Intrapancreatic accessory spleen with an epidermoid cyst: a malignant mimicry.

With the liberal use of CT scan for clinical diagnosis, clinicians are faced with an increasing number of pancreatic incidentalomas. Compared with other incidentalomas, pancreatic incidentalomas have higher chances of future malignant transformation. There are many differential diagnoses, and epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS) is extremely rare, with only a handful of reports. Preoperative diagnosis is often complicated, and the final diagnosis is usually only made after surgical resection.We report a 34-year-old man who had an incidentally noted 2.8 cm pancreatic tail cystic lesion on a CT scan done for urinary symptoms. The lesion had a solid nodular component that was worrisome for malignancy, and the patient underwent further evaluation with an MRI scan and endoscopic ultrasound of the pancreas. The differential diagnoses of cystic degeneration of neuroendocrine tumour, branch-duct intraductal papillary mucinous neoplasm with worrisome features or ectopic intrapancreatic spleen were made. A multidisciplinary tumour board recommended surgical resection given risk features of malignancy. The patient subsequently underwent a laparoscopic distal pancreatectomy with splenectomy, and histology confirmed the diagnosis of ECIPAS.Imaging characteristics of ECIPAS are non-specific, and most patients have a diagnosis made only after surgery. Therefore, more evidence is warranted for accurate preoperative imaging diagnosis to avoid unnecessary pancreatic surgery, which is not without its risks.

Intrahepatic splenosis: a world review.

Splenosis is defined as the autotransplantation of viable splenic tissue throughout various anatomic compartments. Intrahepatic splenosis (IHS) is rare and diagnosis is often challenging. This study aims to provide a comprehensive review on IHS. A literature review was performed on PubMed database. Fifty-six articles with 59 reported cases were included. The majority of the patients were male (n = 49, 83.1%). Median age was 51 years. Risk factors for hepatocellular carcinoma (HCC) included hepatitis B (n = 8, 13.6%) and cirrhosis (n = 12, 20.3%). The majority of the patients were asymptomatic (62.7%) and did not have risk factors for HCC (55.9%). We report a diagnostic triad for IHS: 1) previous history of abdominal trauma or splenectomy, 2) absence of risk factors for liver malignancy and 3) typical imaging features. Non-invasive diagnostic tests such as technetium-99m-tagged heat-damaged red blood cell scintigraphy are useful in diagnosis. Malignancy should be ruled out in the presence of risk factors for HCC.

Necrotizing Fasciitis Caused by Cryptococcus gattii.

Necrotizing fasciitis (NF) is a severe soft-tissue infection that can lead to high morbidity and mortality. The etiology of NF is often polymicrobial. Although rare, fungal organisms have been known to cause NF. Cryptococcus is a fungal infection that may lead to NF. Here we report the case of a 73-year-old man who had diabetes and presented with pain and swelling in the left hand after being bitten by an insect over the dorsum of the hand. Operative débridement revealed NF caused by Cryptococcus gattii. Antifungal medication was started, and the patient underwent multiple débridements of the hand with subsequent skin grafting. Four months later, the hand wound was completely healed. Authors have reported several cases of NF secondary to Cryptococcus neoformans in immunocompromised patients. The emerging C gattii pathogen affects immunocompetent patients. Although the transmission route is mainly respiratory, direct inoculation has been described as well. Ours is the first reported case of NF secondary to C gattii. It is important to consider fungal elements as a source of NF. Appropriate treatment includes aggressive surgical débridement and antifungal therapy.