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Tadalafil is one of the approved phosphodiesterase type 5 inhibitors, which are used in the treatment of erectile dysfunction. Few cases of intracerebral hemorrhage have been reported in the English literature, post-ingestion of PDE-5 inhibitor. We present a case of a previously healthy 35-year-old man, presenting for acute onset of severe headache post-ingestion of tadalafil to enhance his sexual performance. CT brain showed the presence of subarachnoid hemorrhage, and angiography eliminated the presence of vascular malformation. We believe that this is the 5th and youngest case of intracerebral hemorrhage post-tadalafil ingestion.

Highlights • The spleen is normally located in the left hypochondriac region just underneath the 9th to 11th intercostal spaces. • Splenoptosis, wandering spleen or floating spleen, is a rare entity in which the spleen migrates from its normal position. • The diagnosis is confirmed by imaging modalities. • The only definitive treatment is surgical intervention., Background Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. Case presentation In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

Highlights • Adenomyoepithelioma is a rare tumor of the breast characterized by a biphasic proliferation. • Variable spectrum of behavior ranging from benign to malignant, with tendency to local recurrence. • Combine sentinel lymph node dissection (SLND), with simple mastectomy. • Hematogenous spread is the more common means of spread. • Adjuvant chemotherapy for malignant AME cases is recommended., Background Adenomyoepithelioma is a rare tumor of the breast characterized by a dual/biphasic proliferation of two cell populations: the epithelial cells and the myoepithelial cells. The first case was reported in 1970. The majority of the cases are benign, but few malignant cases were reported in literature. Case presentation A case of a 66-year-old lady presenting with an asymptomatic breast mass, of 18 × 17 × 15 mm size with irregular borders and negative metastatic workup. The patient was operated for wide local excision of the tumor, with a confirmed negative margins intraoperatively. The final pathology was Adenomyoepithelioma. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of breast mass.

Highlights • CAP can be a challenging diagnosis, with a presentation of acute abdominal pain mimicking a surgical abdomen. • In pediatric patients pneumonia is considered as the main extra-abdominal cause of acute abdominal pain. • Abdominal Pain mimics is an entity by itself with a vast differential diagnosis. • Acute abdomen requires precise and rapid diagnosis and treatment to avoid an increase in mortality. • Laparoscopy is safe and effective in setting the diagnosis., Introduction Community acquired pneumonia usually presents with typical clinical and radiological signs allowing for a quick diagnosis. Nevertheless, pneumonia can infrequently mimic acute abdominal pathologies, leading to invasive unnecessary procedures. Presentation of case We report a case of a 44-year-old man, previously healthy, admitted with a diagnosis of a surgical abdomen, investigated with an exploratory laparoscopy after inconclusive imaging and failure of improvement. Clinical evolution revealed the diagnosis of pneumonia. Discussion Community acquired pneumonia is a frequently encountered condition. While its clinical presentation is usually related to the respiratory system, extrapulmonary manifestations, including abdominal pain in the pediatric population, are well documented. However, solely severe acute abdominal pain, being as the major presentation, without respiratory symptoms or radiological signs is very rarely reported. Conclusion Community acquired pneumonia can sometimes be a challenging diagnosis. Acute abdominal pain mimicking a surgical abdomen is an infrequent presentation but can confuse physicians when no radiological or clinical signs of pneumonia are present.

Highlights • Liposarcomas are a malignant transformation of fat tissue, found in two major subtypes according to their differentiation. • Enhanced CT is essential for diagnosis and confirmed by percutaneous large core needle guided biopsies. • Surgery remains the standard practice in treating non-metastatic liposarcomas. • No clear definition for giant liposarcoma, Only 52 cases reported between 1998 and July 2020. • Our patient has the longest reported follow up in the literature of 10 years, with 3 operations and 3 recurrences., Introduction This case is of a patient with a recurrent giant retroperitoneal liposarcoma, followed-up and operated multiple times over 10 years. We report this case because of its rarity and review all previous articles reporting “Giant Retroperitoneal Liposarcoma” in the English literature. Case description A 70 years old man presented to our clinic for dizziness and fatigue. He was incidentally found to have a large retroperitoneal mass filling all the length of the abdominal cavity and shifting all intraabdominal viscera and kidney to the left side. En bloc excision of a 50 × 30 × 18 cm, 9 kg tumor was performed. Final pathology revealed a well-differentiated liposarcoma. Five years later, the patient was reoperated for recurrence and a well-differentiated liposarcoma was excised in 2 pieces (the biggest measuring 14 × 11 × 7 cm) along with the appendix. Four years later the patient was operated on again for a second recurrence, and again a well-differentiated liposarcoma (16 × 10 × 7 cm) extending into the right inguinal canal was excised. One year thereafter, the patient was diagnosed with a third recurrence (22 × 12 cm). Discussion Retroperitoneal Liposarcomas are rare tumors, presenting with different histological differentiation. They are diagnosed using multiple imaging modality, mainly CT scan, and it is confirmed by percutaneous large core needle biopsy. R0 Surgical excision remains the proper treatment for non-metastatic tumors, which may necessicate multiorgan resection. They rarely grow to reach a large size and be labled as “Giant Retroperitoneal Liposarcoma”.

Highlights • The small intestine is an essential constituent of the digestive system and plays a major role in the absorption of nutrients. • Acute mesenteric ischemia remains an emergency case. • Failure to adapt and the inadequate nutritional supply result in Short bowel syndrome. • A minimal indispensable length is required for nutritional autonomy. • Parenteral Nutrition still presents a pertinent problem of complications, charges and impairment in quality of life., Introduction The small bowel is an essential organ for maintaining adequate nutrition. Decrease in length could be associated with malnutrition and may require that the patient receives parenteral nutritional support. We report a case of a 59-year-old man who survived32 years with a short bowel of 35 cm length without any parenteral nutrition. Case presentation A 59-year-old gentleman, with a history of hypercoagulable state, presented for severe abdominal pain and obstipation of one day's duration. Upon presentation, the patient was hemodynamically unstable, with abdominal guarding and tenderness upon physical examination. Laboratory studies showed metabolic acidosis with leukocytosis and electrolyte disturbances, and an abdominal CT scan showed thickening of the sigmoid and multiple air-fluid levels. The patient was operated urgently for suspicion of mesenteric ischemia, however, he was found intraoperatively to have a very short dilated small bowel with jejunotransverse anastomosis. Discussion The necessity for surgical resection of the small bowel can arise for a sum of reasons. However, the removal of a big amount of small bowel may not be adaptive and appropriate digestion will no more be possible. In the aftermath of the resection, patients require parenteral nutrition for a certain period after which they may switch to enteral and oral nutrition, and subsequently intestinal adaptation by thickening and growth of the remaining intestinal villi. Conclusion Patients with a short bowel, particularly those surgically removed, can survive even with a very short remaining bowel length, as a result of intestinal adaptation, nutrition enhancement, and elimination of parenteral nutrition.

Highlights • Gastric stenosis is seldom encountered in adult patients. Suicide attempt should be considered as differential diagnosis. • Multiple etiologies results in gastric stenosis. They do not usually cause acute gastric obstruction. • Both acidic and alkaline chemicals are implicated. • 4th type of gastric strictures is the “Linitis-Plastica-like” appearance. • The management of caustic gastritis ranges from supportive to surgical treatment., Introduction This report is a case of a suicide attempt by bleach ingestion. mistaken for gastric cancer after oral contrast studies and esophagogastroduodenoscopy. We report this case to encourage physicians to take this etiology into consideration as part of differential diagnosis especially in front of a secretive patient. Presentation of case We report a case of a 38-year-old lady admitted for an acute onset of symptoms leading to a diagnosis of antral stenosis. Further workup which included endoscopic and surgical biopsies failed to reveal an underlying malignancy. After 24 days of inconclusive inpatient investigations, and due to failure of conservative treatment, distal gastrectomy was performed. Final pathology also revealed an absence of any signs of malignancy, and reported only inflammatory changes. One month after discharge, the patient confessed that she had attempted suicide by ingestion of corrosive agents before the symptoms started and wanted to keep the incident as a secret. Discussion Gastric stenosis is seldom encountered in adult patients, however, it can occasionally result secondary to gastric ulcer disease, malignancies, foreign body ingestion, certain drugs or chemicals, or after endoscopic or surgical interventions. These etiologies do not usually cause acute gastric obstruction, and usually follow a more indolent course. Identification of an underlying etiology is mandatory to determine the proper medical or surgical treatment to relieve the obstructive symptoms. Conclusion We report this bizarre case to encourage physicians to keep this etiology in mind in otherwise unexplained gastric stenosis.

Highlights • CAIS is a rare sexual development disorder with X-linked recessive inheritance. • Usually present with primary amenorrhea, inguinal hernias and with near normal female external genetalia. • Testosterone levels are equal or higher than in male. Different imaging types together with karyotyping are crucial in diagnosing. • Treatment debates include prepubertal or postpubertal Gonadectomy. • CAIS must be suspected in any case of young females with bilateral inguinal hernias., Introduction Complete Androgen Insensitivity Syndrome (CAIS) is a rare sexual development disorder with X-linked recessive inheritance. It is prevalent in 1:20400 to 1:99000 of female phenotypes, yet characterized by an XY genotype. Cases of CAIS usually present with primary amenorrhea together with unilateral/bilateral inguinal hernias. Case presentation A previously healthy 19 year old sexually inactive girl presents to our clinics for delay in menarche and bilateral palpable inguinal masses 3 years ago. She has normal female habitus, tanner stage 3 and external female genetalia with sparse pubic hair. She has a family history of 2 aunts (mother side) having infertility with Bilateral inguinal hernias surgery. Hormonal tests showed male range testosterone levels. MRI showed bilateral inguinal masses with Mullerian structures agenesis and a misdiagnosis of Mayer-Rokitansky-Küster-Hauser syndrome (MRHKS) was interpreted. While karyotype showed XY genotype. She is then planned for bilateral orchiectomy. Final pathology of the 2 specimens taken showed testicular tissue correlating with CAIS. Discussion CAIS patients presents with near normal female external genetalia, absence of Mullerian structures, taller status than regular females and testosterone levels equal or higher than male levels. Different imaging types together with karyotyping are crucial in diagnosing and differentiating CAIS from other entities such as MRHKS and Swyer syndrome. Treatment debates include prepubertal or postpubertal gonadectomy correlating with the age related malignancy rate and site of testis followed by Hormonal replacement therapy. CAIS management needs a multidisciplinary approach and decisions by the patient or his family sometimes. Conclusion CAIS must be suspected in any case of young females with bilateral inguinal hernias as in our case, and precise diagnostics tests such as MRI and Karyotyping must be done followed by biopsy or excision for diagnosis and then adequate treatment. Hormonal therapy must be continued after gonadectomy that is best to be postpubertal.

Primary breast tuberculosis is a rare extrapulmonary tuberculosis mainly affecting young women of childbearing age in endemic countries. Its incidence is increasing in immunocompromized and HIV-infected people and with the emergence of drug-resistant strains of Mycobacterium tuberculosis. There are no specific clinical signs suggestive of this disease, and it often presents as a hard mass or breast abscess. There is an overlap of features with other inflammatory, infectious, benign lesions, fat necrosis, and malignant neoplasms of the breast. The detection of Mycobacterium tuberculosis remains the gold standard for diagnosis. Several diagnostic modalities are used, with varying degrees of lack of sensitivity and specificity, and with a range of false negatives. A quarter of cases were treated solely on the basis of clinical, imaging, or histological suspicion, without confirmation of the diagnosis. Therefore, we report the case of a young Vietnamese woman who presented with a non-healing breast abscess and was diagnosed with breast tuberculosis based on the patient’s ethnicity, histological findings, lack of clinical response to conventional antibiotic therapy, and a good clinical response to antituberculosis treatment.

Primary accessory breast cancer is an extremely rare pathology, representing less than 1% of all breast cancers, and it is found in more than 90% of cases in the axilla. The diagnosis of accessory axillary breast cancer (AABC) is often late and at an advanced stage, with an average delay of 40.5 months. Histological sampling and immunohistochemical results confirm the diagnosis. Most patients are diagnosed with stage II disease or higher, so it is considered to have a poor prognosis. There is no proper management for AABC; it follows the guidelines for orthotopic pectoral breast cancer. We therefore report the case of a 50-year-old woman diagnosed with grade II invasive ductal carcinoma found in accessory axillary breast, treated with neoadjuvant chemotherapy followed by a wide local resection and axillary lymph node dissection.

Introduction Vascular access is essential in the management of patients, and sometimes poses a problem, especially in patients requiring chronic treatment. Surgical insertion of the port-a-cath solved this problem by providing easy access, but unfortunately, it's associated with some complications. Case presentation We present a case of 32 year-old woman, diagnosed with advanced breast cancer, admitted for insertion of a port-a-cath for neoadjuvant chemotherapy. A few hours after the operation, the patient developed hoarseness and a cough. A flexible laryngoscope showed the left vocal cord which was fixed in the middle position and did not move, while the other maintained normal motility. The patient was treated conservatively. Conclusion This case demonstrated a rare and unexpected complication of the insertion of a port-a-cath, which is the result of an injury to the recurrent laryngeal nerve. We are reporting this case to encourage physicians to take note of this complication and know how to manage it., Highlights • Vascular access is primary in the management of patients • Insertion of an implantable chamber catheter is used mainly for chemotherapy • It is considered a safe surgical intervention • Damage to the recurrent laryngeal nerve can cause vocal cord paralysis • In most cases they recover by themselves

Highlights • Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. • Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. • Histopathology and immunohistochemistry are the gold standard in diagnosis. • Resection/surgery is the mainstay treatment., Introduction Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. Gastric type is usually asymptomatic or may show nonspecific symptoms. Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. Presentation of case A 42 years old healthy female presenting with chronic symptoms for epigastric discomfort and mild nausea. Labs showed mild anemia. A gastric lesion was detected by Endoscopy and being studied by echo-endoscopy and needle aspirate. Gastric Inflammatory fibroid polyp was diagnosed after distal gastrectomy by histopathology and immunohistochemistry. Conclusion Gastric inflammatory fibroid polyp is a preoperative diagnostic challenge of unclear pathogenesis. Histopathology and immunohistochemistry are the gold standard. Studies around this exact pathology are required for better management and prevention.

Highlights • Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases. • Pseudo-aneurysm is an overlooked complication. • Angiography followed by embolization is best for diagnosing and treating. • Common risk factors for pseudo-aneurysm include, infection, trauma, neoplasm, inflammation and surgery. • Treatment was surgical, this case was treated by interventional radiology., Introduction Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases however pseudo-aneurysm is an overlooked complication. Case For instance, we present case of a 25 year-old Lebanese woman that undergone sleeve gastrectomy and presented 3 weeks later with a bleeding left gastric artery pseudo-aneurysm. Conclusion Angiography followed by embolization is best for diagnosing and treating the pseudo-aneurysm by coiling. Serious outcomes could arise from such a complication. Hence, accurate diagnosis and treatment using the appropriate methods is essential to avoid life-threatening events.