal bleeding from an ulcerative duodenal lesion, with recurrence-free survival for 5 years.

CASE SUMMARY

A 68-year-old female was admitted to our hospital with melena and mild anemia. An urgent esophagogastroduodenoscopy (EGD) revealed bleeding from an ulcerative lesion in the transverse part of the duodenum, for which hemostatic treatment was performed. MEITL was diagnosed following repeated biopsies of the lesion, and cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy was administered. She achieved complete remission after eight full cycles of CHOP therapy. At the last follow-up examination, EGD revealed a scarred ulcer and ¹⁸Fluorodeoxyglucose (¹⁸FDG) positron emission tomography/computed tomography showed no abnormal FDG accumulation. The patient has been in complete remission for 68 mo after initial diagnosis.

CONCLUSION

To rule out MEITL, it is important to carefully perform histological examination when bleeding from a duodenal ulcer is observed.

Low-grade intracranial meningioma with bilateral pulmonary metastases incidentally detected postpartum: a case report and review of the literature

Introduction

Meningiomas are the most commonly encountered intracranial tumors, usually showing indolent behavior. Extra-axial spreading and distant metastases are seldom detected in these tumors, and lung metastasis from a low-grade meningioma is a rare event.

Case presentation

This case report aimed to present the clinical, imaging, and pathological features of a 37-year-old Caucasian pregnant woman with bilateral lung metastases incidentally detected during preoperative workup ahead of surgery for a primary intracranial meningioma. The possible metastatic routes and risk factors of dissemination to the pulmonary circulation were discussed as well.

Conclusion

Metastasis must be considered in patients with intracranial meningiomas accompanied by venous sinus invasion and extension through the calvarium. Thorough paraclinical investigations are suggested in such cases.

When a vesicular placenta meets a live fetus: case report of twin pregnancy with a partial hydatidiform mole

BACKGROUND

Hydatidiform moles exhibit a distinctive gross appearance of multiple vesicles in the placenta. The advances in cytogenetic technologies have helped uncover novel entities of hydatidiform moles and enabled elaborate diagnoses. However, management of a vesicular placenta with a coexistent live fetus poses a bigger challenge beyond hydatidiform moles.

CASE PRESENTATION

A 33-year-old woman was referred to our department for suspected hydatidiform mole coexistent with a live fetus at 24 weeks' gestation. The patient had conceived through double embryo transplantation, and first-trimester ultrasonography displayed a single sac. Mid-trimester imaging findings of normal placenta parenchyma admixed with multiple vesicles and a single amniotic cavity with a fetus led to suspicion of a singleton partial molar pregnancy. After confirmation of a normal diploid by amniocentesis and close surveillance, the patient delivered a healthy neonate. Preliminary microscopic examination of the placenta failed to clarify the diagnosis until fluorescence in situ hybridization showed a majority of XXY sex chromosomes. The patient developed suspected choriocarcinoma and achieved remission for 5 months after chemotherapy, but relapsed with suspected intermediate trophoblastic tumor.

CONCLUSION

We report a rare case of twin pregnancy comprising a partial mole and a normal fetus that resembled a singleton partial molar pregnancy. Individualized care is important in conditions where a vesicular placenta coexists with a fetus. We strongly recommend ancillary examinations in addition to traditional morphologic assessment in such cases.

Cavernous lymphangioma of the urinary bladder in an adult woman: an additional case report of a rare lesion and literature review

Background

Urinary bladder lymphangioma is a rare and benign lesion that is often causes symptoms related to irritation and urinary tract obstruction. Because a lymphangioma may resemble a true neoplasm of the urinary bladder clinically, the lesion must be removed for accurate histologic diagnosis and to rule out malignancy.

Case presentation

We present a case of a 40-year-old female who was evaluated for painless gross hematuria. Clinical and diagnostic work up revealed a sharply defined mass involving the wall and bulging into the cavity on the dome of the bladder. Partial cystectomy was performed and histologic findings were compatible with cavernous lymphangioma. The symptom of hematuria relieved after the procedure and the patient was in good status without evidence of recurrence by cystoscopy at follow-up 6 months later.

Conclusions

Lymphangioma of the urinary bladder is treated with surgical excision and seems to have no recurrence once completely resected, but long-time follow-up may be needed.

Intraoperative management of liver transplant in a patient with an undiagnosed ventricular septal defect: A case report

BACKGROUND

The intraoperative management of patients undergoing orthotopic liver transplantation (OLT) frequently encounters hemodynamic instability after reperfusion of the new liver graft. The resulting post-reperfusion syndrome is characterized by an increase in pulmonary vascular resistance and decrease in systemic vascular resistance. In the presence of a left to right intracardiac shunt, this hemodynamic perturbance can lead to shunt reversal followed by hypoxemia and embolization of air and debris into the systemic circulatory system.

CASE SUMMARY

A 43 years-old male with end-stage liver disease due to primary sclerosing cholangitis complicated by portal hypertension and hepatocellular carcinoma presented for an OLT. A bedside transthoracic echocardiography (TTE) was performed immediately before the procedure and unexpectedly identified a ventricular septal defect (VSD). The patient and the surgical team agreed to proceed with the surgery as it was a time critical donation after circulatory organ death. We developed an intraoperative plan to optimize pulmonary and systemic pressures using vasoactive support, optimized mechanical ventilation, and used transesophageal echocardiography (TEE) for intraoperative monitoring. During reperfusion, considerable turbulent flows with air were noted in the right ventricle, but no air was visualized in the left ventricle. Color flow Doppler showed no reversal flow in the VSD. At the end of the procedure, the patient was extubated in the operating room without complication and was transferred to the transplant unit for recovery.

CONCLUSION

Our case highlights the importance of echocardiography in the perioperative assessment of patients undergoing liver transplantation. The TTE findings obtained immediately before the procedure and the real-time use of intraoperative TEE to modify our management during the critical phases of the transplant resulted in continuity of care and a good surgical outcome for this patient.

Bovine xenograft pericardial patch use for definitive single stage repair of a large esophageal defect: a case report

Background

Large esophageal perforations are challenging and often treated with exclusion or resection. This case demonstrates the feasibility of definitive surgical repair of a large esophageal perforation using large bovine pericardial patch.

Case

A patient with missed Boerhaave Syndrome underwent transesophageal echocardiography causing worsening perforation and sepsis. At thoracotomy and faced with a large esophageal defect, a large Bovine pericardial patch was used for repair with omentopexy. The patient recovered promptly and at 8 months was asymptomatic with satisfactory studies.

Conclusion

Xenograft pericardium is available and widely used for vascular reconstructions. It’s use for primary repair of large esophageal perforations should be considered.

Malignant primary pericardial mesothelioma presenting as effusive constrictive pericarditis: a case report study

Background

Primary pericardial mesothelioma (PPM) is a rare malignancy with a high prevalence of mortality. The diagnosis is usually challenging using a variety of imaging modalities and invasive procedures and is generally performed at the later stages of the disease or in autopsy. This case study points to an unconventional presentation of PPM and the challenges in diagnosing this rare mortal malignancy.

Case presentation

This study presents a 44-year-old woman with no remarkable medical history with an initial diagnosis of effusive constrictive pericarditis at first hospitalization. Imaging evaluations, including transthoracic echocardiography and chest computed tomography scan, demonstrated visible thickened pericardium, pericardial effusion, and mass-like lesions in pericardium and mediastinum. The definite diagnosis of primary pericardial mesothelioma was established after pericardiectomy and histopathology examinations. Chemotherapy with pemetrexed and carboplatin was administrated to the patient, and she has been through four cycles of chemotherapy with no complications to date.

Conclusion

Constrictive pericarditis is an uncommon presentation of PPM. Due to the high mortality rate and late presentation, difficulties and uncertainties in diagnosis, being aware of this rare malignant entity in different cardiac manifestations, particularly when there is no clear explanation or response to treatment in such conditions, is highly important.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01684-8.

A rare case of benign multicystic peritoneal mesothelioma misdiagnosed as hydatid cyst found in the liver parenchyma and abdomen cavity of a male with asbestos exposure

Background

Benign Multicystic Peritoneal Mesothelioma (BMPM) is one of the rarest diseases in medicine with only more than 200 cases worldwide. This paper aims to report a case of Benign Multicystic Peritoneal Mesothelioma that strangely arose from the liver and was long treated as Hydatid cyst. The case also had many risk factors including asbestos exposure that had not yet been linked with Benign Multicystic Peritoneal Mesothelioma.

Case presentation

We report a case of a 62 years old male with a history of a perforated peptic ulcer and a cystic mass in the liver that was misdiagnosed as hydatid cyst 7 years ago. He presented with generalized abdominal pain and bloating. Image studies showed many cystic formations filled with clear fluid. An en bloc surgery was performed and a pathologic study showed a multiloculated mass lined by flat or cuboidal epithelium leading to the diagnosis of BMPM. A follow up was scheduled after 3 months revealed total recurrence.

Conclusion

BMPM resembles many other cystic lesions in the abdomen and should be taken into consideration when dealing with nontypical cystic formations. Its diagnostic and treatment methods are still hazy making this disease difficult to approach.

A rare emphysematous splenic infection caused by diabetes mellitus: a case report

Emphysematous splenic infection is a rare disease. In this case, a 33-year-old woman presented to the emergency department with a 10-day history of left-upper-quadrant abdominal pain and intermittent fever. She positively denied any previous history of illness or trauma. On admission to the hospital, her white-cell count, neutrophil percentage, C-reactive protein level, blood glucose, and urine glucose were higher than normal. Computed tomography (CT) revealed gas-fluid levels and infection in the spleen. After multidisciplinary consultation and discussions, the patient was diagnosed with emphysema spleen infection and diabetes, and the infection was most likely related to the diabetes. The patient was treated with antibiotics, hypoglycemic therapy, and transabdominal spleen infection puncture and drainage. Finally, the patient's infection and blood sugar were controlled, and the drainage fluid was unobstructed. To the best of our knowledge, emphysematous spleen infection has only been reported once previously in a super obese female patient in 2007. Interestingly, the patient in the present case was also an obese and diabetic middle-aged woman. Similar to other documented emphysematous infection cases, the disease onset of our patient was indistinct and insidious. Due to advances in imaging tools and knowledge of emphysematous nephritis, the patient was successfully diagnosed and treated in time.

Ruptured middle cranial fossa arachnoid cysts after minor trauma in adolescent boys presenting with subdural hygroma: two case reports

Background

Intracranial arachnoid cysts are common, cerebrospinal fluid-filled, innocent lesions that are usually detected incidentally on brain imaging. They may rupture and complicate due to subdural hematoma or hygroma after minor trauma.

Case summary

Authors present two cases of ruptured middle cranial fossa arachnoid cysts in adolescent (12-year-old and 15-year-old) Afghan boys presenting with subdural hygroma after minor trauma.

Conclusion

Imaging work-up is necessary for symptomatic patients following minor head trauma as incidentally detected ruptured intracranial arachnoid cysts can be responsible for the symptoms.

Heart transplantation in the era of COVID-19 pandemic: delirium, post-transplant depression, and visitor restrictions; the role of liaison and inpatient psychosomatic treatment-a case report

Background

Heart transplant recipients show a high risk of developing major depression with an increased risk of post-transplant morbidity and mortality. Heart transplant specialists and patients face unprecedented challenges during the COVID-19 pandemic, which have enormous clinical implications such as the increased risk of COVID-19 as well as visitor restrictions with social isolation during the post-transplant inpatient treatment.

Case summary

We present a case of a 64-year-old woman with end-stage heart failure caused by non-compaction cardiomyopathy who received an orthotopic heart transplant (OHT) without any intra-operative complications. Post-operatively, she showed acute psychotic symptoms in the intensive care unit (ICU) with improvement after switching intravenous tacrolimus treatment to an oral intake. Furthermore, the patient developed severe depressive symptoms with malnutrition and had a prolonged hospitalization. Standard medical care was complemented by intensive psychocardiological treatment to overcome the crisis.

Conclusion

High complexity of the post-transplant management after OHT underlines the importance of multidisciplinary teamwork, involving heart transplant specialists and allied mental health professionals. This collaboration led to an excellent long-term result. Facing the COVID-19 pandemic, the hospital visitor policies may be scrutinized, carefully looking at the role of social isolation, post-operative experience in the ICU, and medical complications after OHT.

Ischemic stroke revealing COVID-19 infection: Case report

Introduction

SARS-COV-2 viral infection primarily targets the respiratory system with a clinical picture that varies from simple symptoms to respiratory distress syndrome requiring hospitalization in the intensive care unit; SARS-CoV-2 also has neuro-invasive capabilities and could spread from the respiratory system to the central nervous system. Recently, some patients with COVID-19 have been shown to have neurological symptoms such as headache, anosmia, dysgeusia, dizziness, impaired consciousness, and ischemic stroke.

Case presentation

we describe a case of ischemic stroke as the main presentation of COVID-19 in a 68 years old man with no previous history, without any associated respiratory signs; clinical examination revealed left hemiparesis with dysarthria and left facial paralysis, NIHSS score was at 11, the brain CT scan performed 1h30min later, completed by a brain MRI that came back in favor of right frontal, temporal and parietal ischemic stroke. The decision of thrombolysis was indicated in urgency, and the patient benefited from thrombolysis, which proceeded without incidents; the outcome was favorable with regression of symptoms.

Ischemic stroke has been widely described among the thromboembolic complications of COVID-19, but only a few papers have reported it as a primary manifestation of COVID-19.

Conclusion

SARS-COV 2 infection can spread from the respiratory system to the central nervous system, resulting in an inflammatory response and excessive secretion of inflammatory markers, leading to ischemic stroke.

•

COVID-19 can be revealed by ischemic stroke.

•

Ischemic stroke has been widely described among the thromboembolic complications of COVID-19, but only a few papers have reported it as a primary manifestation of COVID-19.

•

SARS-COV2 infection can spread from the respiratory system to the central nervous system, resulting in an inflammatory response and excessive secretion of inflammatory markers, leading to ischemic stroke.

Hemophagocytic lymphohistiocytosis and thrombotic microangiopathy after parvovirus B19 infection and renal transplantation: a case report

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening disease characterized by hyperactivation of the immune system that causes hypercytokinemia and potentially multi organ failure. HLH can occur in patients with underlying rheumatic or autoinflammatory disorders. Additionally, HLH can develop in patients during infections or malignancies without a known genetic predisposition.

CASE PRESENTATION

We herein report a patient, who presented with fever, both acute kidney and liver injury, anemia, thrombocytopenia and HSV stomatitis. HLH was diagnosed based on clinical criteria and qPCR revealed an acute parvovirus B19 infection as potential underlying infectious trigger. Treatment was started with both IVIG and dexamethasone. Subsequently, kidney biopsy demonstrated TMA.

CONCLUSIONS

In rare cases both HLH and aHUS can occur simultaneously in a patient as a consequence of viral infections. Insights from this unusual case might help physicians understand this complex symptom constellation.

Longitudinal extensive transverse myelitis following ChAdOx1 nCOV-19 vaccine: a case report

Background

Transverse myelitis (TM) is a relatively uncommon condition, and vaccine-associated myelitis is even rarer. Concern regarding neurological complications following vaccination escalated following the report of TM during the safety and efficacy trials of the COVID-19 vaccine.

Case presentation

We report the first case of Longitudinal Extensive Transverse Myelitis (LETM) in Malaysia following administration of the chimpanzee adenovirus-vectored (ChAdOx1 nCoV-19) vaccine. A 25-year-old female presented with bilateral lower limb weakness and inability to walk with a sensory level up to T8 with absent visual symptoms. Urgent gadolinium-enhanced magnetic resonance imaging (MRI) of the spine showed long segment TM over the thoracic region. Cerebrospinal fluid autoantibodies for anti-aquaporin-4 and anti-myelin-oligodendrocyte were negative. A diagnosis of LETM following vaccination was made, and the patient was started on a high dose of intravenous methylprednisolone. The patient eventually made a recovery following treatment.

Conclusion

LETM is a rare but serious adverse reaction following vaccination. Previously reported cases showed an onset of symptoms between 10 to 14 days post-vaccination, suggesting a delayed immunogenic reaction. However, the incidence of myelitis in COVID-19 is much more common, far greater than the risk associated with vaccination.

Delayed splenic rupture following trivial trauma: A case report and review of literature

Introduction and importance

Delayed Splenic Rupture (DSR) is a rare but well-known presentation of Blunt Splenic Injury (BSI), most of which occur due to motor accidents, fall from height or direct blow to the left thorax or abdomen. Here we present a case of DSR five days after a trivial trauma.

Case presentation

A 37-year-old female presented with pain in the left-hypochondrium after an accidental bump against a furniture at home. Initially, it was a grade III splenic injury but upon arrival to our hospital from her hometown it had progressed to grade IV. Since the patient was hemodynamically stable, non-operative management (NOM) was chosen with close monitoring at the intensive care unit (ICU). However, the next morning, the patient deteriorated, showing signs of hemorrhagic shock, and a successful emergency splenectomy was done.

Clinical discussion

Over the last two decades, there has been an increasing inclination of surgeons towards NOM, even for high grade injury. NOM failure has been found to be associated with advancing age, high Injury Severity Score (ISS) or splenic injury. Some factors that improve the success of NOM are admission to ICU/floor, frequent monitoring of hemoglobin/hematocrit, vital signs, abdominal examination, and limiting heavy physical activity.

Conclusion

Clinicians should not limit the possibility of occurrence of DSR to only major traumatic events. It is imperative that a detailed history of major or trivial trauma in the preceding weeks be elicited for any patients presenting with abdominal pain.

•

Delayed Splenic Rupture is a rare but well reported presentation following blunt splenic injury.

•

Delayed Splenic Rupture can even occur following trivial trauma.

•

Clinicians must consider the entire clinical scenario to decide between operative or non-operative management.

•

A detailed history of major or minor trauma must be elicited for any patients with abdominal pain.

Gallbladder cancer spreading into the aberrant cystic duct: First literature report

Introduction and importance

Although variations from the standard anatomy of the extrahepatic bile ducts are common, duplication of the cystic duct draining a single gallbladder is an extremely rare variant. We herein describe the first report of gallbladder cancer spreading into the aberrant cystic duct.

Case presentation

A 60-year-old female presented with upper abdominal pain, and she was diagnosed with gallbladder cancer. Intraoperatively, she was found to have a duplicated cystic duct draining a single gallbladder, and her cancer had spread into the aberrant cystic duct entering the anterior right hepatic duct. Right hepatectomy with extrahepatic bile duct resection was performed to achieve R0 resection.

Clinical discussion

In the English literature, 28 cases of duplicated cystic duct draining a single gallbladder have been reported. However, no cases of gallbladder cancer have been described in these previous reports.

Conclusion

We report the first case of gallbladder cancer spreading into the aberrant cystic duct. To perform an oncologically adequate operation, exact assessment of the biliary tree is essential not only preoperatively but also intraoperatively.

•

Duplication of the cystic duct draining a single gallbladder is rare in the anatomical variations of the biliary tract.

•

A 60-year-old female with gallbladder cancer was found to have a duplicated cystic duct draining a single gallbladder.

•

Her cancer had spread into the aberrant cystic duct entering the anterior right hepatic duct.

•

We report the first case of gallbladder cancer spreading into the aberrant cystic duct.

Remedial repair of extensive distal muscle secondary necrosis due to high level crush injury of the upper thighs: a case report

Extensive necrosis of lower extremity muscles through the clinical practice of limb salvage after a case of high level crushing injury. A case of car accident injury complicated with necrotizing fasciitis, myositis, and septic shock was admitted to our hospital. The pathogenic factors, clinical characteristics, and surgical repair of this case were analyzed. Septic shock, pulmonary infection and atelectasis, and skin and soft tissue injury of lower limbs were all effectively treated, and limbs were saved successfully. After wound healing, the patient was discharged from hospital and entered the follow-up rehabilitation treatment. Although there is no direct trauma to the distal extremity below the cross-section of both lower extremities, there are still hypoxic ischemic changes, which can easily be ignored in the early stage. If not treated in time, myofascial and osteofascial compartment syndrome, necrotizing fasciitis, myositis, and sepsis are often secondary in the later stage, which should be warned against. During surgical debridement, attention should be paid to the protection of the source artery, and debridement and surgical exploration should be carried out according to the trend of blood vessels. The interecological muscle tissue between the intersections should be kept as far as possible, and the main nerves, blood vessels, and musculocutaneous perforators should be kept to ensure the blood supply of the skin flap.

Intraabdominal and ganglionic desmoplastic small round cell tumor: a case series

Introduction

Desmoplastic small round cell tumor is a rare malignancy with poor prognosis, affecting young male patients. It frequently presents as a large abdominal mass with widespread peritoneal involvement at diagnosis. In late stages, metastases may be present.

Aim

We retrospectively reviewed patient characteristics, presenting symptoms, tumor pathology, treatment, and outcome of four patients with desmoplastic small round cell tumor at our institution.

Cases presentation

The first three cases reported are 32-, 17-, and 30-year-old North African males with intraabdominal desmoplastic small round cell tumor treated by surgery, chemotherapy, and radiation therapy with different follow-ups. The final case is a 16-year-old North African male with ganglionic desmoplastic small round cell tumor but no evidence of a tissue mass. He underwent two lines of chemotherapy with no response. The patient was lost after 2 years of follow-up. In all cases, desmoplastic small round cell tumor was confirmed by presence of t(11,22) (p13,q12) translocation.

Conclusion

Treatment of desmoplastic small round cell tumor is based on multidisciplinary therapy. Despite high-dose chemotherapy, extensive surgical resection, and radiotherapy, desmoplastic small round cell tumor remains lethal.

Allergic fungal rhinosinusitis caused by Neoscytalidium dimidiatum: A case report: Allergic fungal rhinosinusitis due to Neoscytalidium dimidiatum

Neoscytalidium dimidiatum is a rare dematiaceous fungus that was first described in 1916 as Dothiorella mangiferae. From the standpoint of epidemiology and therapy, early detection of fungal rhinosinusitis (FRS), the causative agents, and their associated risk factors can improve the therapeutic outcome and decrease the mortality rates among patients. In this study, we report a 34-year-old Iranian female patient with allergic bronchopulmonary aspergillosis (ABPA), who presented to our facility with an 8-year history of chronic fungal sinusitis, drug-resistant asthma, pneumonia, bronchitis, post-nasal discharge, nasal obstruction, nasal polyposis, and anemia. The patient was subjected to diagnostic nasal endoscopy and computed tomography (CT) scan of paranasal sinuses, as well as routine, complementary mycological, and molecular methods, which confirmed the diagnosis of allergic fungal rhinosinusitis in patients with ABPA. Neoscytalidium dimidiatum was isolated from the sinus of the patient. Results of in vitro susceptibility tests indicated that the case isolate was susceptible to amphotericin B and itraconazole at concentrations which are commonly achieved in patients receiving recommended dosages for invasive mycoses (0.25 to 0.75 mg/kg of body weight daily for amphotericin B and 100 to 400 mg daily for itraconazole) and resistant in vitro to caspofungin, voriconazole, and posaconazole. The patient was successfully treated with amphotericin B / itraconazole + postoperative oral corticosteroids (OCS). Neoscytalidium dimidiatum infection should be considered as a possible additional factor in the etiology of AFRS, especially in immunocompromised patients.

Median 10 years follow-up of patients with covert Cushing's syndrome: a case series

Background

Ectopic adrenocorticotropic hormone secretion syndrome occurs in 10% of all patients with adrenocorticotropic-hormone-dependent hypercortisolism. It is usually associated with overt malignancies or with occult and indolent tumors. This study aims to confirm the source of ectopic adrenocorticotropic hormone in four patients with ectopic Cushing’s syndrome over time.

Case presentation

A 38-year-old Iranian man with Cushing’s syndrome underwent bilateral adrenalectomy since the source of ectopic adrenocorticotropic hormone secretion was not localized and pituitary imaging was normal. A whole-body scan revealed a right-lung tumoral mass with mediastinal lymph node metastasis. The mass was assumed a lung carcinoid tumor with mediastinal adenopathy. Right-lung mid-zone lobectomy and mediastinal lymphadenectomy were done. In a 47-year-old Iranian man with Cushing’s syndrome, whole-body computed tomography scan revealed a pulmonary nodule in the posterior segment of the left lower lobe of the lung. The third case was a 25-year-old Iranian man who presented with symptoms and signs of Cushing’s syndrome. Pituitary magnetic resonance imaging revealed a microadenoma 5 × 9 mm. Whole-body scan showed abnormal focal somatostatin receptors analog avid lesion in the posterior aspect of inferior third of right lung, highly suggestive of ectopic adrenocorticotropic-hormone-producing tumor. The last case was a 43-year-old Iranian woman with Marfan syndrome with a history of mitral and aortic valve replacement and chronic dissection of the aorta, who presented with symptoms and signs of Cushing’s syndrome. She underwent bilateral adrenalectomy 1 year later owing to failure to locate ectopic adrenocorticotropic hormone syndrome. Whole-body scan showed abnormally increased radiotracer uptake in the midline of the skull base and posterior aspect of the middle zone of left hemithorax and bed of left lobe of thyroid.

Conclusion

The clinical spectrum of ectopic adrenocorticotropic hormone secretion syndrome is wide, and distinguishing Cushing’s disease from ectopic adrenocorticotropic hormone secretion syndrome is difficult. Initial failure to identify a tumor is common. Pulmonary carcinoid or occult source of ectopic adrenocorticotropic hormone secretion syndrome is usually the cause. In occult cases of ectopic adrenocorticotropic hormone in which the tumor cannot be localized, serial follow-up with serial computed tomography, magnetic resonance imaging, or scintigraphy is recommended for several years until the tumor can be localized and treated.

Huge intraligamental leiomyoma: Two cases and review of the literature

Intraligamental leiomyomas are usually small and asymptomatic. On very rare occasions, it can become so enlarged as to occupy the whole abdominopelvic cavity. Here, we report the clinical presentations and peri-operative management of two cases with massive intraligamental leiomyoma which weighed 11.1 kg and 3.7 kg respectively. Both of the cases presented with indolent symptoms lasting for months. One patient underwent hysterectomy, whereas the other underwent myomectomy. The postoperative courses were uneventful. Huge intraligamental leiomyomas are challenges even for experienced surgeons and thus need careful attention. The operation for every patient should be individualized to avoid the risk of injury to adjacent organs and incur massive blood loss.

Intestinal ulcers in a patient with myelodysplastic syndrome: a case report

BACKGROUND

Trisomy 8 positivity myelodysplastic syndrome with Behçet's disease is rare. Isolated trisomy 8 is a frequent cytogenetic abnormality in the MDS, but the characteristic of trisomy 8 and the association between trisomy 8 positivity myelodysplastic syndrome and Behçet's disease is unclear.

CASE PRESENTATION

Here, we reported a 63-year-old man, who presented with fever, abdominal pain and hematochezia. Imaging studies revealed bowel wall thickening and mural hyperenhancement of terminal ileum and cecum. Colonoscopy found multiple round ulcers in terminal ileum, ileocecal valve and multiple yellow dotted pseudomembranous attachments throughout the colon. Capsule endoscopy also revealed multiple irregular ulcers in lower ileum. Serum C-reactive protein levels and fecal calprotectin were abnormally high. The clostridium difficile toxin A and B was positive. However, the patient's intestinal ulcers did not resolve after two weeks course of vancomycin. Considered that the patient was diagnosed as MDS-RAEB2 with a karyotype of 47 XX, + 8. And detailed inquiry of medical history revealed epifolliculitis and frequently recurrent oral ulcers 2 months before admission. A diagnosis of trisomy 8 positivity MDS with BD was made. Then he received glucocorticoid along with the 5th course of azacytidine. The follow-up endoscopy showed significantly improved intestinal ulcer 2 months after treatment. we report a rare disease and provide the diagnose and treatment ideas.

CONCLUSIONS

We highlight the challenges and the process of thinking about of the diagnosis. This may provide a new idea for the diagnosis of intestinal ulcers.