The present study aims to raise awareness about the necessity of a thorough differential diagnosis process when diagnosing paraganglioma as it is an extremely rare entity with a high malignant potential. A 64-year-old female patient was admitted to the hospital with symptoms of bowel obstruction and a palpable abdominal mass. Abdominal and pelvic computed tomography revealed a cystic heterogeneously enhanced mass. The tumor was surgically removed and then microscopically analysed. Microscopically, the mass was composed of nests of small polygonal and round cells with central vesicular nuclei, consistent with the diagnosis of mesenteric paraganglioma which was later confirmed by immunohistochemistry. The critical markers for paragangliomas, namely chromogranin A and S100, should be used as the first step in diagnosis, followed by other valuable immunohistochemical markers. A long-term follow-up is extremely important following the diagnosis of paraganglioma as all these tumors have a malignant potential.

BACKGROUND Primary appendiceal tumors are histologically diverse and have an insidious onset and few specific clinical manifestations. In the majority of cases, these tumors are discovered after appendectomy during pathological exam of the resected tissue. Treatment may include appendectomy (simple or radical) and right hemicolectomy depending on factors such as histological type, tumor size and lymph node/organ involvement. The aim of this case study is to describe a rare case of a giant appendicular mucocele and raise awareness of this condition and its management options and follow-up protocol. CASE SUMMARY We present the case of a 43-year-old patient who presented to our emergency department with mild right lower quadrant pain. After the initial check-up and imaging exams, he underwent surgery, where a giant 20 cm × 13 cm appendicular tumor was found and resected. Appendicular mucocele was suspected due to the macroscopic appearance and was later confirmed by the pathological exam. The patient’s postoperative evolution was uneventful, and after discharge, he was included in our follow-up program. CONCLUSION In conclusion, mucinous appendiceal neoplasms embody a rare pathology; they are asymptomatic or have few, unspecific clinical signs and in many cases are discovered after appendectomy.

Gallstones and colorectal cancer (CRC) are two common disorders that may develop simultaneously. In such situations, there is a significant chance of missing one of the conditions due to the primary clinical presentation. Late detection, diagnosis and treatment can be especially problematic in the case of unrecognized CRC. In the present study, the medical charts were retrospectively reviewed for all consecutive patients who were treated in the Second Department of Surgery, University Emergency Hospital Bucharest (Romania) between February 2015 and December 2017 following a diagnosis of CRC and/or biliary stones. There were 203 patients with CRC, 433 with biliary gallstones and 19 patients with both conditions. There were 125 men (61.6%) in the CRC group and 138 men (31.9%) in the gallstone group. The average age was 54.1±15.9 years in the gallstone group and 66.1±11.6 years in the CRC group. Obesity was observed in 96 patients (22.2%) with gallstones and in 14 (6.9%) patients in the CRC group. In the CRC group, 80 patients had medical comorbidities (39.4%), while in the gallstone group 126 patients (29.1%) had medical comorbidities. Bivariate analysis comparing gallstone only vs. gallstone and CRC identified age (P=0.001), male sex (P=0.001) and thyroid disease (P=0.001) as significant factors associated with synchronous diagnosis. The multivariable logistic regression of factors predicting CRC in patients with gallstones identified age (OR, 1.06; 95% CI, 1.023-1.105; P=0.002) and thyroid diseases (OR, 11.15; 95% CI, 2.532-49.06; P=0.001) as independent factors. There were significant differences regarding the location of the tumor between the CRC-only group and the gallstone and CRC group (P=0.001): Rectum (39.7 vs. 5.3%), left colon (26.6 vs. 21.1%), transverse colon (13 vs. 26.3%) and right colon (20.7 vs. 47.4%). The study concluded that, in patients with gallstones, age and thyroid conditions were significantly associated with CRC. Patients with a synchronous diagnosis of gallstones and CRC had significantly more right-sided CRC compared with regular CRC.

Calitatea actului chirurgical, limitele de rezecţie, excizia totală a "mezorectului", anastomoza mecanică sau manuală şi tratamentul oncologic pre-şi postoperator al cancerului rectal pot influenţa incidenţa recidivei locale. Am analizat cazul unui pacient în vârstă de 62 de ani, cu rectoragii, diaree şi tenesme rectale. Colonoscopia efectuată evidenţiază o tumoră rectală situată la 10 cm de OA, din care s-a prelevat biopsie: adenocarcinom moderat diferenţiat. Markerii tumorali CEA şi CA19.9 au fost găsiţi în limite normale S-a practicat rezecţie anterioară de rect cu colorectoanastomoză termino-terminală cu Stappler 32, visceroliză, apendicectomie. Postoperator-examenul histopatologic: adenocarcinom rectal NOS cu grad scăzut de malignitate G2-moderat diferenţiat, infiltrativ difuz până la nivelul muscularei, fără metastaze la nivelul limfoganglionilor locoregionali (identificaţi doar 5), complet excizat chirurgical-stadiuI pT2pNo(G2). Postoperator, pacientul nu a efectuat tratament oncologic. La colonoscopia efectuată la 1 an de la intervenţia chirurgicală, se descoperă formaţiune tumorală sângerândă burjonată, situată la nivelul anastomozei, din care se prelevează biopsii. Rezultatul confirmă recidiva locală de adenocarcinom invaziv. Se decide şi se practică amputaţie de rect tip Milles. Postoperator, pacientul efectuează tratament oncologic. Stadializarea preoperatorie reprezintă un factor important în stabilirea indicaţiei de radioterapie.

Encephalitis is a rare complication of cervical - cranial zoster infection. Myelitis is a similar, severe complication of thoracic zoster. They occur in patients with immune deficiencies, in 5-21 days after the rash and progress in the same time frame. We are presenting the case of a 54 year old male with rapid evolution of an ascending encephalomyelitis with onset at 17 days after a left cervical-thoraco-brachial zoster episode. Neurologic examination: lower limb paresthesia, ascending to the trunk, unstable gait, which becomes impossible with closed eyes, absent deep tendon reflexes, bilateral Babinski sign. After 48 hours, left cerebellar syndrome appears, in one week the patient had asymmetrical tetraparesis and in 11 days he becomes paraplegic, left side more affected than the right one. After 16 days, the clinical state stabilizes, he begins moving his right lower limb. Lumbar puncture on admission: CSF albumin 1220 mg% (after 3 days it becomes normal); 81 cells/mm3, 100% mononuclear cells, 50 cells after 3 days and after a week 23 cells/mm3. Cervical and thoracic spine MRI performed on the 3rd day from admission was normal but after repeating it in 10 days it showed T2, STIR and FLAIR hyper intense intraspinal, infra- and supratentorial lesions, well contoured, with homogenous gadolinium enhancement: demyelinating lesions. He received Acyclovir, Solumedrol, Insulin and symptomatic treatment. After 2 weeks from leaving the hospital with symptomatic treatment and kinetic therapy, he returns in a septic state, with deep bed sores, positive blood cultures (Fusobacterium nucleatum, Staphylococcus Epidermidis) and urine cultures (Klebsiella). The outcome was death in 4 days. Differential diagnosis – polyradiculoneuritis, paraneoplastic syndrome, cerebral and vertebral metastases. Pathology exams: low grade acinary adenocarcinoma of the pancreatic head, invasive, with a solid pattern. The particularity of the case: the severity of the acute ascending encephalomyelitis, the fulminant evolution of the pancreatic cancer, the disruption of the blood-brain barrier by an inflammatory and tumoral mechanism, showed on spine and brain contrast MRI.