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Percutaneous image-guided biopsies are becoming increasingly common in routine pathology practice, with the greater omentum emerging as a common target. We present herein an account of a middle-aged lady with a complex ovarian mass, omental thickening, and raised serum CA125; clinically suspected to have advanced ovarian malignancy. Fine needle aspiration cytology (FNAC) from the ovarian mass was inconclusive. Omental biopsy revealed only refractile, birefringent crystalline material with surrounding foreign body giant cell reaction; thus surprising the clinical team. Subsequent resection of the ovarian mass showed a teratoma composed exclusively of thyroid tissue, diagnosed as struma ovarii. The omental crystals, interpreted as calcium oxalate crystals, were possibly a consequence of colloid seeding during the ovarian mass FNAC. [ABSTRACT FROM AUTHOR]

Bell’s palsy is a rapid unilateral peripheral paralysis of cranial nerve VII whose etiology is varied, most commonly associated with an acute infectious or inflammatory demyelinating process. Nerve injury can result in edema because of increased permeability of vascular structures, which can sometimes be seen as a locus of enhancement of magnetic resonance imaging (MRI). Bell’s palsy is typically considered a clinical diagnosis and the specificity and sensitivity of imaging have been poorly studied. Herein is describe a case of a 73-year-old male who presented to the emergency department with left-sided facial droop and no other focal neurological abnormalities. With a history of a Janus kinase 2 (JAK2) mutation and the new initial facial drooping, acute cerebrovascular insult was high on the differential. Initial labs and computerized tomography (CT) head were inconclusive, but MRI showed pronounced enhancement of the left distal internal carotid artery (ICA) with contiguous enhancement of the labyrinthine, geniculate, and tympanic segments of the left facial nerve. Diagnosing Bell’s palsy can be a challenge as there are numerous postulated etiologies stemming from trauma, infection, and neoplasm; with infection (particularly viral) postulated to be the most likely source. Though MRI is currently not validated as a tool in expediting Bell’s palsy diagnosis, findings such as the enhancement seen here provide some insight into the benefit of MRI as a diagnostic modality in some cases. This case is unique both for the diagnostic dilemma between stroke and Bell’s palsy and the potential for MRI imaging to help guide clinical decision-making into treatment.

Introduction: Baló’s concentric sclerosis (BCS) is a rare subtype of multiple sclerosis characterized by inflammatory demyelination within the central nervous system. Case Presentation: This case report presents a challenging diagnostic scenario involving a 26-year-old woman diagnosed with BCS. Despite treatment, her condition did not ameliorate, and magnetic resonance imaging (MRI) findings remained unchanged. A subsequent stereotactic biopsy revealed tumefactive Balo disease, highlighting the intricate diagnostic and therapeutic issues surrounding BCS. Conclusion: The juxtacortical location of the BCS lesion, as observed in our case, suggests an unfavourable prognosis due to treatment-resistant seizures.

BACKGROUND: Histopathologically ambiguous melanocytic lesions lead some pathologists to list multiple diagnostic considerations in the pathology report. The frequency and circumstance of multiple diagnostic considerations remain poorly characterized. METHODS: Two hundred and forty skin biopsy samples were interpreted by 187 pathologists (8976 independent diagnoses) and classified according to a diagnostic/treatment stratification (MPATH-Dx). RESULTS: Multiple diagnoses in different MPATH-Dx classes were used in n = 1320 (14.7%) interpretations, with 97% of pathologists and 91% of cases having at least one such interpretation. Multiple diagnoses were more common for intermediate risk lesions and are associated with greater subjective difficulty and lower confidence. We estimate that 6% of pathology reports for melanocytic lesions in the United States contain two diagnoses of different MPATH-Dx prognostic classes, and 2% of cases are given two diagnoses with significant treatment implications. CONCLUSIONS: Difficult melanocytic diagnoses in skin may necessitate multiple diagnostic considerations; however, as patients increasingly access their health records and retrieve pathology reports (as mandated by US law), uncertainty should be expressed unambiguously.

Abstract Background Pleural involvement by non-tuberculous mycobacteria (NTM), especially NTM empyema in the immunocompetent patient without pulmonary diseases is a rare disease. It is difficult to diagnose with only a few cases of immunodeficient patients in the literature. Case presentation We describe a 63-year-old male with empyema due to NTM and highlight the challenges of diagnosis. Conclusions Non-tuberculous mycobacterial infection should be considered as a cause of pleuritis or empyema without pulmonary disease, however it is a real diagnostic dilemma.

The solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas is a relatively uncommon entity. The aim of the present study was to summarize our experiences with regard to diagnostic dilemma, surgery, postoperative follow-up, and management. This retrospective data were collected during the period from January 1, 2018 to December 31, 2020. A total of four patients (three females and one male) were identified within an age range of 13 to 25 years. All the patients were presented with nonspecific symptoms such as abdomen lumps, swelling in the abdomen, and abdominal pain. To reach a definite diagnosis, imaging studies were conducted along with endoscopic ultrasound fine-needle aspiration (EUS-FNA) and biopsy. After confirmation of SPEN on biopsy, all the patients underwent surgery without any complications. Patients are on follow-up, and to date, no metastasis has been detected. SPEN is a rare pancreatic tumor with unusual pathological features leading to a diagnostic dilemma. The pathologist should be familiar with SPEN and its salient histological characteristics that differentiate it from other look-alike pancreatic tumors and can help in timely surgery and management.

Background: Pleural involvement by non-tuberculous mycobacteria (NTM), especially NTM empyema in the immunocompetent patient without pulmonary diseases is a rare disease. It is difficult to diagnose with only a few cases of immunodeficient patients in the literature. Case presentation: We describe a 63-year-old male with empyema due to NTM and highlight the challenges of diagnosis. Conclusions: Non-tuberculous mycobacterial infection should be considered as a cause of pleuritis or empyema without pulmonary disease, however it is a real diagnostic dilemma. [ABSTRACT FROM AUTHOR]

Background: Immunohistochemistry is the definitive diagnosis in cases where a definite diagnosis cannot be made morphologically and histologically. IHC helps classify tumors. It also helps to solve the diagnosis problem of benign and malignant tumors. Material And Methods: We studied 100 different ovarian epithelial tumors over a 2 year period. Three immune markers were included in the study. Result: Out of 100 case 70% are benign and 30% aremalignant. Serous cystadenoma was most common benign lesion(60%)& among malignant lesions Serous cystadenocarcinoma was most common(60%).83.33% cases of serous carcinoma showed positivity for CK7 & 100% negativity for CK20 & CEA Conclusion: IHC helps to classify and confirm the histological diagnosis. IHC is particularly useful in solving the diagnostic problem of ovarian cancer and is poorly differentiated. [ABSTRACT FROM AUTHOR]

Granulomatosis with polyangiitis (GPA) is an etiologically unknown systemic disease characterized by necrotizing granulomatous inflammation. Additionally, it is accompanied by vasculitis of small and medium-sized blood vessels. It manifests clinically as a triad involving the lungs, upper airways, and kidneys. It is estimated that 90% of patients will exhibit upper or lower airway symptoms and around 80% develops the renal disease. In this article, we describe three case scenarios with varying presentations. GPA should be considered among the possible etiologies of cavitary pulmonary lesions with ear manifestations including hearing loss with poor response to unusual treatment.

Odontogenic cutaneous sinus tract (OCST) of the facial region is rarely found and mostly misdiagnosed because of its variable cutaneous manifestations with the absence of obvious dental symptoms. Usually, patients consider such lesions of dermatologic origin instead of dental origin, and hence, seek its treatment from medical specialists which results in recurrence due to inappropriate treatments without considering the dental etiology, dental history, intra-oral examination, and dental radiographs. The current article presents a case report about chronic OCST at mental region (chin) of the face in a 10-year-old male patient. The source of infection was completely eliminated by endodontic therapy using calcium hydroxide Ca(OH)2 and by conservative surgical debridement of periapical necrotic granulation tissue without excising the extra-oral sinus-tract orifice. The appropriate dental treatment resulted in the resolution of symptoms and rehabilitation of facial esthetics without any recurrence in follow-ups. Thus, the patient's quality of life was improved after successful dental treatment as evaluated by Child's Perception Questionnaire 8–10.

Hale Teka,1 Awol Yemane,1 Mebrihit Gebremeskel,2 Birhanu A Kinfe,3 Sara Kiros,3 Mizan Kidanu4 1Department of Obstetrics and Gynecology, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia; 2Department of Radiology, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia; 3Department of Pathology, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia; 4Department of Surgery, College of Health Sciences, Mekelle University, Mekelle, Tigray, EthiopiaCorrespondence: Hale Teka, Department of Obstetrics and Gynecology, College of Health Sciences, Mekelle University, P.O. Box: 1871, Mekelle, Tigray, Ethiopia, Email haleteka@gmail.comBackground: Heterotopic pregnancy is the coexistence of intrauterine and extrauterine (ectopic) pregnancies. This is a relatively rare phenomenon with an incidence of 1 in 30,000 in spontaneously conceived pregnancies and 1 in 100 pregnancies achieved through assisted reproduction. Due to its relative rarity, diagnosis can be challenging. The presence of adnexal cystic masses complicating pregnancies can obscure the examination of the pelvis to rule in/out heterotopic pregnancy further adding to the complexity of the diagnosis.Case Presentation: In this study, we present a 26-year-old primigravid, ethnic Tigrayan lady from the Tigray region of Ethiopia. She presented to our hospital with the complaint of progressively worsening abdominal pain of three days duration. She also had a subjective period of amenorrhea of 2 months duration. Pregnancy test was positive a few days prior to her current presentation. She reported that she had a history of treatment for pelvic inflammatory disease three months prior to her current conception. At presentation to our hospital, she was acutely ill-looking in pain, tachycardic, and hypotensive. Pelvic ultrasound showed an adnexal mass, hemoperitoneum, and an intrauterine pregnancy at 7 weeks + 5 days gestation. With the impression of ruptured ovarian cyst to rule out heterotopic pregnancy emergency, an explorative laparotomy was done which was pertinent for significant hemoperitoneum, ruptured left tubal ectopic pregnancy, and intact left ovarian cyst.Conclusion: Physicians should consider a broad range of differential diagnosis in pregnant mothers who present with acute abdominal pain. Moreover, in the presence of an adnexal mass and hemoperitoneum, there is a need to maintain a low threshold for rare but life-threatening complications such as heterotopic pregnancy. The presence of an intrauterine gestation does not rule out extrauterine gestation. Thus, the presence of a viable intrauterine gestation should not stop physicians from carefully examining patients for the coexistence of an ectopic pregnancy.Keywords: heterotopic pregnancy, ectopic pregnancy, adnexal cyst, diagnostic dilemma, case report

Introduction: diagnosing and managing highly myopic patients who might have or willdevelop glaucoma stillappears to be challenging and genuine diagnostic dilemma. This is due to the fact that high myopia is associated with elongation of the eye and resulting in tilting and torsion of the optic disc, causing visual filed defects that may resemble glaucomatous damage. This is why we are constantly asking ourselves is it glaucoma or just myopia? Or even both. Allophthalmologists assessing high myopic patients often encounter this dilemma. By 2050, about half the world's population will have myopia and in some parts of the world, these rates are already approaching 90%. Aim: early diagnosis assessment in myopic patients with changes in the visual field that might indicate glaucoma is the main goal of our research. Structural and functional defects in myopic eyes are difficult to distinguish from those caused by glaucoma. Materials and methods: this was prospective-retrospective randomized, clinical research. In order to make a scientifically valuable statistical comparison, a total of 300 eyes has been examined, i.e. 100 eyes in 3 groups of respondents of both gender: I group - patients with glaucoma, II group - patients with myopia and glaucoma, III group - patients only with myopia. Each group was also divided regarding the size of the optic disc diameter into 3 categories: small (<1.30 mm), medium (1.31-2.09 mm) and large (>2.10 mm). The following ophthalmological examinations were performed on all patients: natural visual acuity and best-corrected visualacuity, Goldman applanation tonometry, biomicroscopy examination, autorefractometry, gonioscopy, fundus examination - direct ophthalmoscopy (Volk lens +90D), spectral three-dimensional optical coherence tomography (SOCT 3D), static computerized perimetry. Results: our research results showed that respondents with progressive visual field loss have accordingly a higher numeric value of Disc Damage Likelihood Scale (DDLS). There is a statistically significant difference in the quality of the visual field in relation to the size of the disc in respondents diagnosed with glaucoma with and without the associated diagnosis of myopia. Conclusion: analyzing the comorbidity of glaucoma and myopia, it is possible to create a diagnostic algorithm technique and procedure with emphasis and aim in early detection of glaucoma. [ABSTRACT FROM AUTHOR]

Follicular dendritic cell sarcoma is a rare low grade malignant neoplasm that arises from follicular dendritic cells in lymphoid tissue germinal centres and accounts for 0.4% of all soft tissue sarcomas. It is extremely rare to have pulmonary follicular dendritic cell sarcoma with endobronchial extension and as an anterior mediastinal mass with mediastinal lymph node involvement. We present the case of a 34-year-old male non-smoker who had been experiencing chest pain for three months. A lobulated left peri-hilar mass with endobronchial spread into the left main bronchus and mediastinal lymphadenopathy was identified on chest CT. The bronchoscope-guided cryobiopsy of the endobronchial mass was inconclusive. After a thorough multidisciplinary discussion, the patient underwent left sided pneumonectomy, mediastinal mass resection, and systematic lymph node dissection. Histologic examination using immunohistochemistry revealed follicular dendritic cell sarcoma. [ABSTRACT FROM AUTHOR]

Both cor triatriatum (CorT) and partial anomalous pulmonary venous connection (PAPVC) come under the rare spectrum of congenital heart diseases. These entities may coexist in a patient or may appear independent of each other. The diagnosis is established routinely by echocardiography. Here, we describe the case of a 45-year-old female presenting with exertional dyspnea and palpitations. She was diagnosed to have CorT in the preoperative echocardiography; later, intraoperatively, transesophageal echocardiography revealed the additional presence of PAPVC with CorT. This case report highlights the limitations of echocardiographic findings in the patient and the importance of multimodal imaging techniques in such situations. [ABSTRACT FROM AUTHOR]

A Solitary swelling over the mandible in adolescence may pose a significant diagnostic dilemma. The differential diagnosis ranges from traumatic, infectious, and metabolic processes to benign and malignant tumors. Also may present with similar clinical and radiological features, making an accurate diagnosis quite difficult. This is a case involving a 12-year-old child who presented with pain and swelling over the left angle of the mandiblefor 15 days. Investigations likeOrthopantomogram, Fine needle aspiration, Culture & sensitivity testing, and Ultrasonogram were required to arrive at a conclusive diagnosis. This article highlights a case report of swelling over the angle region of the mandible, finally diagnosed as Parotid abscess an unusual presentation highlighting the importance of diagnosis and treatment planning for Dental Surgeon in particular Maxillofacial Surgeon. [ABSTRACT FROM AUTHOR]

Introduction: Baló's concentric sclerosis (BCS) is a rare subtype of multiple sclerosis characterized by inflammatory demyelination within the central nervous system. Case Presentation: This case report presents a challenging diagnostic scenario involving a 26-year-old woman diagnosed with BCS. Despite treatment, her condition did not ameliorate, and magnetic resonance imaging (MRI) findings remained unchanged. A subsequent stereotactic biopsy revealed tumefactive Balo disease, highlighting the intricate diagnostic and therapeutic issues surrounding BCS. Conclusion: The juxtacortical location of the BCS lesion, as observed in our case, suggests an unfavourable prognosis due to treatment-resistant seizures. [ABSTRACT FROM AUTHOR]

Granulomatosis with polyangiitis (GPA) is an etiologically unknown systemic disease characterized by necrotizing granulomatous inflammation. Additionally, it is accompanied by vasculitis of small and medium-sized blood vessels. It manifests clinically as a triad involving the lungs, upper airways, and kidneys. It is estimated that 90% of patients will exhibit upper or lower airway symptoms and around 80% develops the renal disease. In this article, we describe three case scenarios with varying presentations. GPA should be considered among the possible etiologies of cavitary pulmonary lesions with ear manifestations including hearing loss with poor response to unusual treatment. [ABSTRACT FROM AUTHOR]

Odontogenic cutaneous sinus tract (OCST) of the facial region is rarely found and mostly misdiagnosed because of its variable cutaneous manifestations with the absence of obvious dental symptoms. Usually, patients consider such lesions of dermatologic origin instead of dental origin, and hence, seek its treatment from medical specialists which results in recurrence due to inappropriate treatments without considering the dental etiology, dental history, intra-oral examination, and dental radiographs. The current article presents a case report about chronic OCST at mental region (chin) of the face in a 10-year-old male patient. The source of infection was completely eliminated by endodontic therapy using calcium hydroxide Ca(OH)2 and by conservative surgical debridement of periapical necrotic granulation tissue without excising the extra-oral sinus-tract orifice. The appropriate dental treatment resulted in the resolution of symptoms and rehabilitation of facial esthetics without any recurrence in follow-ups. Thus, the patient's quality of life was improved after successful dental treatment as evaluated by Child's Perception Questionnaire 8–10. [ABSTRACT FROM AUTHOR]

Abstract Background Oesophageal atresia is a congenital abnormality commonly encountered in neonates. Classification proposed by Gross is the most frequently used. It divides the oesophageal anomalies into five types. Type C—proximal oesophageal atresia and distal tracheo-oesophageal fistula—is the most common. Dafoe and Ross described a rare subtype with a long proximal pouch. Only 11 cases of a long proximal pouch have been reported in the English literature so far. We describe a neonate with long proximal pouch oesophageal atresia with distal tracheo-oesophageal fistula emphasizing the difficulty in arriving at the diagnosis. Case presentation A 1-week-old neonate presented with feed intolerance and failure to advance orogastric tube into the stomach. Water soluble upper gastrointestinal tract contrast revealed a blind ending proximal oesophagus at the level of the diaphragm. Gastric volvulus was considered as a diagnosis. Patient underwent a laparotomy where a normal stomach was found. Bubbles were seen coming from the fashioned gastrostomy with each inspiration. This prompted us to consider the possibility of a missed oesophageal atresia with distal tracheo-oesophageal fistula. Diagnosis was confirmed on bronchoscopy and right thoracotomy. The tracheo-oesophageal fistula was ligated and a cervical oesophagostomy and Stamm gastrostomy were performed due to irreparable tear in the long upper pouch. Conclusion This rare subtype of long upper pouch oesophageal atresia poses a diagnostic dilemma that can result in delay in the diagnosis and management. This diagnosis should be suspected if the tip of the orogastric/feeding tube is seen to be far below the level of the carina.

Synchronous malignancies involving acute leukemia and a solid organ are rare. Bleeding per rectum is a common manifestation of acute leukemia during induction chemotherapy and might mask the presence of synchronous colorectal adenocarcinoma (CRC). Here we present two rare cases of acute leukemia with synchronous CRC. We also review previously reported synchronous malignancies to investigate demographics, diagnosis, and treatment modalities. Management of these cases requires a multispecialty approach. [ABSTRACT FROM AUTHOR]

Purpose: To report a case of atypical nodular posterior scleritis mimicking as a melanotic choroidal melanoma., Methods: Descriptive case report., Results: A 38-year-old female presented with sudden onset diminution of vision, severe pain and redness in her right eye. She was diagnosed to have choroidal melanoma in her left eye one year ago and underwent enucleation. On examination, conjunctiva was injected in right eye with cells in anterior vitreous face (AVF). Fundus examination revealed a large pigmented choroidal mass temporal to macula with exudative retinal detachment. Systemic evaluation and multimodal imaging ruled out the possibility of a choroidal melanoma or metastasis, with a presumptive diagnosis of nodular posterior scleritis. Three cycles of intravenous methyl prednisolone (IVMP) with a tapering dose of oral corticosteroids showed drastic improvement in symptoms with resolution of choroidal mass - further confirming the diagnosis., Conclusions: In cases of choroidal mass with an inflammatory component, a trial of steroids is worthwhile to prevent clinical misjudgement and devastating treatment outcomes including enucleation., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Follicular dendritic cell sarcoma is a rare low grade malignant neoplasm that arises from follicular dendritic cells in lymphoid tissue germinal centres and accounts for 0.4% of all soft tissue sarcomas. It is extremely rare to have pulmonary follicular dendritic cell sarcoma with endobronchial extension and as an anterior mediastinal mass with mediastinal lymph node involvement. We present the case of a 34-year-old male non-smoker who had been experiencing chest pain for three months. A lobulated left peri-hilar mass with endobronchial spread into the left main bronchus and mediastinal lymphadenopathy was identified on a chest CT. The bronchoscope-guided cryobiopsy of the endobronchial mass was inconclusive. After a thorough multidisciplinary discussion, the patient underwent left sided pneumonectomy, mediastinal mass resection, and systematic lymph node dissection. Histologic examination using immunohistochemistry revealed follicular dendritic cell sarcoma.

Autoimmune hepatitis (AIH) is an extremely rare cause of chronic liver disease (CLD) in sub-Saharan Africa—there have only been 3 reported cases of AIH in Nigeria, a country of about 200 million people. We report the first case of AIH in a male patient in Nigeria and highlight its unusual presentation. A 41-year-old man with jaundice and malaise for 3 months was referred for evaluation after investigations revealed deranged liver enzymes and a cirrhotic liver. Laboratory evaluation revealed high serum immunoglobulin G, but there was also marked elevation of serum ferritin and transferrin saturation, resulting in a diagnostic dilemma between AIH and an iron overload condition such as hemochromatosis. A liver biopsy was crucial in providing a definitive diagnosis of AIH. Despite its rarity, clinicians should maintain a high index of suspicion for AIH in sub-Saharan Africa and should proceed to a liver biopsy when the cause of CLD is unclear. [ABSTRACT FROM AUTHOR]

Background: Oesophageal atresia is a congenital abnormality commonly encountered in neonates. Classification proposed by Gross is the most frequently used. It divides the oesophageal anomalies into five types. Type C—proximal oesophageal atresia and distal tracheo-oesophageal fistula—is the most common. Dafoe and Ross described a rare subtype with a long proximal pouch. Only 11 cases of a long proximal pouch have been reported in the English literature so far. We describe a neonate with long proximal pouch oesophageal atresia with distal tracheo-oesophageal fistula emphasizing the difficulty in arriving at the diagnosis. Case presentation: A 1-week-old neonate presented with feed intolerance and failure to advance orogastric tube into the stomach. Water soluble upper gastrointestinal tract contrast revealed a blind ending proximal oesophagus at the level of the diaphragm. Gastric volvulus was considered as a diagnosis. Patient underwent a laparotomy where a normal stomach was found. Bubbles were seen coming from the fashioned gastrostomy with each inspiration. This prompted us to consider the possibility of a missed oesophageal atresia with distal tracheo-oesophageal fistula. Diagnosis was confirmed on bronchoscopy and right thoracotomy. The tracheo-oesophageal fistula was ligated and a cervical oesophagostomy and Stamm gastrostomy were performed due to irreparable tear in the long upper pouch. Conclusion: This rare subtype of long upper pouch oesophageal atresia poses a diagnostic dilemma that can result in delay in the diagnosis and management. This diagnosis should be suspected if the tip of the orogastric/feeding tube is seen to be far below the level of the carina. [ABSTRACT FROM AUTHOR]

Epstein–Barr virus mucocutaneous ulcers (EBV MCU) are B‐cell lymphoproliferative disorders associated with immunosuppression. We report EBV MCU in a multiple myeloma patient on lenalidomide maintenance after stem cell transplant that resolved with decreased immunosuppression. Furthermore, the subsequent development of classical Hodgkin lymphoma suggests an underlying predisposition to EBV‐driven lymphoproliferative disorders. [ABSTRACT FROM AUTHOR]

We aim to report the management of a patient who presented with a choroidal mass masquerading as an amelanotic choroidal melanoma. A 57-year-old male presented with defective vision in his right eye, which was associated with mild periocular pain. Fundus examination showed a large dome-shaped yellowish-orange subretinal mass in the macular region and exudative retinal detachment (RD). Magnetic resonance imaging (MRI) showed a 16 mm × 8 mm choroidal mass, which was hyperintense on T1-weighted images and hypointense on T2-weighted images. B-scan ultrasonography revealed a dome-shaped mass with homogeneous echogenicity, inferior RD, and fluid collection in the sub-Tenon space. There was no choroidal excavation. He was diagnosed as nodular posterior scleritis (NPS) with exudative RD in the right eye. The lesion regressed completely after treatment with oral steroids. Choroidal mass can pose a diagnostic dilemma to ophthalmologists. Atypical MRI features can further augment the confusion. Despite its low incidence, NPS should always be kept as a differential in the presence of an amelanotic choroidal mass.

Abstract Epstein–Barr virus mucocutaneous ulcers (EBV MCU) are B‐cell lymphoproliferative disorders associated with immunosuppression. We report EBV MCU in a multiple myeloma patient on lenalidomide maintenance after stem cell transplant that resolved with decreased immunosuppression. Furthermore, the subsequent development of classical Hodgkin lymphoma suggests an underlying predisposition to EBV‐driven lymphoproliferative disorders.

Anti-N-methyl-D-aspartate (NMDA) receptor antibody (anti-NMDAR Ab)-mediated encephalitis is an autoimmune disorder involving the production of antibodies against NMDARs in the central nervous system that leads to neurological or psychiatric dysfunction. Initially described as a paraneoplastic syndrome in young women with teratomas, increased testing has found it to be a heterogeneous condition that affects both the sexes with varying clinical manifestations, severity, and aetiology. This case report describes a 67-year-old man with a 40-year history of relapsing, severe, treatment-refractory schizophrenia. Due to the worsening of his condition during a prolonged inpatient admission for presumed relapse of psychosis, a revisit of the original diagnosis was considered with extensive investigations performed including an autoimmune panel. This revealed anti-NMDAR Abs in both the serum and cerebrospinal fluid on two occasions. Following treatment with intravenous immunoglobulin and methylprednisolone, he demonstrated rapid symptom improvement. This is a rare case of a long-standing psychiatric presentation with a preexisting diagnosis of schizophrenia subsequently found to have anti-NMDAR Ab-mediated encephalitis. Whether the case is one of initial NMDAR encephalitis vs. overlap syndrome is unknown. Most importantly, this case highlights the need for vigilance and balanced consideration for treatment in cases of long-standing psychiatric presentation where the case remains treatment refractory to antipsychotics or when atypical features including seizures and autonomic dysfunction or focal neurology are observed. [ABSTRACT FROM AUTHOR]

Granulomatosis with Polyangiitis (GPA) is an uncommon condition belongs to the group of ANCA-associated necrotizing vasculitides. It is characterized by necrotizing granulomatosis of upper and lower respiratory system with coexisting glomerulonephritis. Its signs and symptoms are largely varied due to a wide spectrum of involvement sites. In the present case report, we describe a case of 26-year-old female presented to our centre with history of bilateral ear discharge, earache, and dry cough with a deviated mouth angle to left. Diagnostic work up was done and patient was treated with pulse methylprednisolone, plasmapheresis, and rituximab. Timely diagnosis and prompt initiation of the treatment has prevented the GPA progression and helped the patient to improve quickly. Currently, the patient is doing well and is in remission. [ABSTRACT FROM AUTHOR]

Background: Tumefactive demyelinating lesions (TDL) share similar clinical features and magnetic resonance imaging (MRI) characteristics with high grade glioma (HGG). This study develops an approach to navigating this diagnostic dilemma, with significant treatment implications as the management of both entities is drastically different. Methods: A retrospective analysis of 41 TDLs and 91 HGG with respect to demographics, presentation and classical MRI characteristics was performed. A diagnostic pathway was then developed to help diagnose TDLs based on whole neuraxis MRI and cerebrospinal fluid (CSF) examination. Results: The diagnosis of TDL is more likely than HGG in younger females who present with subacute or chronic symptoms. MRI characteristics favoring TDL over HGG include smaller size, open rim enhancement, little or no associated edema or mass effect and the presence of a T2 hypointense rim. MRI of the whole neuraxis for detection of other lesions typical of multiple sclerosis (MS), in combination with a lumbar puncture (LP) showing positive CSF-specific oligoclonal bands (OCB), was positive in 90% of the TDL cohort. Conclusion: The diagnostic pathway, proposed on the basis of specific clinicoradiological features, should be followed in patients with suspected TDL. If MRI demonstrates other lesions typical of MS and LP demonstrates positive CSF-specific OCBs, then patients should undergo a short course of IV steroids to look for clinical improvement. Patients, who continue to deteriorate, do not demonstrate other lesions on MRI or where the LP is negative for CSF-specific OCB, should be considered for biopsy if safe to do so. This pathway will give the patients the best chance at neurological preservation. [ABSTRACT FROM AUTHOR]

Anti-N-methyl-D-aspartate (NMDA) receptor antibody (anti-NMDAR Ab)-mediated encephalitis is an autoimmune disorder involving the production of antibodies against NMDARs in the central nervous system that leads to neurological or psychiatric dysfunction. Initially described as a paraneoplastic syndrome in young women with teratomas, increased testing has found it to be a heterogeneous condition that affects both the sexes with varying clinical manifestations, severity, and aetiology. This case report describes a 67-year-old man with a 40-year history of relapsing, severe, treatment-refractory schizophrenia. Due to the worsening of his condition during a prolonged inpatient admission for presumed relapse of psychosis, a revisit of the original diagnosis was considered with extensive investigations performed including an autoimmune panel. This revealed anti-NMDAR Abs in both the serum and cerebrospinal fluid on two occasions. Following treatment with intravenous immunoglobulin and methylprednisolone, he demonstrated rapid symptom improvement. This is a rare case of a long-standing psychiatric presentation with a preexisting diagnosis of schizophrenia subsequently found to have anti-NMDAR Ab-mediated encephalitis. Whether the case is one of initial NMDAR encephalitis vs. overlap syndrome is unknown. Most importantly, this case highlights the need for vigilance and balanced consideration for treatment in cases of long-standing psychiatric presentation where the case remains treatment refractory to antipsychotics or when atypical features including seizures and autonomic dysfunction or focal neurology are observed.

Competing Interests: Declaration of competing interest None.

We aim to report the management of a patient who presented with a choroidal mass masquerading as an amelanotic choroidal melanoma. A 57-year-old male presented with defective vision in his right eye, which was associated with mild periocular pain. Fundus examination showed a large dome-shaped yellowish-orange subretinal mass in the macular region and exudative retinal detachment (RD). Magnetic resonance imaging (MRI) showed a 16 mm × 8 mm choroidal mass, which was hyperintense on T1-weighted images and hypointense on T2-weighted images. B-scan ultrasonography revealed a dome-shaped mass with homogeneous echogenicity, inferior RD, and fluid collection in the sub-Tenon space. There was no choroidal excavation. He was diagnosed as nodular posterior scleritis (NPS) with exudative RD in the right eye. The lesion regressed completely after treatment with oral steroids. Choroidal mass can pose a diagnostic dilemma to ophthalmologists. Atypical MRI features can further augment the confusion. Despite its low incidence, NPS should always be kept as a differential in the presence of an amelanotic choroidal mass. [ABSTRACT FROM AUTHOR]

Abstract Xanthogranulomatous prostatitis as mimicker of prostate adenocarcinoma can cause a diagnostic dilemma, as presented in this case. Therefore, alongside histopathology analysis, multiparametric magnetic resonance imaging (mpMRI) would be useful in this situation by identifying and characterizing suspicious prostatic lesions before biopsy thereby supporting current recommendations on the use of mpMRI.

Papillary thyroid carcinoma (PTC) mostly occurs within the thyroid gland (entopic site), with its occurrence within an ectopic thyroid tissue being rare comprising less than 1% of all thyroid cancers. The coexistence of PTC in entopic and ectopic sites is even rarer, and differentiating ectopic PTC from a metastatic cervical lymph node may pose a diagnostic conundrum. This report is aimed at highlighting the diagnostic challenges and treatment of this rare condition. [ABSTRACT FROM AUTHOR]

Background: Tumefactive demyelinating lesions (TDLs) share similar clinical features and MRI characteristics with high-grade glioma (HGG). This study develops an approach to navigating this diagnostic dilemma, with significant treatment implications as the management of both entities is drastically different. Methods: A retrospective analysis of 41 TDLs and 91 HGG with respect to demographics, presentation, and classical MRI characteristics was performed. A diagnostic pathway was then developed to help diagnose TDLs based on whole neuraxis MRI and cerebrospinal fluid (CSF) examination. Results: The diagnosis of TDL is more likely than HGG in younger females who present with subacute or chronic symptoms. MRI characteristics favoring TDL over HGG include smaller size, open rim enhancement, little or no associated edema or mass effect, and the presence of a T2 hypointense rim. MRI of the whole neuraxis for detection of other lesions typical of multiple sclerosis (MS), in combination with a lumbar puncture (LP) showing positive CSF-specific oligoclonal bands (OCB), was positive in 90% of the TDL cohort. Conclusion: The diagnostic pathway, proposed on the basis of specific clinicoradiological features, should be followed in patients with suspected TDL. If MRI demonstrates other lesions typical of MS and LP demonstrates positive CSF-specific OCBs, then patients should undergo a short course of IV steroids to look for clinical improvement. Patients who continue to deteriorate, do not demonstrate other lesions on MRI or where the LP is negative for CSF-specific OCB, should be considered for biopsy if safe to do so. This pathway will give the patients the best chance at neurological preservation. [ABSTRACT FROM AUTHOR]

Objectives: Paragonimiasis is a global foodborne zoonosis. Overlapping clinical and imaging features with other lung pathologies hamper correct diagnosis and require differential diagnosis.Methods: During 1982-2003, 49,012 samples were referred for immunodiagnosis of helminthiases. We detected paragonimiasis cases by enzyme-linked immunosorbent assay (ELISA). We assessed clinical, radiographical and laboratory characteristics, and diagnostic dilemmas associated with delayed diagnosis.Results: We analyzed 685 pleuropulmonary paragonimiasis cases. ELISA-positive was 665. Eggs were detected in 50. Symptom duration correlated well with the appearance of chest radiographs; 359 pleural, 33 pleuroparenchymal, and 264 parenchymal lesions (P < 0.001). Twenty-nine had normal chest images. Eosinophilia, seen in 304, was common in pleural and pleuroparenchymal patients (P < 0.05). Chest pain and dyspnea were characteristic for pleurisy patients. Sputum (odds ratios [OR]: 6.79; 95% CI: 4.41-10.47), blood-tinged sputum (OR: 5.62; 95% CI: 3.75-8.42), and foul-odor (OR: 2.70; 95% CI: 1.42-5.16) were significant in parenchymal patients. Delayed diagnosis (119) for ≥ 25 weeks was attributed mainly to misdiagnosis as tuberculosis, malignancy, or chronic obstructive pulmonary disease (COPD) (OR: 111.75; 95% CI: 43.25-288.74).Conclusions: Variable symptoms and radiographs of pleuropulmonary paragonimiasis depended on the stage of infection. Suspicion of tuberculosis, malignancy, or COPD was major cause of delayed diagnosis. [ABSTRACT FROM AUTHOR]

Retroperitoneal cystic mass is a rare surgical condition that is often misdiagnosed preoperatively. Here, we report a case of a 56-year-old woman who presented with abdominal swelling for a 1-year duration, which was associated with lower abdominal pain for 6 months. Her abdominal radiograph showed a huge radiopaque lesion, and contrast-enhanced computed tomography scan of the abdomen reported it as a left ovarian serous cystadenoma causing local mass effect to the left ureter leading to mild left hydronephrosis. She underwent exploratory laparotomy and noted there was a huge retroperitoneal cystic mass. The histopathological assessment finding was consistent with a benign retroperitoneal cyst. This case report aims to share the rare case of primary retroperitoneal lesions, which can cause a diagnostic challenge preoperatively to all clinicians despite advanced achievement in medical imaging.

Fibrous dysplasia (FD) and Ossifying fibroma (OF) of the jaws belong to a group of lesions called benign fibro-osseous lesions of the craniofacial skeleton (BFOL). This group of intraosseous disease processes which are comparable in their microscopic features are characterized by hypercellular fibroblastic stroma containing various combinations of bone or cementum-like tissue and other calcified structures. Of these lesions, FD and OF are the most closely related, and although FD is recognized as a harmatomatous lesion and OF a tumour, these lesions are difficult to distinguish both clinically and histologically from each other. This review of current literature aims to highlight emerging features clinically, genetically and histologically that can help in distinguishing these two lesions.

Diffuse alveolar hemorrhage (DAH) is a usual presentation of pulmonary vasculitis. However, several rare conditions have a similar presentation. We present a 73-year-old man with DAH whose diagnosis only became conclusive near the end of his life. The objective is to discuss the important differential diagnoses in a patient presenting with diffuse alveolar hemorrhage. There are very few case reports on pulmonary angiosarcoma and all of them discussed the rarity of the diagnosis, presentation, and treatment. Here, we would like to bring about the dilemma and challenges we internists face when managing any patient with Diffuse Alveolar Hemorrhage.

A cutaneous sinus tract of dental origin is relatively uncommon and may easily be misdiagnosed, owing to its uncommon occurrence and absence of dental symptoms. Such a lesion continues to be a diagnostic dilemma. The case described here presented a nasolabial cutaneous sinus tract of dental origin that was treated by a surgical approach with an excellent esthetic improvement.

A 70-year-old female with a history of lobular carcinoma of the breast, status post-mastectomy followed by adjuvant radio-chemotherapy in remission for 4 years was admitted with the features of acute liver failure (ALF). Iron studies revealed a hemochromatosis picture and the CT and MRI scans of the abdomen suggested cirrhosis. An extensive workup failed to identify an etiology. A trans-jugular liver biopsy was obtained and revealed poorly differentiated carcinoma consistent with the metastasis of breast primary. The patient's condition deteriorated and died within a week following the onset of acute hepatic failure. DNA testing revealed that the patient was heterozygous for H63D mutation. In cases of ALF with the suspicion of malignancy, liver biopsy should be obtained to evaluate an infiltrative hepatic disease. [ABSTRACT FROM AUTHOR]

• Obturator hernia causes significant diagnostic dilemma due to a lack of clinical signs • We present a case report of an elderly female who presents with atypical transient symptoms mimicking ureteric colic. • Timing of imaging studies with patient symptoms proved vital to establishing a diagnosis. • A laparoscopic repair was safely conducted with good results. Obturator hernia is a rare condition and can cause significant diagnostic challenges due to a lack of reliable clinical examination signs. Presentations can have a variety of features and it is a diagnosis that needs to be considered – especially in elderly multiparous women. We present a 76-year-old female who has multiple presentations to the Emergency Department (ED) with transient episodes of severe loin to groin pain. Imaging Computer Tomography (CT) initially demonstrated a mild left hydronephrosis and she underwent an unremarkable ureteroscopy and stenting. Following stent removal she continued to have recurrent episodes of the pain. She presented to the ED with one such episode. A repeat CT scan was performed and this demonstrated an obturator hernia with partial small bowel obstruction. She underwent a laparoscopy by which time the hernia had reduced and her pain had settled. Laparoscopy revealed bilateral obturator herniae with the one on left larger than the right. Both were repaired laparoscopically and she made an uneventful recovery. Obturator hernia is an uncommon condition and can have a varied presentation. Comprehensive review of literature demonstrates the difficulty in making accurate diagnosis. Open intervention was the initial gold standard of treatment but there is a growing body of evidence advocating for the use of laparoscopy in an emergency setting. Early diagnostic imaging with CT while a patient is symptomatic can aid in making an accurate diagnosis. Laparoscopic repair can be safely used with good outcome in the context of an incarcerated obturator hernia. [ABSTRACT FROM AUTHOR]