Nodular fasciitis is a benign proliferation of myofibroblast often misdiagnosed as a sarcoma of soft tissues. It is characterized by rich cellularity, mitotic activity and rapid growth. It is usually solitary, and occurs in the head and neck in childhood, and upper extremities in adulthood. We report the case of a four-year-old child who developed multiple lesions in the head, neck and trunk. Nodular fasciitis was diagnosed in this reported case by incisional biopsy. Case ReportA four-year-old Sudanese boy presented with a two-week history of a painless scapular mass, which was progressively increasing in size and was associated with moderate restriction of right arm movement. His father denied any history of trauma. The patient had a history of bilateral halux valgus, which had been corrected two years previously. He was a product of a spontaneous vaginal delivery and had no family history of a similar problem. The result of clinical examination showed a 5x10 cm firm mass at the angle of the right scapula fixed to underlying muscle. The area was not tender to palpation, had no warmth or erythema, and the overlying skin was freely mobile. There was limitation of abduction up to 70°, and restriction in bending forward due to a bulky right paraspinal muscle Initial laboratory findings revealed the following: WBC count, 8.2x10/L; ESR, 7 mm in the first hour; creatine kinase, 169 U/L (normal, 25-200 U/L); alkaline phosphatase, 455 U/L (98-279 U/L); and calcium level of 10.46 mg/dL (8.1-10.4 mg/dL).The radiological evaluation of the patient included a chest x-ray (Figure 1), which showed right-sided chest wall swelling mainly at the scapular region. The opacity was homogenous, with no calcification or bony lesion. Enhanced CT scan showed slightly infiltrating mass of soft tissue density among muscles of the right shoulder and chest wall. Fine-needle aspiration was inconclusive. The patient was taken to the operating room, and incisional biopsy was performed under general anesthesia. At surgery, there was no line of demarcation between the subcutaneous tissue, tumor and underlying muscle. Therefore, a wedge biopsy was taken, including subcutaneous tissue and muscle. Closure was performed in the usual fashion.The patient was discharged home while awaiting histopathology report. Microscopic examination of the biopsy demonstrated a sparsely cellular lesion, composed of immature, plump and slender fibroblasts in a loose background, and containing extravasated red blood cells and rare inflammatory cells, particularly mast cells. The fibroblasts were haphazardly arranged, relatively uniform in size and shape, and had oval pale staining nuclei, with prominent nucleoli and rare mitotic figures. These cells resembled fibroblasts seen in tissue culture ( Figure 2). Residual skeletal muscle fibers were seen within the lesion, which indicated infiltration of the surrounding skeletal muscle. These microscopic features were consistent with nodular fasciitis. The child was seen in the outpatient clinic one week after the operation....

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Pleural effusion is a common finding following pneumonia. It can become infected with accumulation of pus, forming empyema thoracis (ET), which is frequently encountered in childhood. Proper drainage and broad-spectrum antibiotics are the mainstays of treatment. However, operative intervention is another mode of therapy in later stages of the condition. Election of either mode of therapy is a controversial issue, and depends largely on the discipline of the treating clinician. We report a case of bilateral ET treated by operative intervention, and review the current modes of therapy in the literature. Case ReportA 10-month-old Saudi girl born after a normal term pregnancy and uneventful delivery presented to the pediatric service with high-grade fever, productive cough, shortness of breath, lethargy and poor suckling of two weeks' duration.On examination, she was febrile, dehydrated, irritable and underweight. She had a flaring of the ala nasi and subcostal recession, but there was no lymphadenopathy. Examination of the chest revealed reduced air entry bilaterally, bilateral ronchi and a dull percussion note at the base of the right hemithorax. Initial laboratory investigations revealed white cell count of 16.3x10 9 /L, with 63% polymorphonuclear forms, hemoglobin of 10.2 g/dL, Westerngren erythrocyte sedimentation rate of 75 mm in the first hour, and blood glucose of 100 mg/dL (normal, 80-110 mg/dL). Other laboratory investigations were normal.Initial radiographic study of the chest revealed a bilateral homogenous alveolar infiltrate mainly at the lower lobes, with minimal pleural effusion at the right hemithorax (Figure 1). Thoracocentesis revealed a turbid, yellowish aspirate, analysis of which showed pH 7.12, protein 6 g/dL, glucose 30 mg/dL, lactate dehydrogenase 1416 U/L and white cell count 300/mm 3 . The initial working diagnosis was bilateral bronchopneumonia with a right-sided complicated parapneumonic effusion. Initial treatment included chest physiotherapy, antipyretics and broad-spectrum antibiotics (thirdgeneration cephalosporin, ceftriaxone, and gentamycin) covering both gram-positive and negative bacteria. An intercostal tube (ICT) was inserted through the right fifth intercostal space, mid-axillary line under local anesthesia. Around 100 mL of turbid fluid was drained. The pleural fluid culture grew no bacteria, while throat swab grew Klebsiella species sensitive to gentamycin.One week after initiation of the antibiotics, a follow-up chest radiograph revealed development of a left-sided pleural effusion. Another ICT was inserted at the left hemithorax. Minimal purulent fluid was drained, and bacterial culture revealed Staphylococcus aureus, sensitive to vancomycin, which was added to the antibiotics.Four weeks after admission, the patient was referred to the thoracic surgical service, where a CT scan revealed bilateral, loculated, pleural effusions with a thickened cortex around both lower lobes ( Figure 2).The decision was made to perform surgical decortication of both lungs for two reasons: 1)...