Evgeny V. Arshava

We describe a patient that acutely presented with concomitant non-infected diffuse pericardial, intraabdominal, and subcutaneous fat necrosis in the setting of previously undiagnosed chronic calcific pancreatitis. There was no associated pancreatic necrosis, pseudocyst, or fistula. We have not encountered in the literature a previous description. The patient was managed with combination of abdominal and thoracoscopic resections and a favorable 4-year outcome. Exact mechanism of this case is uncertain. Based on clinical, intraoperative, and imaging findings, we consider that the etiology was intraabdominal and most likely related to chronic pancreatitis in the setting of metabolic syndrome.

Introduction and importance: Epidermal inclusion cysts are a common benign finding, and they are predominantly asymptomatic. They can rarely form in the pelvis or abdomen, however, and may cause symptoms secondary to mass effect. This case highlights management of an anterectal epidermal inclusion cyst connected to the perineal cyst, mimicking a dumbbell-shaped lesion, found in a male. Case presentation: This is a unique case of a 21-year-old Caucasian male with a palpable perineal mass, lower extremity hypoesthesia, and constipation who was found to have a complex-shaped cyst on computed tomography and magnetic resonance imaging. This was ultimately managed with a two-stage perineal and transabdominal resection. Clinical discussion: This case highlights that perineal epidermal inclusion cysts may have pelvic extension, especially in patients with additional new-onset neurologic, gastrointestinal, or urologic symptoms. These symptoms should completely resolve after resection. Additionally, resection is recommended to prevent complications including malignant degeneration and fistulization. Conclusion: This is the first reported case of an anterectal, epidermal inclusion cyst connected to a perineal cyst found in a male. Perineal and pelvic cysts may be synchronous and may be connected through the pudendal canal. These masses can be safely removed via a combined perineal and transabdominal resection. The connecting portion of lesions that have both pelvic and perineal components should be meticulously identified and dissected because even a thin, patent segment – if left unresected – may result in lesion recurrence. Highlights:

Diverticulosis of the foregut and small bowel is uncommon. In this article we provide an overview of various types of esophageal, gastric, and small bowel diverticula. Asymptomatic diverticula are usually found incidentally during imaging or encountered during unrelated procedures and managed conservatively by observation. Symptomatic patients with esophageal diverticula typically present with dysphagia, regurgitation, and aspiration. These symptoms should prompt elective work-up and treatment. Esophageal diverticulum should be a differential diagnosis for dysphagia, and necessary precaution should be taken during endoscopy to prevent inadvertent perforation. Ideally, patients with dysphagia should be evaluated with imaging prior to endoscopy. Spontaneous perforation and bleeding are very rare, and erosive perforation tends to occur secondary to midesophageal traction diverticula. Gastric, duodenal, and small bowel diverticulosis is frequently asymptomatic. Symptomatic cases may present with obstruction, perforation, and bleeding. While endoluminal techniques have be recently utilized for the management of pharyngoesophageal (Zenker’s) diverticulum, other symptomatic and complicated diverticula of the foregut and small bowel required operative treatment. The complications may be life-threatening and require urgent surgical interventions.

A 45-year-old- man presented with left chest wall pain, swelling and cough. Over a 2-month period he developed abscesses in the right foot, right anterior thigh, left buttock and left chest. Incision and drainage of the soft tissue abscesses and video-assisted thoracoscopic surgery to drain the loculated empyema contiguous with the chest wall abscess were performed as surgical management. Gram stain showed beaded Gram-positive rods and the culture initially grew Aggregatibacter actinomycetemcomitans and Eikenella corrodens. Pathological evaluation of the pleura showed sulfur granules and organisms consistent with Actinomyces spp. on Gomori methenamine silver stain; Actinomyces israelii was recovered in culture with extended incubation. The patient was treated for 3 weeks with ceftriaxone and oral metronidazole, followed by oral amoxicillin. Culture of A. actinomycetemcomitans with other findings consistent with actinomycosis warrants 6–12 months of antibiotic therapy.