Diagnosis and treatment of epiploic appendagitis in a Middle Eastern country: An observational retrospective analysis of 156 cases.

BACKGROUND: Epiploic appendagitis (EPA) is an uncommon emergency surgical condition that causes acute abdominal pain, rendering a list of differential diagnoses. Therefore, careful examination and imaging tools are required. EPA is a self-limiting condition that can be resolved in 1-2 weeks and rarely needs surgical intervention. Its low incidence makes EPA less well-known among the public and some medical professionals, and it is frequently under-diagnosed. We aimed to explore the incidence, clinical presentation, modalities of imaging to diagnose and options for treating EPA. METHODS: An observational retrospective analysis was conducted between 2016 and 2022 at a tertiary hospital in an Arab Middle Eastern country. RESULTS: There were 156 EPA cases diagnosed over six years, with a mean age of 33 years. Males represented 82% of the cohort. The entire cohort was treated non-operatively except for eight patients who had surgical intervention using open or laparoscopic surgery. The diagnosis was made by a computerized tomographic scan (CT). However, plain X-ray, abdominal ultrasound, and magnetic resonance imaging (MRI) were performed initially in a few selected cases to rule out other conditions. No specific blood test indicated EPA; however, a histopathology examination was diagnostic. No mortality was reported in the study cohort. CONCLUSION: This is the most extensive study analyzing EPA patients from the Middle East. EPA is a rare and mostly self-limiting acute abdominal disorder; however, early ultrasound and CT scan can pick it up quickly after a high index of suspicion.

Hereditary Pheochromocytoma With a Mutation in the Succinate Dehydrogenase Subunit A Gene.

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with diverse clinical presentations. Pathogenic variants in the genes encoding different subunits of the succinate dehydrogenase enzyme complex that plays a central role in energy metabolism have been linked to hereditary PPGL syndromes. Here we report a rare case of hereditary pheochromocytoma with a novel mutation in the succinate dehydrogenase subunit A (SDHA) gene.  A middle-aged woman presented with left-sided abdominal pain and was incidentally found to have bilateral adrenal lesions on abdominal imaging. Imaging characteristics were suggestive of pheochromocytoma. She denied any symptoms of catecholamine excess but her plasma metanephrines level was elevated. Iodine-131 metaiodobenzylguanidine (131I-MIBG) whole-body scan showed abnormal focal radiotracer uptake at the left adrenal gland, and she then underwent left-sided adrenalectomy. Following surgery, the patient had symptomatic relief and histopathology confirmed the diagnosis of pheochromocytoma. Genetic testing revealed that she was positive for a pathogenic mutation in the SDHA gene consistent with the diagnosis of hereditary PPGL syndrome.  The detection of susceptibility genes for hereditary PPGL syndromes has key implications, for surveillance to detect extra-adrenal disease and recurrent tumors, as well as for consideration of genetic testing for family members.

A Case Report on Fish Bone Perforating Meckel's Diverticulum Mimicking Appendicitis.

Meckel's diverticulum (MD) is the most frequent congenital abnormality of the digestive tract. Although it is silent, it can rarely come up as a complicated case including but not limited to obstruction, inflammation, and neoplasm. Perforation as a consequence of MD is extremely infrequent and mostly related to foreign objects. We report a case of a 24-year-old man who presented to the emergency department with signs and symptoms suggestive of acute appendicitis. Computed tomography (CT) of the abdomen demonstrated foreign body perforation from a protrusion outside the small bowel. The patient underwent laparoscopy and a fish bone perforating MD was found which was removed.

Rare presentation of chronic recurrent multifocal osteomyelitis of the Iliac wing mimicking Ewing's sarcoma.

This report describes a case of chronic recurrent multifocal osteomyelitis (CRMO) in an 11-year-old girl, involving the iliac bone as an initial, solitary site. Atypical imaging features were suspicious of a bone tumour, such as Ewing's sarcoma. Chronic recurrent multifocal osteomyelitis is a great masquerader and can present atypically. Radiologists should be familiar with both typical and atypical presentations, to determine an accurate diagnosis and guide appropriate management. Timely diagnosis may avoid invasive bone biopsy and inappropriate long-term antibiotic prescription for children.

Agenesis of the piriformis muscle: A case report with review of literature.

Agenesis of the piriformis muscle is an extremely rare occurrence. Knowledge about this anatomic variant is important because of its close proximity with the sciatic nerve and sacral plexus. The piriformis muscle also serves as an important anatomic landmark for image-guided intervention and hip surgery. We report a case of piriformis muscle agenesis in a 28-year-old woman, incidentally detected on magnetic resonance imaging of the lumbosacral spine and pelvis, performed for low back pain.

Epithelioid Hemangioendothelioma of the Ulnar Artery Presenting with Neuropathy.

We present a rare case of epithelioid hemangioendothelioma arising from the wall of ulnar artery in distal forearm. The presentation was interesting in a 34-year-old man, with progressively worsening symptoms of ulnar neuropathy. A mass was seen arising from the ulnar artery on imaging with ultrasound and magnetic resonance imaging. Soft tissue epithelioid hemangioendothelioma in extremities almost always arise from the veins. Existing literature do not have elaborated imaging findings of epithelioid hemangioendothelioma arising from the arterial wall. The aim of this paper is to briefly review the interesting presentation and imaging features of this rare entity. Knowledge of such vascular tumor would avoid the mishap during surgery. Our case will add an interesting presentation of such rare pathology to the existing literature.

Sarcomatous Transformation of Recurrent Scapular Osteochondroma in a Patient with the Hereditary Multiple Osteochondromas: A Case Report and Literature Review.

Hereditary multiple osteochondromas (HMO) is an autosomal dominant disease diagnosed by the presence of two or more than two osteochondromas on radiographs. The majority of cases are asymptomatic. The presence of bony growth, pain, and compression of the surrounding structure are the usual presentations. Malignant transformation into chondrosarcoma is the most feared complication. A rapid increase in size, recurrence after the surgical excision, and infiltrating mass may suggest the conversion into chondrosarcoma. Radiological imaging helps in diagnosing malignant transformation. MRI is the investigation of choice to exclude cancer. We hereby present a case of multiple osteochondromas with suspected malignant transformation due to rapidly increasing painful osseous swelling.